Haematemesis
and melaena
Upper gastrointestinal haemorrhage remains a
major medical problem and in spite of improvements in diagnosis and the
proliferation in treatment modalities over the last few decades is still
attended by significant mortality. A hospital mortality in the region of 5
per cent can be expected. In patients in whom the cause of bleeding can be
found the most common causes are bleeding peptic ulcer, erosions,
Mallory—Weiss tear and bleeding oesophageal varices (Table 51.4).
Whatever
the cause the principles of management are identical. First, the patient
should be adequately resuscitated and following this investigated urgently to
determine the cause of the bleeding. Only then should treatment of a definitive
nature be instituted. For any significant gastrointestinal bleed intravenous
access should be established and, for those with severe bleeding, central venous
pressure monitoring set up and bladder catheterisation performed. Blood should
be cross matched and the patient transfused as clinically indicated. As a
general rule most gastrointestinal bleeding will stop, albeit temporarily, but
there are sometimes instances when this is not the case. In these circumstances
resuscitation, diagnosis and treatment should be carried out in quick
succession. There are occasions when life-saving manoeuvres have to be
undertaken without the benefit of an absolute diagnosis. For instance, in
patients with known oesophageal varices and uncontrollable bleeding, a
Sengstaken—Blakemore tube may be inserted before an endoscopy has been carried
out. This practice is not to be encouraged, except in extremis. In some patients bleeding is secondary to a
coagulopathy. The most important current causes of this are liver disease and
inadequately controlled warfarin therapy. In these circumstances the
coagulopathy should be corrected, if possible, with fresh frozen plasma.
Upper
gastrointestinal endoscopy should be carried out by an experienced operator as
soon as practicable after the patient has been stabilised. In patients in whom
the bleeding is relatively mild, endoscopy may be carried on the morning after
admission. In all cases of severe bleeding it should be carried out immediately.
Bleeding peptic
ulcers
The epidemiology of bleeding peptic ulcers
exactly mirrors that of perforated ulcers. The population affected has in recent
years become much older and the bleeding is
Medical and minimally interventional treatments
Medical treatment has limited efficacy. All
patients are commonly started on either an H2 antagonist or a
proton pump antagonist, but well-performed studies have failed to show that such
treatments influence rebleeding, operation rate or mortality. Meta-analysis of
studies, however, does suggest that tranexamic acid, an inhibitor of
fibrinolysis, reduces the rebleeding rate. Octreotide, a somatostatin analogue,
has not proved effective.
Numerous
endoscopic devices are now available which can be used to achieve haemostasis
ranging from expensive lasers to inexpensive injection apparatus. There are few
conclusive studies available but a review of the literature suggests that these
modalities may have some utility, although they will probably never be effective
in patients who are bleeding from large vessels and with which the majority of
the mortality associated with the condition is associated.
Surgical treatment
Criteria for surgery are well worked out. A
patient who continues to bleed requires surgical treatment. The same applies
to a significant rebleed. Patients with a visible vessel in the ulcer base, a
spurting vessel or an ulcer with a clot in the base are statistically likely to
require surgical treatment to stop the bleeding. Elderly and unfit patients are
more likely to die as a result of bleeding than younger patients. Ironically,
they should have early surgery. A patient who has required more than 6 units of
blood in general needs surgical treatment. Various scoring systems have been
devised which predict the probability of rebleeding and mortality with some
degree of accuracy.
The
aim of the operation is to stop the bleeding. The advent of endoscopy has
greatly helped in the management of upper gastrointestinal bleeding as a surgeon
can usually be confident about the site of bleeding prior to operation. The most
common site of bleeding from a peptic ulcer is the duodenum. In tackling this
it is most important essential that the duodenum is fully Kocherised. This
should be done before the duodenum is opened as it makes the ulcer much more
accessible and also allows the surgeon’s hand to be placed behind the
gastroduodenal artery that is commonly the source of major bleeding. Following
mobilisation, the duodenum and usually the pylorus are opened longitudinally as
in a pyloroplasty. This allows good access to the ulcer, which is usually
found posteriorly or superiorly. Accurate haemostasis is important. It is the
vessel within the ulcer that is bleeding and this should be controlled using
well-placed sutures which under run the vessel. The placing of more and more
inaccurately positioned sutures is counter productive. Following under running it is possible often to close
the mucosa over the ulcer. The pyloroplasty is then closed with interrupted
sutures in a transverse direction as in the usual fashion.
The
principles of management of bleeding gastric ulcers are essentially the same.
The stomach is opened at an appropriate position anteriorly and the vessel in
the ulcer under run. If the ulcer is not excised then a biopsy of the edge
needs to be taken to exclude malignant transformation. Sometimes the bleeding is
from the splenic artery and if there is a lot fibrosis present then the
operation may be challenging. Most patients, however, can be managed by
conservative surgery. Gastrectomy for bleeding has been widely practised in the
past but is attended by higher levels of perioperative mortality even if the
incidence of recurrent bleeding is less.
Much
argument still remains about the use of definitive acid-lowering operations
versus haemostatic surgery alone. Bearing in mind that most patients nowadays
are elderly and unfit, the minimum surgery that stops the bleeding is probably
optimal. Acid can be inhibited by pharmacological means and appropriate
eradication therapy will prevent ulcer recurrence. Patients on long-term NSAIDs
can be managed as outlined earlier.
Stress
ulceration
This commonly occurs in patients with major
injury or illness, who have undergone major surgery or who have major
comorbidity. Previously, many such patients were to be found in intensive care
units. There seems little doubt that the incidence of this problem has reduced
in recent years owing to the widespread use of prophylaxis. Ranitidine has been
shown to reduce the incidence of stress ulceration, as has the nasogastric
administration of sulcrafate. There is no doubt that the prevention of this
condition is far better than trying to treat it once it occurs. Endoscopic means
of treating stress ulceration may be ineffective and operation required. The
principles of management are the same as for the chronic ulcer.
Gastric
erosions
Erosive gastritis has a variety of causes,
especially NSAIDs. Fortunately, most such bleeding settles spontaneously but
when it does not it can be a major problem to treat. In general terms,
although there is a diffuse erosive gastritis, there is one (or more) specific
lesion which has a significant sized vessel within it. This should be dealt with
appropriately, preferably endoscopically, but sometimes surgery is necessary.
Mallory—Weiss
tear
This is a longitudinal tear below the gastro-oesophageal
junction, which is induced by repetitive and strenuous vomiting. Doubtless,
many such lesions occur and do not cause bleeding. When it is a cause of
haematemesis the lesion may often be missed as it can be difficult to see as it
is just below the gastro-oesophageal junction, a position that can be difficult
Dieulafoy’s
disease
This is essentially a gastric arterial venous
malformation that has a characteristic histological appearance. Bleeding due to
this malformation is one of the most difficult causes of upper gastrointestinal
bleeding to treat. The lesion itself is covered by normal mucosa and, when not
bleeding, it may be invisible. If it can be seen whilst bleeding all that may be
visible is profuse bleeding coming from an area of apparently normal mucosa. If
this occurs cause is instantly recognisable. If the lesion can be identified
endoscopically there are various means of dealing with it, including injection
of sclerosant. If it is identified at operation then only a local excision is
necessary. Occasionally a lesion is only recognised after gastrectomy and
sometimes not even then. The pathologist, as well as the endoscopist, may have
difficulty in finding it.
Tumours
All of the gastric tumours described below may
present with chronic or acute upper gastrointestinal bleeding. Bleeding is not
normally torrential but can be unremitting. Gastric smooth muscle tumours
commonly present with bleeding and have a characteristic appearance, as the
mucosa breaks down over the tumour in the gastric wall (Fig.
51.26). Whatever
the nature, the tumours should be dealt with as appropriate.
Portal
hypertension and portal gastropathy
The management of bleeding gastric varices is
very challenging. Fortunately, most bleeding from varices is oesophageal and
this is much more amenable to sclerotherapy, banding and balloon tamponade.
Gastric varices may also be injected, although this is technically more
difficult. Banding can also be used, again with difficulty. The gastric balloon
of the Sengastaken—Blakemore tube can be used to arrest the haemorrhage if
it is occurring from the fundus of the stomach. Octreotide is a somatostatin
analogue which reduces portal pressure in patients with varices and trials
suggest that it is of value in arresting haemorrhage in these patients, although
its overall effect on mortality remains in doubt. Glypressin is also said to be
of use.
Most
surgeons prefer to avoid acute surgery on bleeding varices as, by contrast with
elective operations for portal hypertension, acute shunts are attended by
considerable operative mortality. For this reason the acute TIPSS procedure (transjugular
intrahepatic portosystemic shunt) which is described in Chapter 52 can be an
extremely useful, although technically demanding, procedure.
Portal
gastropathy
Portal gastropathy is essentially the same
disease process as described above. The mucosa is affected by the increased
portal pressure and may exude blood even in the absence of well-developed
visible varices. The treatment is as above.
Aortic enteric
fistula
This diagnosis should be considered in any
patient with haematemesis and melaena which cannot be otherwise explained.
Contrary to expectation, the bleeding from such patients is not always massive,
although it can be. Very often there is nothing much to distinguish the bleeding
from the aortic enteric fistula from any other recurrent upper gastrointestinal
bleeding. The vast majority of patients will have had an aortic graft and in the
absence of this the diagnosis is unlikely. However, it is occasionally seen in
patients with an untreated aortic aneurysm. A well-performed CT scan will
commonly allow the diagnosis to be made with certainty. The condition should be
managed by an expert vascular surgeon as, whether secondary or primary, the
morbidity and mortality are high.