*** What is the most important thing you can do for a GI bleed from the surgical perspective?
- realize from where the bleeding originates (i.e. LOCALIZE the bleed to UPPER or LOWER GI).
- stabilize the patient.
What constitutes the upper GI tract?
- mouth down to the ligament of Treitz (band between the 4th part of the duodenum and jejunum)
*** What is the first thing you want to do when a person comes into your emergency room with a suspected GI bleed?
place a nasogastric (NG) tube to aspirate the stomach, in order to help you make your diagnose of the bleeding source.
What 3 possible colors will the aspirate of an NG tube tell you?
- GREEN= bile; NO upper GI bleed.
- RED= blood; UPPER GI BLEED.
- clear= indeterminate; means you have not sampled the duodenum
Should you let the NG tube in a patient after using it diagnostically to evaluate for an upper GI bleed?
NO, unless the patient is vomiting, then you can.
** When is the appropriate time to do an upper endoscopy?
at the INITIAL INCEPTION of ADMISSION! (NOT once the patient is stabilized).
*it is essential to learn from where the bleeding is coming. So SCOPE IMMEDIATELY!
Do you treat an upper GI bleed, secondary to an esophageal varice, differently than a peptic ulcer bleed?
YES! This is why you must figure out what is bleeding.
When is the time to figure out where the bleeding originated?
- as the source is ACTIVELY BLEEDING (duh).
Besides using upper endoscopy to acutely diagnose, what else makes this nice?
- it is also THERAPEUTIC, as you can use a heater probe to burn a bleeding vessel.
What happens to blood that leaks out into the stomach?
- it COAGULATES. So your job as the surgeon is to clean this out for the endoscopist to get the best view possible.
Why do physicians use ICE SALINE to lavage the stomach?
- it really does nothing more than buy you time to think without distraction as you have some people leave to get you these things hahaha.
- so basically these don’t help.
Will most GI bleeding stop on its own?
YES
What are the common causes for GI bleeding?
- GASTRITIS (serious bc all a surgeon can do is remove your entire stomach).
- PUD
- esophageal injury
- GASTRIC TUMOR (bad because it has direct extension to other organs, lush blood supply, and lush lymphatic supply, allowing it to metastasize easily).
- varices
Can upper endoscopy be done at the bedside in 5-10 mins?
YES with appropriate mild sedation.
*** How do we treat esophageal varicocele bleeding?
- Sengstaken–BLAKEMORE tube= long NG tube with an upper and lower balloon. You inflate the LOWER BALLOON first and pull back to impact the varicoceles at the gastroesophageal junction.
The upper balloon can be inflated in the rare case of an upper esophageal bleed.
*Can only be used for 24-48 hours bc it will cause pressure necrosis on the esophagus. - SHUNTING blood from the portal vein to the inferior vena cava (IVC), thus relieving portal hypertension (TIPS procedure; Transjugular Intrahepatic Portasystemic Shunt).
*hepatic encephalopathy is the problem with this, do to bypassing the cleansing action of the liver! - SURGERY by cutting out the veins (vein stripping), but this doesn’t help the source.
- LIVER TRANSPLANT.
How do you keep the lower balloon of the Sengstaken–BLAKEMORE tube from falling back into the stomach?
- have pt wear football helmet and attach tube to chin guard as an anchor.
What is the added risk of inflating the upper tube of a Sengstaken–BLAKEMORE tube in the event of an upper esophageal bleed?
- the esophagus doesn’t have an adventitial covering, rendering it weaker to rupture if you over-inflate the balloon, as opposed to the stomach.
- must use pressure manometer to monitor as you inflate.
What is also important to remember in regard to placement of a Sengstaken–BLAKEMORE tube?
place an NG tube also to suck out saliva that will go down the esophagus bc it has no where else to go, and you don’t want the patient to aspirate.
What causes the esophageal varices to begin win?
- liver cirrhosis, leading to portal hypertension and backing up of blood to the esophagus and to the spleen, engorging the spleen and thus its branching vessels (vasa brevia) to the stomach.
What other things commonly bleed in a hospitalized pt?
- percutaneous endoscopic gastrostomy (PEG) tube= feeding tube that is passed into a patient’s stomach through the abdominal wall, but this can cause pressure necrosis where it touches the gastric mucosa.
Is bleeding from a gastric or duodenal ulcer, easily amenable to surgery?
YES :)
*** What is the criteria for treating PUD?
- 6 weeks of medical therapy. If that fails, switch therapy and try for another 6 weeks.
- If after these 12 weeks, you still have evidence of the ulcer, then this is considered medical failure. Move to Surgery.
*** How do we treat a bleed from PUD?
- heater probe
- H2 antagonist, antacid therapy, or PPI.
- VAGOTOMY= cuts the parasympathetic nerve supply that supplies the parietal cells, which liberate the stomach acid. This is only about the same time course as a gallbladder surgery, but is last resort.
What are the 2 forms of antacids and how do the differ?
- those with an “A” name= aluminum base (causes CONSTIPATION).
- those with an “M” name= magnesium base (causes DIARRHEA).
