MORBIDITY &

MORTALITY CONFERENCE
27th FEBRUARY, 2012
By BASSEY, ASI-OQUA EDET M.B., B.S.

THE
35

PATIENT IS Y.M.

YEARS OLD

SINGLE
FEMALE
A

CHRISTIAN

ALAGO
REESIDENT

AT UGBOKOLO

BIODATA

FIRST

PRESENTATION 1 YEAR AGO

C/O

LEFT ILIAC FOSSA PAIN, PRIOR DGX

OF AN OVARIAN CYST

WAS

GIVEN NSAIDs & PCM

INITIAL PRESENTATION

PRESENTED

ON 11th JANUARY WITH

a. PERSISTENT ABDOMINAL PAIN

b. USS REPORT (SMHO) ENLARGED LEFT OVARY +
SLIGHTLY ENLARGED UTERUS. IMPRESSION LEFT
OVARIAN CYST R/O UTERINE FIBROID
c. USS REPORT (BMMC) UTERINE FIBROID
d. PATIENT BOOKED FOR MYOMECTOMY OR POSSIBLE TAH

SUBSEQUENT PRESENTATION

HAEMATOCRIT 38% (37 47)

TWBC 7.2 (4 11 x 103/ml)

N 56% (40 75%)

L 40% (20 40%)

M 3% (2 10%)

E 1% (1 6%)

BLOOD GROUP A+

FBS 89 (55 100mg/dl)

PREOPERATIVE IV ANTIBIOTICS - CEFTRIAXONE, METRONIDAZOLE

PREOPERATIVE PREPARATION

PATIENT

HAD OP ONE WEEK AFTER

PRESENTATION

FINDINGS INCLUDED
NORMAL UTERUS SAVE FOR MINUTE
LEIOMYOMAS
NORMAL OVARIES AND FALLOPIAN TUBES
INFLAMED TETHERED APPENDIX WHICH WAS
EXCISED
EBL 200ml

INTRAOPERATIVELY

PATIENT

PLACED ON ROUTINE POST-OP

ORDER COMPRISING
CEFTRIAXONE
PARENTERAL METRONIDAZOLE
GENTAMICIN
PENTAZOCINE
5% DEXTROSE/SALINE INFUSION

POSTOPERATIVELY

PATIENT

COMPLAINED OF PAIN AT THE

OP SITE AND WAS GIVEN PARENTERAL
DICLOFENAC FOR 24 HOURS

AT

NIGHT COMPLAINED OF ABDOMINAL

PAIN AND WAS GIVEN IV PENTAZOCINE

1ST DAY POST-OP

COMMENCED

ORAL SIPS AFTER

CONFIRMATION OF PRESENCE OF BOWEL
ACTIVITY

PLACED

ON ORAL AUGMENTIN,
METRONIDAZOLE, DICLOFENAC AND
ACETAMINOPHEN

POST-OP

HAEMATOCRIT 37%

2ND DAY POST-OP

C/O

ABDOMINAL DISCOMFORT

VOMITING

x 1ce ON PREVIOUS DAY

URETHRAL

CATHETER REMOVED

PLACED

ON ORAL METOCLOPROMIDE AND

JAWASIL
WAS

LATER PLACED ON IM DICLOFENAC FOR

24 HOURS

3RD DAY POST-OP

NO REPORT

4TH DAY POST-OP

STILL

HAVING ABDOMINAL PAIN AND

PLACED ON IV CIMETIDINE AND
PENTAZOCINE

PATIENT

DOCUMENTED TO HAVE A
HISTORY OF PUD AND TAB OMEPRAZOLE
PRESCRIBED

5TH DAY POST-OP

COMPLAINTS

CONTINUE

OF ABDOMINAL PAIN

PATIENT

STILL VOMITING AND ORAL

METRONIDAZOLE STOPPED

VOMITING

CONTINUED INTO THE NIGHT

WITH EPIGASTRIC PAIN RADIATING TO
THE BACK

6TH DAY POST-OP

PLAN WAS AS FOLLOWS

STOP ALL ORAL MEDICATION
IV CIMETIDINE
IV PROMETHAZINE
NORMAL SALINE INFUSION
SERUM HCO3 29.8mmol/L (23 34)

6TH DAY POST-OP (contd)

SYMPTOMS
STITCHES

SUBSIDED

WERE REMOVED

IV

AMPICLOX AND METRONIDAZOLE

PRESCRIBED FOR 24 HOURS

7TH DAY POST-OP

NO

COMPLAINTS

PATIENT

DISCHARGED HOME ON GESTID

SUSPENSION

NOTE:

THROUGHOUT THE POST-OP

PERIOD PATIENT HAD SPORADIC
ELEVATIONS IN BLOOD PRESSURE WITH
THE PEAK BEING 180/110mmHg

8TH DAY POST-OP

ABOUT

16 HOURS FOLLOWING
DISCHARGE PATIENT STARTED HAVING
BOUTS OF PROFUSE HAEMATEMESIS
(FIRST OF ALTERED THEN OF FRANK
BLOOD) AND LOOSE MELAENA

PATIENT

PASSED OUT AND

SPONTANEOUSLY REGAINED
CONSCIOUSNESS

9TH DAY POST-OP

PATIENT WAS RUSHED TO THE HOSPITAL UNIT

(LABOUR ROOM) AND THE FOLLLOWING WERE FOUND
BP 110/70mmHg
RADIAL PULSE NOT PALPABLE
BRACHIAL PULSE 98/min
LETHARGY
SWEATING

ASSESSMENT HYPOVOLAEMIC SHOCK 2o UPPER

GASTROINTESTINAL BLEEDING IN A KNOWN PUD
PATIENT

9TH DAY POST-OP (contd)

MANAGEMENT PLAN:
IV N/S 3L STAT
IV CIMETIDINE 600mg STAT
IV PROMETHAZINE 5Omg STAT
IM VIT K 10mg STAT
URETHRAL CATHETERIZATION FOR FLUID BALANCING
O2 BY FACE MASK AT 5L/MIN
ELEVATE FOOT OF BED
COVER PATIENT WITH WARM BLANKETS
URGENT HAEMATOCRIT 35%, PLATELET COUNT NO
REPORT, CLOTTING TIME 15mins
VITAL SIGNS q15mins

9TH DAY POST-OP (contd)

AFTER 3 HOURS OF RESUSCITATORY EFFORT THE

FINDINGS
BP 150/90mmHg
PR 94/min
URINE OUTPUT 850ml (AMBER) OVER 3hrs
EXTREMITIES WARMING UP

REVIEWED PLAN

IV N/S 1L 6 HOURLY x 48 HOURS

G x M 1 UNIT FWB FOR URGENT TRANSFUSION
COLD SALINE GASTRIC LAVAGE CONSIDERED
VITALS q30mins

9TH DAY POST-OP (contd)

71/4

HOURS AFTER ONSET OF EMERGENCY

EVENT PATIENT HAD FOUR BOUTS OF
COPIOUS AMOUNTS OF LOOSE MELAENA IN
THE PRECEEDING THREE HOURS

PATIENT

DESCENDED INTO HYPOVOLAEMIC

SHOCK AGAIN AND WAS RESUSCITATED

ADDITIONAL

3 UNITS FWB FOR URGENT

TRANSFUSION

9TH DAY POST-OP (contd)

30MINS
BP

LATER PULSE BECAME PALPABLE AND BOUNDING @ 126/MIN

/50mmHg

120

2HRS

LATER WITH PATIENT ON THIRD UNIT HAEMODYNAMICS WERE

STILL UNSTABLE

PATIENT

VOMITED 1 1.5 PINTS OF FRANK BLOOD AND HAD

ANOTHER BOUT OF PROFUSE MELAENA

COLD

SALINE GASTRIC LAVAGE COMMENCED

AGGRESSIVE

RESUSCITATION WITH IVF AND FWB CONTINUED BUT

PATIENT DESCENDED A STEEP DECLINE AND WAS CERTIFIED DEAD
ON 9TH DAY POST-OP

9TH DAY POST-OP (contd)

INTRODUCTION
DEFINITION
EPIDEMIOLOGY
AETIOLOGY/DIFFERENTIAL
CLINICAL

DGX

FEATURES

INVESTIGATIONS
MANAGEMENT
SUMMARY
END

UPPER GASTROINTESTINAL
HAEMORRHAGE

UPPER

GASTROINTESTINAL
HAEMORRHAGE IS A SURGICAL
EMERGENCY THAT COULD BE RAPIDLY
FATAL IF AGGRESSIVE AND TIMELY
INTERVENTIONS ARE NOT INSTITUTED
AS APPROPRIATE

IT

IS REVEALED EXTERNALLY AS
HAEMATEMESIS AND/OR MELAENA

INTRODUCTION

DEFINED AS BLEEDING FROM THE

GASTROINTESTINAL TRACT FROM
SOURCES PROXIMAL TO THE DUODENOJEJUNAL JUNCTION MARKED SURGICALLY
BY THE LIGAMENT OF TREITZ

DEFINITION

INCIDENCE

IN THE UK IS 1 IN 1000 ADULTS PER YEAR

BASED ON AETIOLOGY
IN MOST PARTS OF AFRICA CHRONIC PEPTIC ULCER IS BY FAR THE COMMONEST: 50 90%
IN TANZANIA, ZIMBABWE OESOPHAGEAL VARICES ARE COMMONER
IN BRITAIN AND NORTH AMERICA CHRONIC PEPTIC ULCER ACCOUNTS FOR 50%
20%

OF CASES REQUIRE INTERVENTION FOR ONGOING BLEED OR REBLEEDING

DUODENAL

ULCERS ARE MORE LIKELY TO BLEED THAN GASTRIC

OF

THE D.U., POSTERIOR ULCERS ARE MORE LIKELY TO BLEED THAN

ANTERIOR

BLEEDING

IS THE COMMONEST COMPLICATION OF PEPTIC ULCER IN BRITAIN

AND SECOND COMMONEST IN AFRICA AND INDIA

EPIDEMIOLOGY

IN

INDEX PATIENT MOST LIKELY CAUSE OF UGI BLEED

IN A CHRONIC PEPTIC ULCER. HOWEVER,
DIFFERENTIALS INCLUDE
1. STRESS ULCERS
2. OESOPHAGEAL VARICES
3. OESOPHAGITIS
4. MALLORY-WEISS TEARS
5. MALIGNANCIES
6. OESOPHAGEAL ULCERS
7. HIATAL HERNIA (ROLLING)
8. HEREDITARY TELANGIECTASIA
9. ABDOMINAL AORTIC ANEURYSM
10. BLOOD DYSCRASIA

AETIOLOGY/DIFF DGX

HX

OF HAEMATEMESIS AND/OR MELAENA OR

FRANKLY BLOODY STOOL
IN PEPTIC ULCER HAEMATEMESIS FRESH RED BLOOD WITH CLOTS,
OCCASIONALLY MIXED WITH FOOD
IN OESOPHAGEAL VARICES COPIUS DARK RED VENOUS BLOOD +
SIGNS OF PORTAL HTN
OESOPHAGEAL ULCERS SMALL VOL OF BRIGHT RED BLOOD.
STREAKING TYPICAL
MALLORY-WEISS SMALL VOL OF FRESH BLOOD PRECEDED BY
PROLONGED VIOLENT VOMITING OR RETCHING

SYNCOPE

MAY OCCUR IF BLOOD LOSS WAS RAPID

AND SEVERE

CLINICAL FEATURES

PREDISPOSING

FACTORS OR
CONDITIONS MAY BE READILY
IDENTIFIABLE,
STEROIDS
NSAIDs
ALCOHOL
MASSIVE BURNS
ANTICOAGULANTS

CLINICAL FEATURES

EXAMINATION

1.
2.
3.
4.
5.
6.
7.
8.
9.

FINDINGS MAY INCLUDE

PALLOR
SWEATING
COLD EXTREMITIES
COLLAPSED SUBCUTANEOUS VEINS
TACHYCARDIA
HYPOTENSION
RESTLESSNESS
COMA
FINDINGS POINTING TO UNDERLYING CAUSE

CLINICAL FEATURES

Hb/HCT
LFT
ENDOSCOPY
DOUBLE

(OESOPHAGOGASTRODUODENOSCOPY)

CONTRAST BARIUM MEAL

SELECTIVE

VISCERAL ANGIOGRAPHY BEST REULTS WHEN

BLEED RATE IS >0.5 1ml/min. SPECIFICITY APPROACHES 100%

RADIONUCLIDE

TECHNETIUM-99m-LABELED RED CELL SCAN

CAN DETECT BLEEDS AT RATES >0.1ml/min

INVESTIGATIONS

JOINT

MANAGEMENT BY PHYSICIAN AND

SURGEON

MOST

CASES WILL STOP BLEEDING WITH

CONSERVATIVE MGT BUT MANY WILL
REQUIRE SURGERY

MANAGEMENT

RESUSCITATION
START TWO LARGE-BORE IV LINES
RUN IV FLUID e.g. N/S OR R/L
MONITOR PULSE, BP, CVP, VENOUS FILLING, TEMPERATURE, SKIN MOISTURE, MENTATION AND
MOST IMPORTANTLY URINE OUTPUT

IF BLOOD LOSS IS MUCH YOU CAN GIVE AN INITIAL 1L OF COLLOID BEFORE IVF
BLOOD TRANSFUSION BECOMES NECESSARY IF
1.
2.
3.
4.

BLOOD LOSS HAS BEEN CONSIDERABLE

CRYSTALLOIDS ALONE CANNOT MAINTAIN VITALS
Hb<8, HCT<30
EVIDENCE OF CONTINUED BLEED

USE OF A SENGSTAKEN-BLAKEMORE GASTRO-OESOPHAGEAL TUBE MAY BE A LIFE-SAVING

RESUSCITATION MANOEVRE

NASOGASTRIC

TUBE PLACEMENT FOR ASPIRATION (PREVIOUSLY,

LAVAGE AS WELL). THE COLOUR OF THE ASPIRATE CAN SUGGEST
WHETHER BLEEDING HAS STOPPED OR NOT

MANAGEMENT

SEDATION

WITH PHENOBARBITONE 30mg 6HRLY MAY

HELP RELIEVE ANXIETY

TREATMENT

OF SPECIFIC CAUSE. IN THIS CASE A

CHRONIC PEPTIC ULCER
1. NIL PER OS
2. IV CIMETIDINE 900mg/DAY BY INFUSION
3. UPPER GI ENDOSCOPY TO EVALUATE SOURCE OF BLEED & TO APPLY
THERAPY (ADRENALINE 1:10,000 SOLUTION, HYPERTONIC 1.8%
SALINE, SCLEROTHERAPY, THERMAL COAGULATION WITH BIPOLAR
DIATHERMY, CLIPS OR BANDING, TOPICAL CYANOACRYLATE)
4. INTERVENTIONAL RADIOLOGY SELECTIVE CATHETERIZATION AND
EMBOLISATION OF THE COELIAC OR MESENTERIC AXIS

MANAGEMENT

SURGICAL

INTERVENTION TO STOP BLEEDING

IS INDICATED WHEN
1. INITIAL HAEMOSTATIC CONTROL IS NOT ACHIEVED
2. REBLEEDING OCCURS DESPITE REPEATED ENDOSCOPIC
3.
4.
5.
6.

SESSIONS
A LARGE (>2cm) PENETRATING ULCER IS PRESENT
A VESSEL LARGER THAN 2cm IN DIAMETER IS SEEN WITHIN
THE CULPRIT LESION
THE ULCER IS LOCATED IN THE POSTERIOR DUODENAL BULB
THE PATIENT REQUIRES SUBSTANTIAL TRANSFUSION i.e. 4
OR MORE UNITS IN 24 HOURS OR BLOOD IS NOT READILY
AVAILABLE

MANAGEMENT

FOR

A DUODENAL ULCER, IT SAFEST TO

UNDERRUN THE BASE WITH A NONABSORBALE SUTURE TOGETHER WITH
VAGOTOMY AND PYLOROPLASTY

FOR

A GASTRIC ULCER A BILROTH I

PARTIAL GASTRECTOMY IS USED

MANAGEMENT

THE

OVERALL MORTALITY OF UGI BLEEDING IS 10-15%; IT IS

MUCH HIGHER (ABOUT 33%) IN PATIENTS OVER 70.

70

- 80% OF BLEEDING PEPTIC ULCERS STOP BLEEDING

SPONTANEOUSLY.

PREDICTORS

OF MORTALITY ARE AGE, SHOCK, CO-MORBIDITY,

DELAY IN DIAGNOSIS AND REBLEEDING.

IF

THEY HAVE BEEN TREATED COSERVATIVELY 20% REBLEED IN 510 YEARS COMPARED WITH 4.5% AFTER SURGICAL TREATMENT.

WITH

THE ADVENT OF H. PYLORI ERADICATION, THE REBLEEDING

RATE IS LIKELY TO GO DOWN.

SUMMARY

THANK YOU
QUESTIONS? DISCUSSION? CRITICISM
(BE CONSTRUCTIVE PLEASE)

END