Emergency General Surgery

The Bleeding Volcano – Treatment

Shall we stop this bleeding

Abraham Lincoln

Last time we have left our patient with hematemesis to his way to endoscopy. Now, we are going to explore the possible treatment options we have to treat him.

Endoscopy

Esophagogastroduodenoscopy is the gold standard in the upper GI bleeding for both the diagnosis and the treatment of the underlying cause.

The endoscopic treatment allows achieving hemostasis, to reduce the re-bleeding rate, the need for surgery, and the mortality rate. For these reasons, it should be the first-line treatment in bleeding patients. However, the timing of its use depends on the patients’ risk stratification.

The most famous system for risk assessment in patients presenting with upper GI bleeding is the Glasgow-Blatchford Score. According to its result, it is possible to divide patients into three groups, and, consequently, to determine the best timing for endoscopy:

  • Very low risk (GBS 0): outpatient endoscopy;
  • Low risk (GBS 1-6): early inpatient endoscopy (<24 h);
  • High risk (GBS≥7): urgent inpatient endoscopy (<12 h).

During the endoscopy, once the bleeding source has been identified, it is possible to characterize it according to the Forrest classification. This classification correlates with the risk of re-bleeding.  Therefore, it may guide the choice of how to manage the bleeding next.

The suggested management based on the Forrest classification is as follows:

  • Forrest 1a, 1b, and 2a: endoscopic treatment, then continue PPI as above;
  • Forrest 2b: you may consider the endoscopic treatment in high-risk patients, then continue PPI as above;
  • Forrest 2c, and 3: no endoscopic treatment is recommended, and PPI may be switched PO.
Risk assessment in patients with gastrointestinal bleeding

Another score using the result of the endoscopy is the Rockall score. It is a prognostic score. If the score is <3 the patient has a good prognosis, if it is higher than 8 there is a high risk of mortality.

If the endoscopic treatment is advisable, what can be done?

There are several possible endoscopic methods to achieve hemostasis:

  • Epinephrine injection: it may be used, but not on its own. It should be always used in combination with another modality. It must be diluted (1:10,000 or 1:20,000 in normal saline) and injected 0.5-2 mL aliquots in and around the stigmata of hemorrhage in the ulcer base;
  • Thermal therapy: monopolar diathermy, bipolar electrocoagulation, or argon plasma coagulation;
  • Injection of sclerosant: it may be useful in reducing the risk of further bleeding, surgery, and mortality. Absolute alcohol may be used in 0.1-0.2 mL aliquots (a maximum of 1-2 mL);
  • Endo clips;
  • Hemostatic agents (e.g. Hemospray®): they are substances that adhering to a bleeding site activate the coagulation factors, thus promoting the thrombus formation.

In patients with active bleeding (Forrest type 1), dual-modality for endoscopic hemostasis is warranted.

A new improvement in endoscopic treatment of bleeding peptic ulcer is the Doppler probe-guided hemostasis, which seems to achieve a lower re-bleeding rate at 30 days. This technique helps to identify the vessel responsible for bleeding and to target the hemostasis to that spot, thus making the treatment more effective.

Recurrent bleeding after the first endoscopic treatment occurs in approximately 13-23% of cases.

A second endoscopy within 24 hours from the first one is not recommended in all patients, but only in those with clinical evidence of recurrent bleeding, or when further therapy may be warranted because of the higher risk stigmata of bleeding.

So then… Where have we left our patient?

Ah, yeah… You’ve just resuscitated him.

Now… The next step is to calculate his Glasgow-Blatchford Score, which appears to be 16. Therefore, according to the protocol we have reported earlier, he needs an urgent endoscopy (within 12 hours).

The gastroenterologist agrees with you and perform the exam right away.

During the endoscopy, the source of hemorrhage was found in the posterior wall of the first part of the duodenum. There was an active spurting bleeding in the middle of an ulcer about 2 cm in diameter (Forrest 1a). The bleeding was clearly arterial. The gastroenterologist tried to stop the hemorrhage, but without success. He only obtained a reduction in the bleeding rate.

At this point, we know that our patient has a Rockall Score of 5, which means he is at a moderate risk of death.

Angiography with Trans-Arterial Embolization

It is the second-line treatment in patients with recurrent or persistent peptic ulcer bleeding, and it is usually indicated after 2 failed attempts to control the bleeding endoscopically. In the case of hemodynamic instability, angioembolization should be considered on a case-by-case basis and only in selected facilities.

The success rate in achieving hemostasis is up to 98%, and the rebleeding rate after trans-arterial embolization (TAE) is about 10-20%.

Interventional radiologists may require a CT-Angio before proceeding with angiography. CT-Angio has a sensitivity of 86% and a specificity of 95% in detecting active bleeding. However, it requires a bleeding rate of at least 0.5 mL/min to demonstrate the extravasation of contrast at the bleeding source.

Comparing TAE to surgery as the best method to achieve hemostasis in patients with failed endoscopy, TAE showed an increased risk of rebleeding, but a reduced risk of death and lower risk of complications. These results, along with the less-invasive nature of this technique, have elevated TAE as the method of choice in those who have failed endoscopic therapy.

Many techniques exist to achieve hemostasis via angioembolization. Among them, metal coils are the agent of choice. Additional options are glue, polyvinyl alcohol particles, and Gelfoam® (an absorbable compressed gelatin sponge).

In the case of an undetected bleeder, the provocative bleeding technique may be useful to determine the hemorrhage source. The principle is simple: to administer medications inducing bleeding, thus increasing the chances to detect the bleeding source. The drugs are injected selectively into the superior mesenteric or celiac artery, and they usually belong to three classes of medications: anticoagulants (heparin), vasodilators (tolazoline or nitroglycerin), and fibrinolytic agents (urokinase or tPA). This technique should be used with caution, and only in selected centers because of the risk of uncontrollable bleeding.

After the unsuccessful endoscopic treatment, the patient appears hemodynamically stable. Therefore, in agreement with the anesthesiologist, he was brought to angiography to try to embolize the bleeder.

In this case, the patient doesn’t need a CT-Angio, because the active bleeding was recorded during endoscopy.

Unfortunately, due to an arterial malformation, the interventional radiologist was not able to cannulate and embolize the gastroduodenal artery, which was the source of contrast extravasation during the preliminary angiographic phase.

Surgery

Nowadays, surgery has limited indications in patients presenting with bleeding peptic ulcer:

  • Recurrent or persistent bleeding despite endoscopic and angiographic treatments;
  • Ulcer >2 cm in diameter (we do not believe this factor alone should be a criterion for surgery);
  • Hemodynamic instability despite resuscitation;
  • Shock associated with recurrent hemorrhage;
  • Perforation;
  • Fragile patients, who are less likely to benefit from prolonged and vigorous resuscitation.

The outcomes of the surgical treatment depend upon patients’ conditions. If the procedure is performed emergently the mortality rates may reach 36%, while in normal conditions it is around 3-4%. Postoperative rebleeding rates are between 3 and 23 percent.

The recommended approach in these patients is open surgery with/without intraoperative endoscopy. Laparoscopy should be used with caution, mainly if the patient is hemodynamically unstable.

Many surgical procedures have been described over the years to obtain definitive hemostasis in patients with bleeding peptic ulcers. It should be said that there is no best procedure. The choice of which one to use depends on the location of the bleeding source:

  • Greater curvature, antrum, and body: wedge resection;
  • Lesser curvature, pylorus: distal gastrectomy;
  • Gastroesophageal junction: gastrotomy and over-sewing the ulcer, or, if resection is necessary, the Csendes procedure;
  • Duodenum: trans-duodenal gastroduodenal artery ligation.

If antrectomy or gastrectomy was carried out, the duodenal stump should have at least 1 cm of healthy tissue to avoid biliary leakage from it. If this is not possible, the Bancroft procedure may help in protecting the duodenal stump.

Csendes Procedure: subtotal gastrectomy with Roux-en-Y esophagogastrojejunostomy.
Bancroft Procedure: the gastric mucosa is dissected from the submucosa towards the duodenum (A, B & C). The mucosa is then resected at the duodenal junction and closed (D). The excess of the antral seromuscular layer is closed over the duodenal stump with a running nonabsorbable suture (E).

A biopsy of the ulcer should be taken during or after the surgical procedure, because of the risk of underlying cancer, mainly if it is localized in the stomach.

Remember that damage control surgery must be always performed in patients with hemorrhagic shock, in order to quickly stop the bleeding and allow the patient to restore his/her normal physiological state in the ICU. Only after an appropriate resuscitation, the definitive surgery can be carried out.

After the failed attempts to stop the bleeding through endoscopy and angioembolization, surgery appears the only solution. Thus, you decide to bring the patient to the OR.

Approaching a posterior bleeding duodenal ulcer laparoscopically in a patient who’s hemodynamically stable, but far from having normal hemodynamic parameters, is hazardous. So, you perform a laparotomy with a trans-duodenal gastroduodenal artery ligation, obtaining a complete hemostasis.

Further Management & Follow-up

Proton pump inhibitors should be continued as planned before, depending on the Forrest classification.

Helicobacter pylori infection should be always investigated and consequently treated in patients with a bleeding peptic ulcer. However, we are going to address this topic in one of the following posts.

Antithrombotic drugs must be resumed, if interrupted, as reported in the previous post (i.e. as soon as possible, or as soon as the bleeding has stopped).

Follow-up endoscopy should be planned after 6-8 weeks from the index procedure.

In the case of recurrent and/or occult bleeding, colonoscopy or small bowel assessment may be warranted to exclude possible concomitant lesions.

Now you know how to manage a bleeding peptic ulcer…

No need to panic… Small simple steps and you’ll get out from this unpleasant situation…

That’s all folks…

References
  1. Tarasconi A, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World Journal of Emergency Surgery 2020;15:3.
  2. Laine L, et al. Management of patients with ulcer bleeding. Am J Gastroenterol 2012;107:345-60.
  3. Siau K, et al. Management of acute upper gastrointestinal bleeding: an update for the general physician. J R Coll Physicians Edinb 2017;47:218-30.
How to Cite This Post

Bellio G, Marrano E. The Bleeding Volcano – Treatment. Surgical Pizza. Published on September 20, 2020. Accessed on July 31, 2021. Available at [https://surgicalpizza.org/emergency-surgery/the-bleeding-volcano-treatment/].

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