Andrew YoungMarch 22, 2012

Diagnosis: Bleeding duodenal ulcer

Procedures: Pyloroplasty, Truncal Vagotomy, G/J tube Transverse colectomy, Abthera

placementComplication:

Death

64yo woman with chronic back pain and large opiod requirement found down by EMS.

Resuscitated and transferred to MRICU from OSH Acute renal failure Unspecified liver disease (NAFLD?) Respiratory failure

Past Medical History Chronic kidney

disease Hypertension Diabetes Spinal stenosis Anemia Chronic back pain Morbid obesity

Past Surgical History Cholecystectomy

(open) Hysterectomy Tubal ligation

STICU Consult – 11:30 pm bleeding duodenal ulcer on EGD earlier that

day. Received 6 units of PRBC and still hypotensive

Intubated and sedated Pale and diaphoretic Vitals: 36.9 141 116/63 Ventilator 75%

Levophed at 150; Vasopressin at 0.04 Abd: obese, soft, NG with clear output

Procedure: Pyloroplasty Truncal vagotomy G/J tube

Findings: 2 duodenal ulcers

2am: Hgb 7.2 (from 8.1 day prior) 4am: confused, nausea, & coffee ground

emesis 8am:

Hgb 5.1 INR 1.6 1L NS, Levophed begun, 2 units PRBC, 2 FFP

10am: intubated for airway control 11am:

EGD two duodenal ulcers at bulb, one with clot Bronchoscopy: thin secretions

2pm: extubated

6pm: unresponsive; hypotensive; Levophed at 65mcg Intubated

7pm: aline; Levophed at 90mcg; 1L NS 8pm: 1L NS 9pm:

CT abd/pelvis Levophed at 140mcg; Vasopressin begun; 1L NS

11pm: 3 units PRBC; Surgery consulted.

Procedure: Pyloroplasty Truncal vagotomy G/J tube

Findings: 2 duodenal ulcers

6am: 2 units of PRBC, 2 FFP, 1 Plt, 1 cryo 10am:

4 units PRBC, 5 FFP To OR for rexploration▪ Bleeding omental vessel ligated▪ Transverse colon ischemic - resected▪ 1.6L of clot evacuated; abdomen packed▪ Temporary abdominal closure device placed

Family meeting post op – care withdrawn.

PyloroplastyTruncal Vagotomy

Other options: Pylorus sparing

duodenotomy HSV

Judgement Offer operative intervention at all?▪ CKD, Liver disease, pulmonary disease▪ DM & Age

Retrospective review: Demark1998 to 2002: 7k patientsBleeding ulcers: 30 day mortalityMortality (P = 0.003):

DM: 16% Without: 10%

Judgement Offer operative intervention at all? Better resuscitation prior to going to OR

“…the most frequently overlooked aspect of the initial management of the patient with upper GI bleeding…is the need to immediately attempt to establish hemodynamic stability and adequately resuscitate the patient.”

-Bruce Schirmer,Charlottesville, VA Mastery of Surgery, 5th Ed. 2007

Judgement Offer operative intervention at all? Better resuscitation prior to going to OR

Technique 1.6L of blood in abdomen with “bleeding

vessel”

Patients and families must be counseled on risk given comorbidities.

Bleeding ulcer: Resuscitate adequately EGD for first bleed Surgery for second bleed ~ 10%