Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (35 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
The decision on management of patients who re-bleed after initial endoscopic control can be difficult. In a randomised study that compared endoscopic re-treatment to surgery in such patients,
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endoscopic re-treatment secured bleeding again in 75% of patients. With intention-to-treat analysis, complications following endoscopic re-treatment were significantly less when compared to those who received surgery. The gastrectomy rate in the surgery group was 50%. In a subgroup analysis, those re-bleeding with hypotensive shock from ulcers greater than 2 cm were less likely to respond to a repeat endoscopic treatment. It is therefore suggested that a selective approach can be used in re-bleeding patients. Patients with smaller ulcers and subtle signs of re-bleeding should be re-endoscoped and therapy repeated, often with successful outcome. If not successful, surgery should obviously follow. It remains probable that patients with large chronic ulcers and in shock are better treated by expeditious surgery without recourse to endoscopic re-treatment. Some of these patients may benefit from early ‘elective/pre-emptive’ surgery or (increasingly) angiographic embolisation.
Management of re-bleeding following successful endostasis will depend on the specific circumstances. Further endoscopic haemostasis may be appropriate for many patients,
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but high-risk ulcers, particularly those where good endostasis was difficult to achieve at the first procedure, may be better considered for surgery or even transarterial angiographic embolisation.
Transarterial angiographic embolisation (TAE) is an alternative rescue procedure for bleeding duodenal ulcers and the technique has been in use for over two decades. In the 1980s, there were reports of visceral infarcts
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,
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following TAE, and its use was restricted to a small group of patients with refractory bleeding considered unfit for surgical intervention. With advances in embolisation techniques and specifically the use of superselective coiling (
Fig. 7.6
), the success rate in the control of bleeding has been reported to be between 64% and 91%, and mortality between 5% and 25%. There have since been two retrospective comparative studies comparing angio-embolisation with surgery,
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,
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involving a total of 179 patients of whom 72 had TAE and 107 underwent surgery. In the Hong Kong series,
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re-bleeding was higher after TAE compared with surgery but complications were higher in the surgical group and overall mortality was similar at 25%for TAE and 30% for surgery. The Swedish study
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had a lower mortality in both groups (3% and 14% for TAE and surgery, respectively), perhaps reflecting different selection criteria, but again there were no significant differences between the TAE and surgical groups. In the latter comparative study, the lack of outcome difference and the more advanced age in the TAE group suggest that TAE may be at least as good an option as surgery in the management of refractory ulcer bleeding. TAE is certainly now the procedure of choice in the small group of patients who re-bleed after surgery, but a randomised controlled study comparing surgery and TAE in this group of patients would be of great interest. Similarly, the role of semi-elective TAE following successful endostasis in patients considered at high risk of re-bleeding or death has not been studied, but is another area where further research may be interesting.
Figure 7.6
Active bleeding from the gastroduodenal artery complex during transfemoral angiography. Coils were used to embolise the artery leading to cessation of bleeding.
Transarterial embolisation should be considered in patients who re-bleed following surgery for bleeding peptic ulcers and as an alternative to surgery when endoscopic haemostasis has failed, provided appropriate facilities and expertise are available. This may be particularly useful in elderly patients with medical comorbidity. TAE should also be considered as a possible pre-emptive treatment option in high-risk surgical patients who are at high risk of re-bleeding after endostasis.
eradication
A Cochrane review
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concluded that
H
.
pylori
eradication was associated with a significant reduction in the risk of re-bleeding compared with no
H
.
pylori
eradication, from 20% to 2.9%. If antisecretory therapy was continued, the risk was 5.6%, still significantly higher than achieved with
H
.
pylori
eradication. The overall risk of re-bleeding following
H
.
pylori
eradication was less than 1% per year. It is therefore of concern that in a UK review of consultant behaviour, fewer than 60% routinely tested patients for
H
.
pylori
following treatment for complicated peptic ulcers.
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Following treatment for bleeding duodenal ulcer, patients should be tested for
H
.
pylori
and receive eradication therapy where appropriate. Patients should have further testing to ensure successful eradication.
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In patients who continue to require NSAIDs, co-therapy with PPI reduces recurrence in peptic ulcers and bleeding. In these patients, H. pylori should first be tested and treated if confirmed. A randomized controlled trial compared the use of a traditional NSAID plus a PPI to COX-2 inhibitors and found that the rate of further ulcer complications is between 4-6% in 6 months.
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A subsequent randomized trial combined the use of COX-2 inhibitor to PPI and compared them to the use of a COX-2 inhibitor alone.
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At 1 year, the use of COX-2 inhibitor alone was associated with a rate of 8.9% in recurrent bleeding. The risk of recurrent bleeding was completely abolished in those who the combined treatment. COX-2 inhibitor plus PPI appears to offer the best protection to these high risk patients.
The challenge posed by peptic ulcer bleeding has altered with the increasing age of the population at risk and the increasing availability of skilled therapeutic endoscopy. Failure of endoscopic haemostasis is increasingly uncommon but the surgical challenge presented by the elderly patient with refractory bleeding from a large ulcer is considerable. Successful management of UGI bleeding will involve the close cooperation of a multidisciplinary team, which will increasingly include interventional radiologists, aided by local protocols based on evidence-based best practice (
Fig. 7.7
).
Figure 7.7
Management algorithm. SBP, systolic blood pressure.
Key points
A full Rockall score should be calculated for all patients with UGI bleeding following initial endoscopic assessment.
Pre-endoscopy treatment with PPIs is recommended as it reduces the risk of active bleeding at the time of endoscopy and may reduce the need for endoscopic intervention.
Early endoscopy should be performed on all patients with UGI bleeding/haemorrhage.
Endoscopic therapy should be applied where there is active bleeding or a non-bleeding visible vessel in the ulcer base. Adherent clot should be removed and endoscopic therapy applied to the underlying vessel.
Endoscopic therapy for bleeding peptic ulcers should involve use of dual therapy or mechanical therapy rather than adrenaline injection alone in order to reduce the risk of re-bleeding.
High-dose intravenous PPI therapy (80 mg omeprazole followed by 8 mg/h for 72 h) is recommended for patients with active bleeding or visible vessels at the time of endoscopy.
The choice of operation in patients with bleeding peptic ulcers who have failed endoscopic treatment should involve, where possible, simple under-running of the bleeding ulcer, without either vagotomy or gastric resection.
Management of re-bleeding following successful endoscopic haemostasis will depend on the specific circumstances. Further endoscopic haemostasis may be appropriate for many patients but those with high-risk ulcers, particularly where good endostasis was difficult to achieve at the first procedure, may be better considered for surgery or transarterial angiographic embolisation.
Following treatment for bleeding duodenal ulcer, patients should be tested for
H
.
pylori
and receive eradication therapy where appropriate. Patients should have further testing to ensure successful eradication.