Upper gastrointestinal bleeding from the surgeon’s view

Abstract

Upper Gastrointestinal bleeding (GIB) represents about 90% of the total number of haemorrhages for the entire gastrointestinal tract. Its mortality rate approaches 10%, even in specialized Centers. The commonest causes of admissions are benign (60%). Neoplasms account for a percentage of 15%, while other diseases represent the remaining 25%. The main risk factors for bleeding include: elderly, shock on admission, renal or hepatic failure and diffuse cancer, endoscopic findings (active, diffuse bleeding from peptic ulcer, non-bleeding visible vessel, large varices). Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper GIB lesions. Endoscopic therapy reduces the risk of rebleeding, the need for blood transfusions, the requirement for surgery, and patient morbidity. However, in cases of endoscopic haemostasis failure or continuous haemorrhage or recurrence of bleeding despite the initial successful endoscopic haemostasis, an emergency surgical operation will be necessary aimed at the ligation of the bleeding vessel and the haemodynamic stabilization of the patient; in duodenal ulcer either subtotal gastrectomy or vagotomy and pyloroplasty (with a greater chance of recurrence of bleeding), while in gastric ulcer either gastrectomy or vagotomy and draining operation. In Mallory-Weiss syndrome, bleeding episodes are self-limited in 80–90 % of cases and the need for surgery is very rare. In Dieulafoy’s Lesion treatment is endoscopic or surgical, while in gastric antral vascular ectasia, the preferred endoscopic therapy is argon plasma cogulation. Laparoscopic tholoplasty is the operation of first choice for hiatus hernias. Common hepatic artery aneurysms are treated with ligation or excision without arterial repair, as opposed to proper hepatic artery aneurysms that require arterial repair with graft interference. Finally, in regard to esophageal variceal bleeding as a consequence of portal hypertension, new methods of treatment have emerged due to the evolution of endoscopes and interventional actinology, apart from porto-systemic shunts. The essence, however, is to identify those patients who can be managed by such decompressive operations and reserve liver transplantation for those who cannot be managed with any lesser therapy.