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==Overview==
==Overview==
Surgery is the last resort in the management of upper GI bleeding. Surgical options include [[TIPS]], [[balloon tamponade]], and [[Laparotomy|emergency laparotomy]].


==Surgery==
==Surgery==
{| class="wikitable"
Surgery is the last resort in the management of upper GI bleeding. Surgical options include:
! colspan="2" |Surgical options for upper GI bleeding
*[[TIPS]]
*[[Balloon tamponade]]
*[[Laparotomy|Emergency laparotomy]]
===TIPS===
[[TIPS]] is a complex nonsurgical shunt which involves insertion of an expandable [[Stent|metal stent]] that bridges the [[hepatic vein]] and an intrahepatic branch of the [[portal vein]]. [[TIPS]] can halt bleeding in almost all patients, including those with bleeding refractory to other therapies.<ref name="pmid21326708">{{cite journal |vauthors=Ferral H, Bilbao JI |title=The difficult transjugular intrahepatic portosystemic shunt: alternative techniques and "tips" to successful shunt creation |journal=Semin Intervent Radiol |volume=22 |issue=4 |pages=300–8 |year=2005 |pmid=21326708 |pmc=3036298 |doi=10.1055/s-2005-925556 |url=}}</ref><ref name="pmid8264738">{{cite journal |vauthors=Rössle M, Haag K, Ochs A, Sellinger M, Nöldge G, Perarnau JM, Berger E, Blum U, Gabelmann A, Hauenstein K |title=The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding |journal=N. Engl. J. Med. |volume=330 |issue=3 |pages=165–71 |year=1994 |pmid=8264738 |doi=10.1056/NEJM199401203300303 |url=}}</ref><ref name="pmid7551988">{{cite journal |vauthors=Jalan R, Redhead DN, Hayes PC |title=Transjugular intrahepatic portasystemic stent-shunt in the treatment of variceal haemorrhage |journal=Br J Surg |volume=82 |issue=9 |pages=1158–64 |year=1995 |pmid=7551988 |doi= |url=}}</ref><ref name="pmid7696939">{{cite journal |vauthors=Jalan R, Redhead DN, Hayes PC |title=Transjugular intrahepatic portosystemic stent shunt |journal=Natl Med J India |volume=8 |issue=1 |pages=15–21 |year=1995 |pmid=7696939 |doi= |url=}}</ref>
====Indications====
*Uncontrolled variceal hemorrhage from esophageal, gastric, and intestinal varices that do not respond to endoscopic and medical management.
*Refractory ascites
*Hepatic pleural effusion
*Bridge to transplantation and retransplantation
*Budd-Chiari syndrome
*Hepatorenal syndrome (HRS)
*Veno-occlusive disease (VOD)
'''Procedure'''
*[[TIPS]] involves the percutaneous puncture of the right [[internal jugular vein]] and insertion of a vascular sheath into the [[inferior vena cava]] and the [[Hepatic veins|hepatic vein]].<ref name="pmid9146762">{{cite journal |vauthors=Stanley AJ, Redhead DN, Hayes PC |title=Review article: update on the role of transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of complications of portal hypertension |journal=Aliment. Pharmacol. Ther. |volume=11 |issue=2 |pages=261–72 |year=1997 |pmid=9146762 |doi= |url=}}</ref><ref name="pmid7551988">{{cite journal |vauthors=Jalan R, Redhead DN, Hayes PC |title=Transjugular intrahepatic portasystemic stent-shunt in the treatment of variceal haemorrhage |journal=Br J Surg |volume=82 |issue=9 |pages=1158–64 |year=1995 |pmid=7551988 |doi= |url=}}</ref>
*An [[angioplasty]] balloon catheter is used to dilate the tract between the hepatic and [[Portal vein|portal veins]], and a [[stent]] is then placed across the tract.
*Patients should undergo a baseline Doppler study within 24 hours of the procedure to document functional parameters, including the direction of portal vein flow and flow velocities throughout the shunt and within the hepatic vein. 
====Complications====
*[[Hepatic encephalopathy]]<ref name="pmid8290720">{{cite journal |vauthors=Freedman AM, Sanyal AJ, Tisnado J, Cole PE, Shiffman ML, Luketic VA, Purdum PP, Darcy MD, Posner MP |title=Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review |journal=Radiographics |volume=13 |issue=6 |pages=1185–210 |year=1993 |pmid=8290720 |doi=10.1148/radiographics.13.6.8290720 |url=}}</ref><ref name="pmid9163285">{{cite journal |vauthors=Sanyal AJ, Freedman AM, Luketic VA, Purdum PP, Shiffman ML, Cole PE, Tisnado J, Simmons S |title=Transjugular intrahepatic portosystemic shunts compared with endoscopic sclerotherapy for the prevention of recurrent variceal hemorrhage. A randomized, controlled trial |journal=Ann. Intern. Med. |volume=126 |issue=11 |pages=849–57 |year=1997 |pmid=9163285 |doi= |url=}}</ref><ref name="pmid3056820">{{cite journal |vauthors=Grace ND, Conn HO, Resnick RH, Groszmann RJ, Atterbury CE, Wright SC, Gusberg RJ, Vollman R, Garcia-Tsao G, Fisher RL |title=Distal splenorenal vs. portal-systemic shunts after hemorrhage from varices: a randomized controlled trial |journal=Hepatology |volume=8 |issue=6 |pages=1475–81 |year=1988 |pmid=3056820 |doi= |url=}}</ref>
*[[Hemolytic anemia]]
*Intra-abdominal bleeding during stent placement
 
===Balloon tamponade===
[[Balloon tamponade]] is only used as a temporary measure in patients who fail to respond to pharmacologic and endoscopic intervention. [[Balloon tamponade]] stabilizes patients until more definitive treatment can be instituted ([[TIPS]] or [[liver transplantation]]).<ref name="pmid10147943">{{cite journal |vauthors=Cook D, Laine L |title=Indications, technique, and complications of balloon tamponade for variceal gastrointestinal bleeding |journal=J Intensive Care Med |volume=7 |issue=4 |pages=212–8 |year=1992 |pmid=10147943 |doi=10.1177/088506669200700408 |url=}}</ref><ref name="pmid22514572">{{cite journal |vauthors=Tiuca N, Sztogrin W |title=The news of treatment of variceal upper gastrointestinal bleeding |journal=J Med Life |volume=4 |issue=4 |pages=395–8 |year=2011 |pmid=22514572 |pmc=3227155 |doi= |url=}}</ref><ref name="pmid1684947">{{cite journal |vauthors=Sauerbruch T, Fischer G |title=Conservative treatment of upper gastrointestinal bleeding in portal hypertension |journal=Hepatogastroenterology |volume=38 |issue=5 |pages=350–4 |year=1991 |pmid=1684947 |doi= |url=}}</ref><br>
====Procedure====
*[[Balloon tamponade]] involves the passage of a specialized [[Nasogastric tube|nasogastric tube,]] fitted with an inflatable balloon.<ref name="pmid2493628">{{cite journal |vauthors=Ashbridge KR, Booth RJ, Watson JD, Lathigra RB |title=Nucleotide sequence of the 19 kDa antigen gene from Mycobacterium tuberculosis |journal=Nucleic Acids Res. |volume=17 |issue=3 |pages=1249 |year=1989 |pmid=2493628 |pmc=331747 |doi= |url=}}</ref><ref name="pmid25177367">{{cite journal |vauthors=Cremers I, Ribeiro S |title=Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis |journal=Therap Adv Gastroenterol |volume=7 |issue=5 |pages=206–16 |year=2014 |pmid=25177367 |pmc=4107701 |doi=10.1177/1756283X14538688 |url=}}</ref>
*When the balloon is inflated, direct pressure staunches bleeding by compressing the [[varices]].
*Controls active bleeding in 80% to 90% of patients although rebleeding after balloon deflation is common.
====Indications====
*For bleeding varices that are refractory to banding or sclerosant injection.<br>
====Complications====
*Rebleeding upon balloon deflation
*[[Esophageal rupture]]
 
===Emergency laparotomy===
Emergency [[laparotomy]] is generally not indicated in the management of upper GI bleeding. Laparotomy is only performed as a last resort for  managing complications such as perforation. Emergency [[laparotomy]] includes open exploration of the abdomen, oversewing of the ulcer, [[truncal vagotomy]] and [[pyloroplasty]] .<ref name="pmid3338637">{{cite journal |vauthors=Gustavsson S, Kelly KA, Melton LJ, Zinsmeister AR |title=Trends in peptic ulcer surgery. A population-based study in Rochester, Minnesota, 1956-1985 |journal=Gastroenterology |volume=94 |issue=3 |pages=688–94 |year=1988 |pmid=3338637 |doi= |url=}}</ref><ref name="pmid8081927">{{cite journal |vauthors=Croce E, Azzola M, Golia M, Russo R, Angelini S, Contin G, Ubezio D, Pompa C |title=Laparoscopic posterior truncal vagotomy and anterior proximal gastric vagotomy |journal=Endosc Surg Allied Technol |volume=2 |issue=2 |pages=113–6 |year=1994 |pmid=8081927 |doi= |url=}}</ref>
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable"
! colspan="2" style="background:#efefef;" |Surgical options for upper GI bleeding
|-
|-
!Disease Process
! style="background:#efefef;" | Disease Process
!Surgical Options
! style="background:#efefef;" | Surgical Options
|-
|-
| rowspan="5" |Peptic ulcer disease
| rowspan="5" |[[Peptic ulcer disease]]
|Oversew
|Oversew
|-
|-
|3-point ligation of gastroduodenal artery
|3-point ligation of [[gastroduodenal artery]]
|-
|-
|Vagotomy and pyloroplasty
|[[Vagotomy]] and pyloroplasty
|-
|-
|Vagotomy and antrectomy
|[[Vagotomy]] and antrectomy
|-
|-
|Highly selective vagotomy
|Highly selective [[vagotomy]]
|-
|-
|Mallory-Weiss tear
|[[Mallory-Weiss tear]]
|Oversew
|Oversew
|-
|-
Line 31: Line 69:
|Wedge resection
|Wedge resection
|-
|-
| rowspan="3" |Varices
| rowspan="3" |[[Varices]]
|Portacaval shunt
|Portacaval shunt
|-
|-
Line 38: Line 76:
|Distal splenorenal shunt
|Distal splenorenal shunt
|-
|-
| rowspan="3" |Gastric cancer
| rowspan="3" |[[Gastric cancer]]
|Distal gastrectomy
|Distal [[gastrectomy]]
|-
|-
|Total gastrectomy
|Total [[gastrectomy]]
|-
|-
|D2 lymphadenectomy
|D2 [[lymphadenectomy]]
|-
|-
| rowspan="4" |Hemobilia
| rowspan="4" |[[Haemobilia|Hemobilia]]
|Selective ligation
|Selective ligation
|-
|-
|Resection of aneurysm
|Resection of [[aneurysm]]
|-
|-
|Nonselective ligation
|Nonselective ligation
|-
|-
|Liver resection
|[[Liver resection]]
|-
|-
| rowspan="3" |Aortoduodenal fistula
| rowspan="3" |Aortoduodenal fistula
|Angiography and stent (if hemodynamically stable)
|[[Angiography]] and [[stent]] (if hemodynamically stable)
|-
|-
|Open repair
|Open repair
Line 61: Line 99:
|Extra-anatomic bypass
|Extra-anatomic bypass
|}
|}
===TIPS===
TIPS is a complex nonsurgical shunt which involves insertion of an expandable metal stent that bridges the hepatic vein and an intrahepatic branch of the portal vein. TIPS can halt bleeding in almost all patients, including those with bleeding refractory to other therapies.<br>
'''Indications'''
*For treatment of bleeding varices that are refractory to banding or sclerosant injection.
*For treatment of refractory variceal bleeding as a bridge to liver transplantation.
'''Procedure'''
*TIPS involves the percutaneous puncture of the right internal jugular vein and insertion of a vascular sheath into the inferior vena cava and the hepatic vein.
*A needle is inserted through the sheath, into the liver parenchyma, and then into the portal vein.
*Aspiration of blood and injection of contrast media ensure accurate placement.
*An angioplasty balloon catheter is used to dilate the tract between the hepatic and portal veins, and a stent is then placed across the tract.
*Portal venography is used to confirm the placement
*Patients should be monitored closely for bleeding for 12 to 24 hours
'''Complications'''
*Hepatic encephalopathy
*Hemolytic anemia
*Intra-abdominal bleeding during stent placement
===Balloon tamponade===
Balloon tamponade is only used as a temporary measure in patients who fail to respond to pharmacologic and endoscopic intervention. Balloon tamponade stabilizes patients until more definitive treatment can be instituted (TIPS or liver transplantation).<br>
'''Procedure'''
*Balloon tamponade involves the passage of a specialized nasogastric tube, fitted with an inflatable balloon.
*When the balloon is inflated, direct pressure staunches bleeding by compressing the varices.
*Controls active bleeding in 80% to 90% of patients although rebleeding after balloon deflation is common.<br>
'''Indications'''<br>
*For bleeding varices that are refractory to banding or sclerosant injection.<br>
'''Complications'''<br>
*Rebleeding upon balloon deflation
*Esophageal rupture
===Emergency laparotomy===
Emergency laparotomy is performed as a last resort for complications such as bleeding and perforation. Emergency laparotomy involving open exploration of the abdomen, oversewing of the ulcer (to ligate the bleeding artery), plus truncal vagotomy (to decrease acid secretion) and pyloroplasty (for improved gastric drainage).<br>
'''Indications'''
*Treatment of bleeding ulcer that cannot be managed with endoscopy
*Treatment of patients who cannot tolerate endoscopy
'''Complications'''
*Risks of major surgery and general anesthesia
==Indications==


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Disease]]
[[Category:Disease]]

Latest revision as of 01:35, 9 January 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

Surgery is the last resort in the management of upper GI bleeding. Surgical options include TIPS, balloon tamponade, and emergency laparotomy.

Surgery

Surgery is the last resort in the management of upper GI bleeding. Surgical options include:

TIPS

TIPS is a complex nonsurgical shunt which involves insertion of an expandable metal stent that bridges the hepatic vein and an intrahepatic branch of the portal vein. TIPS can halt bleeding in almost all patients, including those with bleeding refractory to other therapies.[1][2][3][4]

Indications

  • Uncontrolled variceal hemorrhage from esophageal, gastric, and intestinal varices that do not respond to endoscopic and medical management.
  • Refractory ascites
  • Hepatic pleural effusion
  • Bridge to transplantation and retransplantation
  • Budd-Chiari syndrome
  • Hepatorenal syndrome (HRS)
  • Veno-occlusive disease (VOD)

Procedure

  • TIPS involves the percutaneous puncture of the right internal jugular vein and insertion of a vascular sheath into the inferior vena cava and the hepatic vein.[5][3]
  • An angioplasty balloon catheter is used to dilate the tract between the hepatic and portal veins, and a stent is then placed across the tract.
  • Patients should undergo a baseline Doppler study within 24 hours of the procedure to document functional parameters, including the direction of portal vein flow and flow velocities throughout the shunt and within the hepatic vein. 

Complications

Balloon tamponade

Balloon tamponade is only used as a temporary measure in patients who fail to respond to pharmacologic and endoscopic intervention. Balloon tamponade stabilizes patients until more definitive treatment can be instituted (TIPS or liver transplantation).[9][10][11]

Procedure

  • Balloon tamponade involves the passage of a specialized nasogastric tube, fitted with an inflatable balloon.[12][13]
  • When the balloon is inflated, direct pressure staunches bleeding by compressing the varices.
  • Controls active bleeding in 80% to 90% of patients although rebleeding after balloon deflation is common.

Indications

  • For bleeding varices that are refractory to banding or sclerosant injection.

Complications

Emergency laparotomy

Emergency laparotomy is generally not indicated in the management of upper GI bleeding. Laparotomy is only performed as a last resort for managing complications such as perforation. Emergency laparotomy includes open exploration of the abdomen, oversewing of the ulcer, truncal vagotomy and pyloroplasty .[14][15]

Surgical options for upper GI bleeding
Disease Process Surgical Options
Peptic ulcer disease Oversew
3-point ligation of gastroduodenal artery
Vagotomy and pyloroplasty
Vagotomy and antrectomy
Highly selective vagotomy
Mallory-Weiss tear Oversew
Dieulafoy lesion Oversew
Wedge resection
Varices Portacaval shunt
Mesocaval shunt
Distal splenorenal shunt
Gastric cancer Distal gastrectomy
Total gastrectomy
D2 lymphadenectomy
Hemobilia Selective ligation
Resection of aneurysm
Nonselective ligation
Liver resection
Aortoduodenal fistula Angiography and stent (if hemodynamically stable)
Open repair
Extra-anatomic bypass

References

  1. ↑ Ferral H, Bilbao JI (2005). "The difficult transjugular intrahepatic portosystemic shunt: alternative techniques and "tips" to successful shunt creation". Semin Intervent Radiol. 22 (4): 300–8. doi:10.1055/s-2005-925556. PMC 3036298. PMID 21326708.
  2. ↑ Rössle M, Haag K, Ochs A, Sellinger M, Nöldge G, Perarnau JM, Berger E, Blum U, Gabelmann A, Hauenstein K (1994). "The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding". N. Engl. J. Med. 330 (3): 165–71. doi:10.1056/NEJM199401203300303. PMID 8264738.
  3. ↑ 3.0 3.1 Jalan R, Redhead DN, Hayes PC (1995). "Transjugular intrahepatic portasystemic stent-shunt in the treatment of variceal haemorrhage". Br J Surg. 82 (9): 1158–64. PMID 7551988.
  4. ↑ Jalan R, Redhead DN, Hayes PC (1995). "Transjugular intrahepatic portosystemic stent shunt". Natl Med J India. 8 (1): 15–21. PMID 7696939.
  5. ↑ Stanley AJ, Redhead DN, Hayes PC (1997). "Review article: update on the role of transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of complications of portal hypertension". Aliment. Pharmacol. Ther. 11 (2): 261–72. PMID 9146762.
  6. ↑ Freedman AM, Sanyal AJ, Tisnado J, Cole PE, Shiffman ML, Luketic VA, Purdum PP, Darcy MD, Posner MP (1993). "Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review". Radiographics. 13 (6): 1185–210. doi:10.1148/radiographics.13.6.8290720. PMID 8290720.
  7. ↑ Sanyal AJ, Freedman AM, Luketic VA, Purdum PP, Shiffman ML, Cole PE, Tisnado J, Simmons S (1997). "Transjugular intrahepatic portosystemic shunts compared with endoscopic sclerotherapy for the prevention of recurrent variceal hemorrhage. A randomized, controlled trial". Ann. Intern. Med. 126 (11): 849–57. PMID 9163285.
  8. ↑ Grace ND, Conn HO, Resnick RH, Groszmann RJ, Atterbury CE, Wright SC, Gusberg RJ, Vollman R, Garcia-Tsao G, Fisher RL (1988). "Distal splenorenal vs. portal-systemic shunts after hemorrhage from varices: a randomized controlled trial". Hepatology. 8 (6): 1475–81. PMID 3056820.
  9. ↑ Cook D, Laine L (1992). "Indications, technique, and complications of balloon tamponade for variceal gastrointestinal bleeding". J Intensive Care Med. 7 (4): 212–8. doi:10.1177/088506669200700408. PMID 10147943.
  10. ↑ Tiuca N, Sztogrin W (2011). "The news of treatment of variceal upper gastrointestinal bleeding". J Med Life. 4 (4): 395–8. PMC 3227155. PMID 22514572.
  11. ↑ Sauerbruch T, Fischer G (1991). "Conservative treatment of upper gastrointestinal bleeding in portal hypertension". Hepatogastroenterology. 38 (5): 350–4. PMID 1684947.
  12. ↑ Ashbridge KR, Booth RJ, Watson JD, Lathigra RB (1989). "Nucleotide sequence of the 19 kDa antigen gene from Mycobacterium tuberculosis". Nucleic Acids Res. 17 (3): 1249. PMC 331747. PMID 2493628.
  13. ↑ Cremers I, Ribeiro S (2014). "Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis". Therap Adv Gastroenterol. 7 (5): 206–16. doi:10.1177/1756283X14538688. PMC 4107701. PMID 25177367.
  14. ↑ Gustavsson S, Kelly KA, Melton LJ, Zinsmeister AR (1988). "Trends in peptic ulcer surgery. A population-based study in Rochester, Minnesota, 1956-1985". Gastroenterology. 94 (3): 688–94. PMID 3338637.
  15. ↑ Croce E, Azzola M, Golia M, Russo R, Angelini S, Contin G, Ubezio D, Pompa C (1994). "Laparoscopic posterior truncal vagotomy and anterior proximal gastric vagotomy". Endosc Surg Allied Technol. 2 (2): 113–6. PMID 8081927.


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