Acute upper gastrointestinal hemorrhage is an acute hemorrhage in the upper gastrointestinal tract with the main symptom of vomiting blood or passing large amounts of tarry stools, which, if not controlled in time, will lead to hemorrhagic shock and death.
The most common causes of acute upper gastrointestinal hemorrhage are gastroduodenal ulcer; portal hypertension; acute gastric mucosal damage; limited intrahepatic infection, liver tumor and trauma. The diagnosis is not difficult when there is a typical medical history, obvious symptoms and signs, or when a definite localization of the lesion has been done preoperatively. However, there are cases of upper gastrointestinal hemorrhage due to the absence of typical symptoms and signs beforehand, sudden bleeding, or due to other rare causes, where the preoperative diagnosis is unclear and a caesarean section is required. This kind of exploration involves a series of problems in diagnosis, lesion treatment, and surgical mode selection, and is often prone to some mistakes.
I. Selection of the timing of surgical exploration
Surgical indications and the timing of surgery should be based on the patient’s age, disease duration, liver and kidney function, diagnosis, bleeding status and other specific circumstances before making a decision.
Generally speaking, the complication rate and mortality rate of surgery in the emergency state are much higher than those of elective surgery, and in cases where the preoperative diagnosis is unclear, it is sometimes difficult to make a clear diagnosis during the exploration, and the bleeding cannot be controlled after surgery. So it is important to discuss carefully before making a specific decision. According to statistics, in cases of upper gastrointestinal bleeding due to portal hypertension, the mortality rate of emergency bypass surgery is as high as about 30%, while the mortality rate of elective surgery is usually within 5%. For acute upper gastrointestinal bleeding due to ulcer disease, medical treatment should also be performed first, and emergency gastrectomy has a high operative mortality rate and a considerable number of recurrent bleeding cases after surgery.
Although the diagnostic accuracy of this disease has been improved since the adoption of fiberoptic endoscopy and angiography in recent times, cases in which even physicians with extensive clinical experience have difficulty in making a clear diagnosis during surgical dissection are common, and there are still 5.3-7.0% of cases in which the site of bleeding is not clear until autopsy.
Therefore, choosing the appropriate timing of surgery is the key to reducing surgical errors. According to general experience, the following cases can be considered for surgical dissection.
1, rapid transfusion of 600 to 800 ml of blood within 8 hours while the circulatory status is still unstable.
2. Those with stable blood pressure followed by sudden bleeding.
3.The amount of circulating red blood cells is reduced to less than 40% of the normal value.
4.Patients who are over 50 years old with arteriosclerosis and still bleeding after 24 hours of treatment.
Second, the failure of intraoperative diagnostic probing
The first step of dissection for upper gastrointestinal bleeding is to find the lesion and bleeding site and make a clear diagnosis, which is the key to surgical treatment. Errors in judgment often occur during the exploration due to the following reasons.
(A) Missing exploration
Exploration requires order, meticulousness and patience, and the more difficult the situation, the more calm one must be so that no lesion is missed. Often some clinicians do not pay attention to systematic and sequential comprehensive exploration during probing, and probing is often prone to omissions based on one-sided tendencies only.
1, gastric probing prone to omissions and treatment.
Gastric ulcers tend to occur in the lesser curvature of the stomach, while easily neglected ulcers are in the posterior wall of the stomach, cardia and the bottom of the stomach. If necessary, we should enter the small omental sac and probe the posterior wall of the stomach by hand. This can also detect hemorrhage due to gastric cancer.
If all the above tests are negative, the anterior wall of the stomach should be incised to explore the stomach, and the anterior wall of the gastric sinus can be incised longitudinally between the greater and lesser curves of the stomach, where there are fewer blood vessels. Intragastric exploration can not only detect gastroduodenal ulcers and gastric tumors, but also facilitate the diagnosis of portal hypertension and hemorrhagic gastritis. If the bleeding comes from the cardia or pylorus on exploration, further up or down can be done to examine where the bleeding is. Bleeding from ruptured esophageal varices is seen as a continuous flow of blood from the cardia into the stomach and a submucosal variceal vein at the cardia. The bleeding in the cardia should also be noted for vomiting lacerations, ulcers or tumors, and some clues can be obtained by extending the finger from the cardia into the lower esophagus for examination. In addition to ulcers, bleeding lesions include hemorrhagic gastritis, stress ulcers, and arteriosclerosis causing small arteries to rupture and bleed. Hemorrhagic gastritis has mucosal inflammation and multiple bleeding; stress ulcers are multiple superficial ulcers with multiple bleeding; arteriosclerosis-induced small arterial rupture is often a small bleeding spot in the normal gastric mucosa and is arterial bleeding.
When no problems are found in the lower esophagus and stomach, the duodenum can be checked for lesions through the pylorus, using a finger to enter the duodenum through the pylorus, and then a finger outside for a pairwise examination. A rubber catheter can also be inserted into the duodenum through the pylorus to aspirate the accumulated blood, and then aspirate it segment by segment to check the bleeding site. After the location is clear, the anterior wall of the duodenum is cut open to look for bleeding lesions.
2, duodenal exploration misses and treatment.
Duodenal ulcers are common in the duodenal bulb, but also occasionally occur in other areas. In addition to ulcers, duodenal tumors or diverticula can also be the cause of upper gastrointestinal hemorrhage, so the entire duodenum should be explored when necessary. By incising the peritoneum lateral to the descending part of the duodenum, the posterior part of the descending part can be reached; by incising the right side of the mesenteric root of the transverse colon, the horizontal part of the duodenum can be revealed; by following the lower edge of the horizontal part, the posterior part of the horizontal part can be reached. In this way, the first, second, and third segments of the duodenum can be clearly identified. This avoids the occurrence of missed lesions.
3. Missing biliary tract bleeding.
Bleeding from the biliary tract inside and outside the liver is not uncommon in clinical practice, and in the past, due to insufficient knowledge of this disease, the diagnosis was often incorrect. There was a case in which the upper gastrointestinal hemorrhage was found to have cirrhosis, splenomegaly and esophageal varices during the dissection, and after surgical treatment, the gastrointestinal bleeding still did not stop, so the patient was forced to have another surgical investigation, and the liver was found to have biliary bleeding due to malignant changes on the basis of hepatic sclerosis.
The general diagnosis of biliary hemorrhage is not difficult, but negligence during the exploration is also very likely to cause a missed diagnosis.
(B) Diagnostic errors of bleeding causes
1.Multiple diseases caused by exploration errors.
The search for lesions and the search for bleeding sites are sometimes inconsistent in the investigation. For example, in a patient with portal hypertension, he was found to have obvious cirrhosis, splenomegaly and esophageal varices during dissection for upper gastrointestinal hemorrhage; splenectomy + portal shunt was performed during the operation, but the bleeding was still not controlled after the operation, and the bleeding was found to be ulcer in the duodenal bulb during the operation again. According to clinical statistics the coexistence rate of ulcer disease and cirrhosis was as high as 29.3%. It may be due to the inactivation of certain pro-secretory substances within the portal venous blood stream after hepatic decompensation or portal shunt, which leads to excessive gastric acid secretion and ulceration; it may also be related to chronic venous stasis in the portal venous system causing hypoxia. Some reports, 30-40% of upper gastrointestinal hemorrhage in esophageal varices is caused by ulcers, hemorrhagic gastritis, etc.
2, several rare causes of acute upper gastrointestinal hemorrhage.
Once the probe is negative, several rare causes of acute upper gastrointestinal hemorrhage should also be thought of and necessary probing. Such as pancreatic origin ulcer, cardia mucosal tear syndrome, upper jejunal hemangioma, gastrointestinal arteriovenous malformation, etc. In one case of a patient with upper gastrointestinal hemorrhage, no obvious lesion was found during the dissection and a blind gastrectomy was performed for most of the stomach. Postoperatively, the bleeding could not be controlled. The patient was found to have jejunal ascending hemangioma during re-operative investigation.
3, the incidence of upper gastrointestinal hemorrhage due to acute gastric mucosal damage increased; the incidence of such lesions increased from less than 5% to 22-31%. This is mainly due to the progress of research on the etiology of bleeding and the development of means such as extensive emergency endoscopy. It is now known that many factors such as drugs (salicylates, antipyretic analgesics, chlortetracycline, bromine, iodine, digitalis), biliary tract infections, tumors, trauma, and lesions of the liver and brain can destroy the gastric mucosal barrier and lead to bleeding due to acute gastric mucosal damage. Since the lesion is limited to the gastric mucosa and many surgeons are not accustomed to applying emergency endoscopy before surgery, it is difficult to explore the lesion without opening the gastric cavity during surgery. There are still many reports of missed explorations. Therefore, it should be highly noticed by clinicians.
(3) Failure of surgical methods and treatment
(A) About bleeding gastric and duodenal ulcer
At present, there are many methods to deal with ulcerative bleeding in the clinic, and the following surgical methods often fail to achieve the purpose of effective hemostasis.
1.The method of wedge excision of bleeding ulcer.
2. The method of hemostasis by simply closing the bleeding point at the base of the ulcer with silk suture “8”.
3.Duodenal bulb ulcers, often due to severe local peri-ulceritis or ulcers are difficult to remove and only simple rerouting or major gastric resection method. It is not uncommon in clinical practice to perform a simple gastrectomy to treat bleeding. The recurrence rate of bleeding after this type of ulcer extraction is high and can be as high as 15% according to statistics.
For patients with duodenal bulb ulcers who are old, in poor general condition, and cannot tolerate a major gastrectomy, a vagotomy with suturing of the bleeding point at the base of the ulcer can be considered. This procedure is less invasive and has been reported to be effective in the literature.
For cases with large ulcers or chronic inflammation around the ulcer that is difficult to resect and must be left open, silk sutures can be used to make “8” sutures at the base of the ulcer and ligate the gastroduodenal artery, and then open surgery can be performed, and most of them can achieve the purpose of hemostasis.
For those bleeding ulcers that can be resected, the ulcer should be resected as much as possible during the majority of gastrectomy.
For bleeding anastomotic ulcers, if vagotomy is not performed during the initial gastric surgery, the most appropriate elective surgery is vagotomy. If the patient has already undergone vagotomy and bleeding from the anastomotic ulcer occurs, the reoperation should include gastrojejunostomy and reperform gastrojejunostomy.
(B) About upper gastrointestinal hemorrhage due to acute gastric mucosal damage
We had such a lesson: a patient with upper gastrointestinal hemorrhage, who underwent emergency dissection after conservative treatment failed, was found to have two small active bleeding spots on the gastric mucosa after opening the gastric cavity intraoperatively. At that time, considering the poor general condition of the patient, the patient was not suitable for excessive surgery, and only a simple suture of the bleeding point was performed. After the operation, the bleeding stopped and the patient gradually recovered***. This experience tells us that in acute gastric mucosal bleeding or stress ulcer bleeding, the lesions are often multiple and there is actually a potential developing lesion that is not visible to the naked eye during the surgery. Therefore, simple bleeding point suturing often fails to achieve hemostasis.
At present, many doctors still treat this disease with partial gastrectomy, but from practice, it is found that the treatment effect is extremely poor and most of them still bleed again after surgery. In recent years, there are 144 cases of simple partial gastrectomy, 55% of which caused rebleeding and 44% of which died, so most of gastrectomy is rarely used to treat acute gastric mucosal bleeding.
Vagotomy alone to treat acute gastric mucosal bleeding should also be treated with great caution, because the effect of vagotomy on the reduction of gastric blood flow and gastric secretion is only transient, and this view is relatively consistent.
Currently, the following surgical methods are commonly used.
1.Total gastrectomy.
2, near-total gastrectomy.
3.Vagotomy plus major gastrectomy.
4, vagotomy plus pyloroplasty.
In summary, for acute gastric mucosal bleeding surgical methods, which one is the best still exists urgent debate, should be selected according to the specific situation, but the more inclined opinion is to choose the third or the fourth surgical method.
(C) About ruptured esophageal variceal bleeding
The surgical treatment of ruptured esophageal variceal bleeding can be divided into two categories, one is to reduce the portal vein pressure by various different shunt procedures. The other category is to block the paradoxical blood flow between the portal veins, thus achieving hemostasis, as to what kind of hemostatic surgical method is used, shunt or dissection? Opinions are very diverse, depending on the patient’s specific situation and the surgeon’s experience. There are several issues that need to be mentioned.
1. Emergency bypasses generally have a statistical mortality rate of 30%, with some reports as high as 50%. In contrast, the mortality rate for elective bypass surgery is about 3.5% to 9.5%. There are more opinions that non-surgical treatment should be used as much as possible in case of acute hemorrhage, and elective bypass surgery should be performed after the patient’s condition has improved. If non-operative treatment is ineffective and bleeding does not stop, emergency splenectomy with peripancreatic vascular dissection can be considered. Because this procedure is simpler than bypass surgery, it is less devastating to the patient and has a relatively low mortality rate.
2, the key to the success of peripancreatic vascular dissection is: never miss ligature, cut off the normal high esophageal branches.
The coronary vein of the stomach includes the gastric branch, esophageal branch and high esophageal branch. The high esophageal branch is located about 3-4 cm from the right side of the cardia and travels horizontally upward and forward on the visceral surface of the left outer lobe of the liver, entering the esophageal muscle layer 4-5 cm or higher above the cardia. It is about 0.5 to 0.8 cm in diameter and is particularly evident in patients after splenectomy. Our experience is to cut the anterior plasma membrane of the subdiaphragmatic esophagus with scissors, pull the cardia downward with a strip of gauze or a catheter, and then make a blunt separation with the fingers along the right posterior side of the esophagus to reveal it. In patients who have undergone multiple surgeries and who are estimated to have transabdominal difficulties, the high esophageal branches can be exposed directly through the left chest by incising the diaphragm. In two patients who had undergone four other surgeries, the left upper abdomen was adherent to the plate, with severe bleeding, making it impossible to separate the lower esophagus, and then bleeding again after surgery. The fifth operation was changed to transthoracic dissection of the high esophageal branch, and no further bleeding has occurred since the follow-up. Therefore, ligation and severance of the high esophageal branch is the key to the success or failure of the dissection.
Therefore, it is not enough to separate, ligate, and cut the branches of the coronary vein immediately adjacent to the gastric wall and the lower esophagus during surgery. In many cases of rebleeding after dissection, it is often found that the high esophageal branch is omitted from treatment in re-operation.
3.Blind suture ligation of coronary vein: There have been many lessons in the past, in the cases of emergency esophageal varices rupture and bleeding, due to various reasons, only splenectomy plus blind coronary vein suture ligation was made, and there were many cases of postoperative rebleeding. This is due to the incompleteness of blind suturing, the missed coronary vessels, which increase the pressure of the leftover veins due to the reduction of collateral branches thus leading to easier rupture and bleeding, and this type of surgery has been eliminated.
(D) Exploratory errors and management of biliary bleeding
Biliary hemorrhage is not uncommon in clinical practice, and it is easy to diagnose when biliary hemorrhage is thought of during dissection for upper gastrointestinal bleeding. The main features of biliary hemorrhage that distinguish it from upper gastrointestinal bleeding due to ulcer disease and portal hypertension are: there is often epigastric pain before vomiting blood, vomiting blood is often accompanied by chills and high fever, and jaundice can occur, and sometimes the enlarged gallbladder can be palpated, and biliary hemorrhage often occurs periodically (5 to 7 to 10 days).
The key to the success of surgical management of biliary hemorrhage is the characterization and localization of the bleeding lesion.
In one case, biliary hemorrhage occurred after repair surgery for traumatic liver rupture. On the 13th day after surgery, epigastric colic with black stool and heavy bleeding suddenly occurred, and reoperative ligation of the intrinsic hepatic artery was performed. On the fifth postoperative day, abdominal pain and bleeding persisted, and another atypical right hepatic lobectomy was performed. After the third surgery, the abdominal pain and bleeding symptoms continued and appeared every 7 to 10 days. On the fourth surgical exploration, the gallbladder was found to be full of blood and there was an old hematoma of 3 cubic centimeters on the cut edge of the original right hepatic diaphragm, so gallbladder resection, ligation of the right hepatic artery and resection of the right hepatic cut edge were performed, and the cut surface was closed with intestinal sutures. On the 10th day after the fourth operation, the original symptoms reappeared again and conservative treatment was ineffective, so the fifth operation was performed 15 days after the fourth operation. After removing the necrotic tissue and old clotted blood, an active arterial bleeding was seen and connected to the right hepatic duct, which was ligated and the stump of the right hepatic duct was ligated. The patient recovered well after this operation and was discharged from the hospital.
The reasons for repeated and multiple failed surgeries in this case were.
In the first surgery, the reason was that the suture was not deep enough and the bleeding area was missed. The second surgery was blinded by ligation of the intrinsic hepatic artery, which had no hemostatic effect if the bleeding came from the portal system, the hepatic venous system, or a mixed bleed. The third atypical right hepatic lobectomy was performed without reaching the major bleeding lesion. The fourth resection of the right hepatic margin was performed only based on the assumption that the bleeding was in the vicinity of the original section and still did not stop the bleeding.
The key to success in this case was to find the bleeding lesion in the last operation and to treat it in a targeted manner. The success was achieved.
Surgery for biliary hemorrhage is best performed during acute bleeding. At the very least, it should be in the early stages of hemorrhage cessation in order to determine the site and nature of the bleeding lesion. The gallbladder, extrahepatic bile ducts and liver are thoroughly observed and explored by hands-on palpation. After dissection of the common bile duct, gauze strips can be placed in the right and left hepatic ducts or key forceps can be used to probe for clots, or ureteral catheters can be inserted or flushed, respectively, or pressure can be applied to the suspected lesion in the liver to observe or induce bleeding, all of which can help determine the site of bleeding. Modern biliary tract examination methods such as intraoperative cholangioscopy, intraoperative biliary tree compression X-ray imaging, or ultrasound under television screen surveillance, selective hepatic arteriography and CT are helpful for the qualitative and localized diagnosis of bleeding.
(V) About blind gastrectomy for most of the stomach
Blind gastrectomy due to negative exploration is undesirable. Because of the superficial ulcer (stress ulcer) or acute gastric mucosal damage caused by the upper gastrointestinal bleeding lesions throughout the stomach, removal of part of the stomach body can not stop the bleeding, such as other parts of the lesion not found in the scope of removal, not to mention the role of hemostasis, and blind gastrectomy itself increases the patient’s unnecessary burden, ensuring that the original critical condition is even worse. Due to the continuous development of modern examination methods and means, it is believed that most of the upper gastrointestinal bleeding can be found as long as the lesions are explored comprehensively, meticulously and patiently in accordance with the order.
IV. Precautions for exploratory surgery
1. Short-term non-surgical treatment before surgery can stabilize the condition and facilitate surgical exploration. Do not rush the operation, resulting in deterioration of the condition and forced to abort the operation.
2.For elderly patients with heart, kidney and lung diseases, the rate of infusion and blood transfusion should be controlled, and it is better to monitor by measuring the central venous pressure.
3, the discovery of lesions without bleeding, often due to clots blocking the bleeding point, then to fully prepare and control the lesion under the circumstances of light removal of clots, in order to observe the bleeding situation, so as to clarify the diagnosis and decide the treatment.
4, do not perform blind resection surgery, especially when the investigation is not complete, such surgery is harmful.
5, in case all probes negative, and then no longer bleeding, do not immediately end the operation to close the abdominal cavity. Blood pressure should be quickly transfused to raise the blood pressure and wait a little to observe whether the blood pressure is raised after the bleeding again.
6, to determine the cause can not be found, should quickly end the operation, to strengthen non-operative treatment.