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Family meeting post op – care withdrawn.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%
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