Upper gastrointestinal bleeding surgery

Upper gastrointestinal bleeding Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Upper Gastrointestinal Bleeding from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography and Ultrasound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Management Initial resuscitation Pharmacotherapy Risk stratification
Surgery Surgical Management Endoscopic Intervention
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Guidelines for Management
Case Studies
Case #1
Upper gastrointestinal bleeding surgery On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Upper gastrointestinal bleeding surgery All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Upper gastrointestinal bleeding surgery
CDC on Upper gastrointestinal bleeding surgery
Upper gastrointestinal bleeding surgery in the news
Blogs on Upper gastrointestinal bleeding surgery
Directions to Hospitals Treating Upper gastrointestinal bleeding
Risk calculators and risk factors for Upper gastrointestinal bleeding surgery

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

Surgery

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.
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).
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.
  

Indications

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

Complications

• 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).
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

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