Common Problems in Acute Care Surgery by Laura J. Moore Krista L. Turner & S. Rob Todd

Author:Laura J. Moore, Krista L. Turner & S. Rob Todd
Language: eng
Format: epub
Publisher: Springer New York, New York, NY

Diagnosis and Management

Diagnostic and Therapeutic Endoscopy

After the initial resuscitation is underway, the source and etiology of the UGIB must be localized. The best initial procedure is usually endoscopy. EGD has proven to be the most important initial procedure. This modality in skilled hands will also offer several therapeutic options. Localization of the source of the bleed is critical. The success of all endoscopic, angiographic, and surgical interventions depends upon localization of the bleeding source. At the minimum, and with the worst conditions, an EGD can differentiate an UGIB from a LGIB. Should the bleeding fail to stop spontaneously or be controlled endoscopically, narrowing down the source vessels or tissues as much as possible makes the possibility of a successful angiographic or surgical intervention with the least amount of morbidity much more likely.

Therapeutic options for the endoscopist have expanded considerably in the last two decades. The techniques used will depend upon the skill and comfort of the endoscopist and the site and etiology of the bleeding. Options include epinephrine or sclerosant injection, thermal coagulation, hemostatic clip application, banding, or a combination of these techniques. Multiple trials have demonstrated that all of these modalities have similar efficacy in arresting bleeding, preventing rebleeding, and reducing the need for urgent surgical intervention. Success after initial treatment can be as high as 98% [4, 24]. Additionally, biopsies can provide useful information and in some institutions, H. pylori testing from biopsied tissue can be done with results much faster than serology or other types of testing. Neoplastic causes of bleeding can also be established by biopsy and can play an important role in treatment strategies. Furthermore, in the case of transpapillary bleeding, endoscopic retrograde cholangiopancreatography (ERCP) can be helpful for both localization and treatment. Recurrent bleeding after endoscopic control is infrequent, occurring in <10% of patients in centers with strong endoscopy departments. Repeat endoscopy for bleeding after initial endoscopic control has been compared to surgical intervention and has been demonstrated to achieve long-term hemostasis in a majority of patients while avoiding the complications of surgery [24]. Repeat endoscopy is widely regarded as the appropriate response to evidence of rebleeding after initial endoscopic control [21].

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