Page 1478 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 105: Gastrointestinal Hemorrhage 1017

patient in whom medical management has failed to heal or prevent The endoscopic treatment of choice is a combination of epinephrine
recurrence of peptic ulceration, particularly if there have been previous injection therapy and thermal coagulation. Also, endoscopic band
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complications attributable to PUD, such as bleeding. The patient who ligation has been used successfully to achieve hemostasis in bleeding
has recurrent hemorrhage owing to noncompliance with maintenance Dieulafoy lesions. 80,81 Endoscopic clipping has also been used with simi-
ulcer therapy should be considered for elective surgical therapy once lar efficacy. The risk of rebleeding after endoscopic therapy remains
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bleeding has stopped. It should be emphasized that surgical morbidity high (up to 40% in some reports) owing to the usually large size of the
and mortality are greatly reduced when the surgeon operates electively underlying artery. In the event of rebleeding, repeat endoscopic inter-
in the nonbleeding patient. Therefore, successful initial hemostasis vention may be attempted, following which surgical wedge resection of
using endoscopic and pharmacologic therapy is preferable prior the lesion should be performed to achieve permanent hemostasis.
to surgical intervention. In the setting of hemorrhage refractory to
nonsurgical intervention, stabilization of cardiopulmonary status and ■ STRESS-RELATED MUCOSAL DAMAGE
optimization of hematologic parameters prepare the patient for emer-
gent surgery and improve postoperative outcome. Stress-related mucosal damage (SRMD), also referred to as stress ulcers
The choice of surgical procedure depends on the location of the ulcer or stress-related erosive syndrome (SRES), is the result of multiple organ
and on the stability of the patient. In the patient with an actively bleed- system failure in the critically ill patient. The incidence of hemorrhage
ing duodenal ulcer undergoing an emergent operation, the bleeding due to SRMD appears to be decreasing, probably as a result of significant
point of the ulcer will be oversewn and truncal vagotomy and pyloro- advances in the intensive care management of the critically ill patient,
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plasty performed. Vagotomy and antrectomy may be considered if the including optimization of hemodynamic status and tissue oxygenation,
patient has been stabilized adequately. In the setting of exsanguinating and the early initiation of stress ulcer prophylaxis. However, in the event
hemorrhage from gastric bleeding, gastric resection may be considered, of SRMD-induced hemorrhage, the mortality rate is greater than 30%
but this procedure carries a high mortality of approximately 50%. owing to the difficulty in controlling such bleeding and the poor prog-
Selective vagotomy with either pyloroplasty or antrectomy, an option in nosis of the underlying disease. With regard to etiology, gastric mucosal
the elective situation, is not advisable in an unstable patient. ischemia secondary to systemic (and splanchnic) hypoperfusion is con-
Gastric ulcer bleeding is treated with the same approach as a bleeding sidered to be the major inciting factor, with acid and pepsin assuming
duodenal ulcer, except that resection is recommended if the situation minor roles. Of note, acid and pepsin secretion are normal to low in
permits. Partial gastrectomy carries a slightly lower mortality in the most critically ill patients, and increased gastric acidity is observed only
setting of gastric ulcer bleeding than when performed for a bleeding in patients exhibiting Cushing ulcers related to central nervous system
duodenal ulcer. Resection for an actively bleeding gastric carcinoma is (CNS) trauma or infection.
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recommended only when performed electively because it is a prolonged Bleeding from SRMD may be overt and significant, resulting in
procedure that may be unsuitable for an unstable patient. hemorrhage and hemodynamic compromise, or occult and minimal,
Following surgical intervention for bleeding peptic ulcers, mortality detectable only by Gastroccult testing of the gastric contents. Although
approaches 30%, with postoperative wound infection being the major occult bleeding due to SRMD may occur frequently in critically ill
complication. patients, it is of little clinical significance because few of these patients
progress to overt bleeding. Multiple studies have attempted to assess the
Secondary Prophylaxis: Once successful hemostasis is achieved, sec- relative importance of the underlying disease processes and biochemical
ondary prophylaxis is initiated to prevent recurrent ulcer bleeding, abnormalities in inducing SRMD. 84,85 Two major risk factors identified
especially following nonsurgical hemostatic therapy. If histologic or are coagulopathy and mechanical ventilation for greater than 48 hours.
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nonhistologic evaluation for H pylori is positive, appropriate treatment Other suggested risk factors include sepsis, hypotensive shock, acidosis,
should be initiated because this reduces the long-term (1-year) rate of peritonitis, extensive burns, hepatic failure, and renal failure, with mul-
rebleeding from gastric or duodenal ulcers. In addition to initiating a tiple risk factors having an additive effect on the probability of SRMD.
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course of treatment, documenting eradication of H pylori is indicated. Endoscopically, SRMD may appear as multiple shallow erosions or
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In addition, long-term acid suppressive therapy with oral H RAs or submucosal hemorrhage during the early stages. After the first several
2
PPIs is indicated, and nonsteroidal anti-inflammatory drugs (NSAIDs) days of the ICU course, SRMD lesions are characterized by multiple,
should be avoided. deeper, acute ulcerations, predominantly in the gastric lesser curvature
■ MALLORY-WEISS TEAR or fundus, and these lesions can erode into the submucosa, causing mas-
sive hemorrhage. Bleeding usually manifests as oozing of blood from
Mallory-Weiss tear generally is a self-limited cause of nonvariceal the margins of these lesions. However, submucosal penetration can
bleeding, rarely requiring more than supportive intervention. However, cause hemorrhage from a major artery, with the typical endoscopic
patients with portal hypertension are at increased risk of massive appearance of an ulcer with a visible vessel.
bleeding from Mallory-Weiss tears compared with those with normal Therapy: The mainstay of therapy for SRMD is supportive, with an
portal pressures. In the rare instance of continued bleeding from a attempt to reverse the underlying precipitating factors. Acid suppression
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Mallory-Weiss tear in a patient without portal hypertension, endoscopic in the form of intravenous H RAs or PPIs may be used as adjunctive
therapy with either thermal coagulation or injection therapy should be therapy to endoscopic or angiographic intervention. The role of endo-
2
attempted prior to surgical oversewing of the lesion. In the presence scopic therapy in SRMD may be limited because the lesions usually are
of portal hypertension, thermal coagulation may worsen the bleeding; diffuse and not amenable to directed therapy. However, in the setting of
therefore, band ligation or sclerotherapy should be performed. Following a single dominant lesion or a few bleeding lesions, endoscopic therapy
hemostasis, acid-suppression therapy with H RAs or PPIs may be given may achieve successful hemostasis in 90% of such cases. Therapeutic
2
as adjunctive therapy to accelerate healing. angiography is recommended for bleeding that is refractory to endo-
■ DIEULAFOY LESION scopic therapy. Both intra-arterial vasopressin therapy and embolo-
therapy are equally successful at controlling hemorrhage without major
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A Dieulafoy lesion is a dilated aberrant submucosal vessel of unclear ischemic complications owing to the rich collateral blood supply of the
etiology that erodes the overlying epithelium in the absence of a primary gastric mucosa. Since the left gastric artery is the source in most cases of
ulcer. It is usually located along the high lesser curvature of the stomach SRMD-induced bleeding, this vessel is a convenient target for emboliza-
near the gastroesophageal junction, although it has been found in all tion therapy.
areas of the GI tract, including the esophagus and duodenum. Massive Surgery usually should be avoided because a near-total gastrectomy
bleeding can occur when the eroding submucosal vessel is an artery. is required in most instances, and mortality exceeds 50%. Gastrectomy

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