bleeding duodenal ulcer

Bleeding Duodenal Ulcer

Dr B D Soni SIDSS, SDMH

Ferguson CB, Mitchell RM: Nonvariceal upper gastrointestinal bleeding:Standard and new treatment. Gastroenterol Clin North Am 34:607–621, 2005.

Introduction • PUD represents the most frequent cause of upper GI hemorrhage,

accounting for approximately 40% of all cases.

• Approximately 10% to 15% of patients with PUD develop bleeding at some point in the course of their disease.

• Bleeding is the most frequent indication for operation and the principal cause for death in PUD.

• Incidence of bleeding peptic ulcer decreased over last decade but despite changing treatment pattern mortality rate from bleeding peptic ulcer have been relatively stable.

Introduction

• High incidences were noted in patients with more advance age (6th decade)

• Incidence of emergency surgery has not changed despite improved medical/endoscopic treatment.

ETIOLOGY• Bleeding peptic ulcers are almost always associated with H.

Pylori Or NSAIDs uses. (~96%)

• Risk of developing bleeding peptic ulcer with corticosteroids use is debated while concomitant use of NSAIDs with steroids raises the incidence of Hemorrhage by 10-fold.

• Alcohol

• Smoking

H.pylori• Testing and diagnosis of Hp infection is essential for every patient

with UGI haemorrhage.

• The presence of the infection is usually underestimated in cases of bleeding peptic ulcers.

• A rapid urease test (RUT), with or without histology, is usually the first test performed during endoscopy.

• If the initial diagnostic test is negative, a delayed 13C-urea breath test (UBT) or serology should be performed

• Once an infection is diagnosed, antibiotic treatment is advocated.Ting-Chun Huang1,2 and Chia-Long Lee, Hindawi Publishing Corporation BioMed Research International Volume 2014, Article ID 658108 (Review article)

H. Pylori• 60% - 70% of patients with a bleeding ulcer are H. pylori

positive

• Several studies and a large meta-analysis, have shown that H. pylori treatment and eradication, in patients who test positive for the infection, result in decreased rebleeding

• Importantly, once the H. pylori infection has been eradicated, there is no need for long-term acid suppression and NO increased risk of further bleeding with this approach.

Liu CC, Lee CL, Chan CC, et al: Maintenance treatment is not necessary after Helicobacter pylori eradication and healing of bleeding peptic ulcer: A 5-year prospective, randomized, controlled study. Arch Intern Med 163:2020–2024, 2003.

BLEED classification

five criteria: 1. Ongoing bleeding,2. Systolic blood pressure less than 100 mm Hg,3. Prothrombin time more than 1.2 times

control,4. Altered mental status,5. Unstable comorbid disease process that

would require ICU admission

• Any of these if present – model predicts approx 3-fold increase in the risk of recurrent hemorrhage, need for surgical management & death.

• Mortality rate is very high in pt with bleeding that develops in the hospital primarily as a result of significant systemic disease .

• Re-bleeding rates (~15-22%) and mortality (14-15%) in this modern endoscopic era remained unchanged.

• Approximately 80-85% bleeding stops spontaneously

• Remaining 15-20% recurrent or continuous bleeding

• Re-bleeding increase mortality by 10 times

pathophysiology• Bleeding develops as a consequence of peptic acid erosion of the

mucosal surface.

• chronic blood loss is common with any ulcer

• significant bleeding typically results when there is involvement of an artery of the submucosa or, with penetration of the ulcer, an even larger vessel.

• The most significant hemorrhage occurs when duodenal or gastric ulcers penetrate into branches of the gastroduodenal artery or left gastric artery, respectively.

Clinical AssessmentClass I Class II Class III Class IV

Blood loss 0-15% 15-30% 30-40% >40%

PR (Bts/Min) <100 >100 >120 >140

BP Normal Normal BUT postural Hypo

Pulse pressure N

RR 14-20 20-30 30-35 35-40

Urine Output >30 20-30 5-15 Negligible

Fluid used crystalloids Crystalloids Crystalloids+ colloids

Crystalloids+ colloids

SABISTON TEXTBOOK OF SURGERY, 19th Edition

Assessment• In patients without shock, postural changes should be elicited

by allowing the patient to sit up with his or her legs dangling for 5 minutes. A fall in blood pressure of more than 10 mm Hg or an elevation of the pulse of more than 20 beats/min again reflects at least a 20% blood loss.

• Obtain CBC, electrolytes, BUN/Cr, PT INR/ APTT, blood type, and cross-match.

Resuscitation • Initiate resuscitation with crystalloid intravenous fluids with the use of “

LARGE BORE(green/Gray)” IV-access catheters

• PRBC – If tachycardia or hypotension is present – If the hemoglobin level is less than 10 g per deciliter. Patients who received

transfusion within 12 h of presentation had a twofold increased rate of re-bleeding (OR 2.26; 95% CI 1.76–2.90) and a 28% increase in mortality (OR 1.28; 95% CI 0.94–1.74) compared to those not early transfused.

• Oxygen

• Consideration of intubation if airway protection is indicated

• correction of coagulopathy (deranged LFT)

Hearnshaw SA, Logan RF, Palmer KR, Card TR, Travis SP, Murphy MF.Aliment Pharmacol Ther. 2010 Jul;32(2):215-24.

NG tube aspirate

American Society For Gastrointestinal Endoscopy

Pharmacotherapy Prior to Endoscopy

• Consider initiating treatment with an IV PPI (80-mg bolus dose plus continuous infusion at 8 mg/hr) while awaiting early endoscopy– Down-staging of endoscopic lesions by stabilizing clot with decrease

need for endoscopic therapy (19 % vs. 28% p value 0.007)– Not have an effect on outcomes (mortality , re-bleeding , transfusion

requirement )

• No role for H2 blocker

• ?Octretide

Clinical Predictors of Poor Outcomes

• Older age (>60years)• Severe co-morbidity• Active bleeding• Hypotension or shock• RBC transfusion6 unit• Inpatient bleeding• Severe coagulopathy

Adler DG et al. Gastrointest Endosc 2004; 60:497-504

Risk-Stratification Tools for Upper Gastrointestinal Hemorrhage

?Timing of endoscopy• Should be performed within 24 hours for all patient

who present with F/o UGI bleed (Index-endoscopy) • Improve certain outcomes

– the number of units of blood transfused– the length of the hospital stay

• Treatment recommendations have focused on the first 72 hours after presentation and endoscopic evaluation and therapy, since this is the period when the risk of rebleeding is greatest (90 %)

?Timimg

Soon after initial resuscitation and initiation of medical therapy, urgent endoscopy is the preferred procedure for diagnosis and treatment because of its high accuracy and low complication rate.

Gastrointest Endosc Clin N Am. 2011 October ; 21(4): . doi:10.1016/j.giec.2011.07.012.

Role of Endoscopy

• Diagnosis : 90-95% sensitive at locating bleeding site

• Prognosis : likelihood of persistent or recurrent

bleeding can be predicted

• Therapy : provide therapeutic options

( inject , burn ,clip )

Endoscopic risk assessment

Forrest grade Ia Forrest grade Ib

Forrest classification

Forrest grade IIa

Forrest grade IIc Forrest grade III

Forrest classification

Forrest grade IIb

Role of IV Erythromycin• May improve the quality of endoscopic exams in patients with

UGI hemorrhage by promoting the emptying of intragastric blood

• cost-effectiveness study confirmed that giving intravenous (IV) erythromycin prior to endoscopy for acute UGI bleeding resulted in cost savings and an increase in quality-adjusted life-years

• IV erythromycin is strongly recommended prior to endoscopy in patients with severe UGI haemorrhage, when clots or blood are anticipated and may obscure the bleeding site.

Winstead NS, Wilcox CM. Erythromycin prior to endoscopy for acute upper gastrointestinal hemorrhage: a cost-effectiveness analysis. Aliment Pharmacol Ther. 2007; 26:1371–1377.

Risk of re-bleeding acc. To SRH

High risk lesions

Indication of endoscopic therapy

Stigmata Endoscopic therapyActive bleeding YesNon-bleeding visible vessel YesAdherent clot YesFlat spot No Clean base No

Risk stratification by ‘EDUP’

• Endoscopic Doppler ultrasound probe (EDUP) technology has been used to interrogate nonvariceal and variceal bleeding lesions

• DUP uses a small (2 mm diameter), flexible pulsed-wave, 16 or 20-MHz probe that is passed through the endoscope’s biopsy channel directly onto the bleeding lesion

EDUP• The output signal is expressed as an audible signal

• Based on EDUP signal, scanning depths, and DUP placement on the lesion, this technology permits evaluation of arterial or venous blood flow, depth of the blood vessel and position of the blood vessel

• Use of DUP has shown that most NBVVs demonstrate an arterial signal while some ulcers with a clean base or pigmented spot also show an underlying arterial signals

• Persistence of a positive Doppler signal after endoscopic treatment correlates with the potential for rebleeding. Therefore, endoscopic DUP may be a useful guide to the completion of hemostasis

• If endoscopic treatment is continued until the underlying blood flow signal is extinguished the rebleeding rate of NVGIB is very low

Research on EDUP• A prospective study in a group of severely

bleeding ulcer patients with active arterial bleeding, NBVV and adherent clot, showed that EDUP–Guided endoscopic treatment provided a significantly reduced rate of recurrent hemorrhage at 30 days than standard therapy based on endoscopic stigmata alone

Jensen DM, Ohning GV, Singh B, et al. For severe UGI hemorrhage Doppler ultrasound probe is more accurate and helpful for complete endoscopic hemostasis than lesion stigmata alone Gastrointest Endosc. 2008; 67:AB81.

Research on EDUP

• A decision-analysis comparing EDUP of acute ulcer hemorrhage with standard treatment, demonstrated an average cost savings ranging from $560 to $1160 per patient in the EDUP-directed group

Chen V, Wong RCK. Endoscopic Doppler Ultrasound versus Endoscopic Stigmata – directed management of acute peptic ulcer hemorrhage: a multimodel cost analysis. Dig Dis Sciences. 2007; 52:149–160.

Summary: EDUP

1. There is a close correlation between a positive signal and endoscopic stigmata

2. EDUP-positive ulcers are more likely to rebleed than EDUP-negative ulcers

3. persistence of a EDUP-positive signal in ulcers after endoscopic coagulation results in an increased risk of ulcer rebleeding.

Endoscopic therapyIdeal Endoscopic hemostasis technique - 1. Reproducible effectiveness2. Easy & rapid application3. Low complication rates4. Low cost5. Portability to bedside6. Widespread availability

Injection therapy• Epinephrine (1:10000 or 1:20000 in saline)

• provides local tamponade, vasoconstriction, and improved platelet aggregation to promote hemostasis

• Other injectables- alcohol, ETHn, polidocanol, tissue glue, fibrin glue, CYN- Not recommended (not evaluated for use)

• The technique involves injection through a sclerotherapy catheter with a 25-gauge retractable needle in 4 quadrants around actively bleeding point or non-bleeding vessel

• Dilute epinephrine/saline solution (1:10,000 – 1:20,000) is injected in 0.5–1.5 ml increments up to a total of 25 – 30 ml.

Injection therapy

• Large-volume injection (>13 mL) is associated with better hemostasis, suggesting that the endoscopic injection works in part by compressing the bleeding vessel and inducing tamponade

Lin HJ, Hsieh YH, Tseng GY, et al: A prospective, randomized trial of large- versus small-volume endoscopic injection of epinephrine for peptic ulcer bleeding. Gastrointest Endosc 55:615 619, 2002

• Should not use alone

Endoscopic Electrocoagulation• Monopolar, bipolar and MPEC

• In bipolar/MPEC current flow in between two or more electrodes separated by 1 to 2 mm at the probe tip

• Current flow is concentrated closer to the tip than with a monopolar probe, providing less depth of tissue injury and lesser potential for perforation

• Coaptive coagulation directly gives pressure on the stigmata temporarily interrupts blood flow through the underlying vessel, reduces the heat sink effect, and with application of heat can coaptively seal arteries up to 2 mm in diameter

• MPEC coagulation is effective for treatment of actively bleeding ulcers, NBVV or adherent clot and prevention of rebleeding by coaptively coagulating the artery underlying these SRH

Mechanical Hemostasis• Metallic clips (endoclips), endoloops, and rubber band ligation

• Grasp into the submucosa, seal the underlying patent blood vessels, and/or approximates the sides of lesions during endoscopy

• The clips can produce hemostasis similar to surgical ligation, if properly applied

• Placement of 2 additional clips to ligate proximally and distally from the bleeding point to occlude the underlying artery is recommended

• Endoclipping may be limited by the vessel size (> 2 mm in diameter), difficulty in accessing ulcers (such as proximal lesser curve of the stomach, posterior wall gastric body and posterior duodenal bulb), fibrotic lesions and single clip deployment

Combined therapy• The technique involves dilute epinephrine injection into four

quadrants around stigmata in the ulcer base followed by thermal coagulation with heater probe or multipolar probe, or deployment of endoclips

• Combination therapy has become the standard treatment for actively bleeding ulcers and non-bleeding adherent clot

• Results of meta-analysis reported that dual therapy achieved significantly better outcomes than epinephrine injection alone

Marmo R, Rotondano G, Piscopo R, et al. Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials. Am J Gastroenterol. 2007; 102:279–289

RECOMMENDATIONS FOR ENDOSCOPIC THERAPY

• Combination therapy with epinephrine injection (1:10,000 or 1:20,000 in saline) and thermal coagulation (multipolar or heater probe) or hemoclipping is recommended

• Successful endoscopic hemostasis occurs in nearly 100% of lesions


• If oozing from an ulcer base persists despite irrigation and observation, monotherapy with thermal probes or hemoclipping is effective

• Rebleeding rates are less than 5%


• Monotherapy with thermal coagulation (heater or multipolar probe) is effective if coaptive coagulation is done

• Hemostasis of NBVV with hemoclips provides similar beneficial outcomes as thermal therapy


• Combination therapyFour-quadrant dilute epinephrine injection close

to the attachment of the clot, in the ulcer base

A rotatable polypectomy snare is used to shave down the clot

Thermal coaptive coagulation or hemoclipping to treat the residual clot or NBVV

Rebleeding rate for adherent non bleedingclots was less than 5% (CURE Trial)


No benefit from endoscopic hemostasis, since patients with these endoscopic findings have a very low rebleeding rate – 7% and 3 % respectively on medical therapy alone

Limitation of endoscopic therapy challenging lesions

• Large ulcer defect more than 2cm • Visible vessel more than 2 mm• Inaccessible lesions • Challenging positions ( posterior wall

stomach ,lesser curve , posterior bulbar wall)• Fibrotic base for hemoclip

Outcome of Endoscopic Management

• Hemostasis>95%• Recurrent bleeding<15%• Death 6-8% (irrespective of any optimal

endoscopic & medical treatment)

Barkun A et al. Ann Intern Med 2003; 139:843-5,

Cipolletta L et al. Endoscopy 2007; 39:7-10

Treat the patient and Not just the source of bleeding

COMPLICATIONS

• perforation or precipitation of bleeding from a NBVV

• In a meta-analysis pooled rates for complications associated with endoscopic treatment were 0.8%

• perforations occurred significantly more frequently in patients receiving combination treatment, such as injection plus thermal coagulation or dual injection (epinephrine followed by a sclerosant) than single therapy

• Perforations were more frequent after endoscopic retreatment with thermal coagulation

Hemospray

Hemospray

• Hemospray, a novel modality, is a inorganic powder, has recently been approved in Canada for the management of nonvariceal upper gastrointestinal bleeding (UGIB)

It achieves hemostasis by adhering to the bleeding site, which leads to mechanical tamponade and, by concentrating and activating platelets and coagulation factors, promotes thrombus formation

Hemospray

95% acute hemostasis

Sung JJ Endoscopy. 2011 Apr;43(4):291-5. Epub 2011 Mar 31.

http://www.ncbi.nlm.nih.gov/pubmed?term=Sung%20JJ%5BAuthor%5D&cauthor=true&cauthor_uid=21455870

http://www.ncbi.nlm.nih.gov/pubmed/21455870/

Hemospray• conventional endoscopic therapies may not be feasible in patients with

active multifocal bleeding sites, particularly those with challenging anatomy and coagulopathy, in which contact coagulation efforts may be hampered by further tissue damage and induction of more bleeding . In contrast, Hemospray can quickly cover large areas and does not require en face view or direct contact with the bleeding lesion

• Hemospray appears to allow safe control of acute bleeding and may be used in high-risk cases as a temporary measure or a bridge toward more definitive therapy

AHL Yau, G Ou, C Galorport, et al. Safety and efficacy of Hemospray® in upper gastrointestinal bleeding. Can J Gastroenterol Hepatol 2014;28(2):72-76.

surgery• Despite significant advances in endoscopic therapy,

approximately 10% of patients with bleeding ulcers still require surgical intervention for effective hemostasis

• Ulcers larger than 2 cm, posterior duodenal ulcers, and gastric ulcers have a significantly higher risk of rebleeding

• Patients with these characteristics need closer monitoring and possibly earlier surgical intervention

• Essentially all patient with bleeding peptic ulcer should undergo UGIE prior to the consideration of surgical therapy Shackelford’s SURGERY of the ALIMENTARY TRACT

Indication

1. Hemodynamic instability despite vigorous resuscitation (>6 U transfusion)

2. Failure of endoscopic techniques to arrest hemorrhage

3. Recurrent hemorrhage (with up to two attempts at obtaining endoscopic hemostasis)

4. Shock associated with recurrent hemorrhage5. Continued slow bleeding with a transfusion

requirement >3 U /dayShackelford’s SURGERY of the ALIMENTARY TRACT

Relative Indication

• Rare blood type or difficult crossmatch,• Refusal of transfusion• Shock on presentation• Advanced age• Severe comorbid disease • A bleeding chronic gastric ulcer for which

malignancy is a concern.

Shackelford’s SURGERY of the ALIMENTARY TRACT

AIM

• First priority at operation should be control of the hemorrhage

• A decision must be made regarding the need for a definitive acid-reducing procedure

• ?H. Pylori treatment


Surgery for Bleeding DU• A pyloroduodenotomy is necessary to inspect the duodenal bulb and

gastric antrum. The gastroduodenal artery is the usual source of bleeding, which should be controlled by placement of suture ligatures

• Once the bleeding has been addressed, a definitive acid-reducing operation may be performed. With the identification of H. pylori, the utility of a vagotomy has been questioned.

• The data, however, suggest that, even in the era of H. pylori and our ability to eradicate it, a TV perhaps should be performed in those patients with a bleeding duodenal ulcer.


?TV• 1. Only 40% to 70% of patients with a bleeding duodenal ulcer are

positive for H. pylori.

• 2. H. pylori testing in the setting of an acute hemorrhage is less reliable, with the CLO (Campylobacter-like organism) test having a false-negative rate of 18% versus 1% in those not actively bleeding.

• 3. If an acid-reducing procedure is not performed, up to 50% of patients are at risk of recurrent bleeding.

• 4. Conflicting evidence that H. pylori treatment changes the risk of recurrent bleeding


• TV with pyloroplasty is the most frequently used operation for bleeding duodenal ulcer

• In most cases the bleeding will have been localized to the first part of the duodenum and the bleeding vessel can be controlled


procedure• Upper midline laparotomy, entering the peritoneal

cavity• A Kocher manoeuvre is then performed to mobilize

the duodenum. This gives better exposure and relieves any tension on the subsequent suture line

• The pyloric vein of Mayo is virtually always present on the anterior surface of the inferior pylorus

• Two 3-0 silk traction sutures are placed astride the anterior pylorus and parallel to each other

Fischer's mastery of surgery 6th edn

• While lifting up on the traction sutures, a longitudinal incision is made through the pyloric muscles and extended 2 to 3 cm proximally into stomach and distally into duodenum

• The duodenal mucosa is inspected for any evidence of active bleeding, ulceration, or induration

• If active bleeding is encountered, this is controlled by digital pressure

• The bleeding vessel is then ligated.

• This vessel is often the gastroduodenal artery• This vessel at the level of the posterior

duodenal wall has a T or three-vessel junction.

• It is important to suture ligate the gastroduodenal artery superiorly and inferiorly, followed by ligation of the medial transverse pancreatic branches using a U-stitch

• Care should be taken to avoid injury to the common bile duct during suture placement

• After gaining control of the bleeding, the pyloroplasty is performed. Most often this is done as a Heineke- Mikulicz pyloroplasty

• If the duodenum is soft, pliable, and minimally deformed, a running closure of the inside layer is done using absorbable suture in an inverting fashion

• An outside Lembert layer of 4-0 silk sutures in an interrupted fashion completes the procedure

• Some prefer a single-layer closure because of the potential risk of obstruction associated with a two-layer closure and the possibility of inverting an excess amount of mucosa

• The procedure is then completed by performing a TV

?HSV• In experienced hands, HSV may represent the best therapy

for a bleeding duodenal ulcer

• Several reports have shown that even in the setting of an acute hemorrhage this procedure can be done safely with good long-term results if surgeon has significant experience with the operation

• As a result, more traditional expedient operation with proven efficacy such as TV with pyloroplasty is recommended over HSV

Vagotomies

If D1 is completely shattered by large duodenal ulcer

Billroth I gastroduodenal anastomosis might be needed.

World Journal of Emergency Surgery Di Saverio et al. 2014, 9:45

Re-bleeding after Surgery

• Several authors have advocated STAE as a viable alternative to operative treatment for ulcer bleeding after surgery

• Data from two large series suggest that TAE can achieve long-term hemostasis in roughly 75% of patients with recurrent bleeding after duodentomy and ulcer oversewingEriksson LG, Ljungdahl M, Sundbom M, et al. Transcatheter arterial embolization versus surgery

in the treatment of upper gastrointestinal bleeding after therapeutic endoscopy failure. J VascInterv Radiol. 2008; 19(10):1413–1418. [PubMed: 18755604]Holme JB, Nielsen DT, Funch-Jensen P, et al. Transcatheter arterial embolization in patients withbleeding duodenal ulcer: an alternative to surgery. Acta Radiol. 2006; 47(3):244–247. [PubMed:16613304]

Re-bleeding after Surgery

• Despite the best surgical efforts, re-bleeding after surgery occurs in between 6–17% of cases

• Endoscopic therapy- not recommended after Sx• Two options- reoperation or STAE• Reoperation when considered in past it was ulcer

excision+ Billroth I GDA

Millat B, Hay JM, Valleur P, et al. Emergency surgical treatment for bleeding duodenal ulcer:oversewing plus vagotomy versus gastric resection, a controlled randomized trial. FrenchAssociations for Surgical Research. World J Surg. 1993; 17(5):568–573. discussion 574.[PubMed: 8273376]

Poxon VA, Keighley MR, Dykes PW, et al. Comparison of minimal and conventional surgery inpatients with bleeding peptic ulcer: a multicentre trial. Br J Surg. 1991; 78(11):1344–1345.[PubMed: 1760699]

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bleeding duodenal ulcer

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