XXIII CURSO DE ACTUALIZACIÓN DE PATOLOGÍA DIGESTIVA

Presentación del tema: "XXIII CURSO DE ACTUALIZACIÓN DE PATOLOGÍA DIGESTIVA"— Transcripción de la presentación:

1 XXIII CURSO DE ACTUALIZACIÓN DE PATOLOGÍA DIGESTIVA
HEMORRAGIA DIGESTIVA BAJA, HIPERTENSIÓN PORTAL, INTERVENCIÓN QUIRÚRGICA PREVIA Delgado Plasencia L.J.; Rahy Martín A.; Sánchez-Lauro Martínez M.; Arteaga Glez. I.; Bravo Gutiérrez A. S. Cirugía General y Digestiva, H.U.C.

2 CASO CLINICO 57 años Motivo Ingreso: HD (melenas + rectorragias)
Deterioro nivel conciencia

3 CASO CLINICO AP: Etilismo importante
Cirrosis hepática OH y VHB (Child-Pugh B) Descompensación ascitico-edematosa Encefalopatia hepática Pancreatitis crónica (26 años de evolución) DMID (16 años de evolución)

4 CASO CLINICO Nefropatía diabética; IRC (Cret: 3,7-4,3 mg/dl)
Quirúrgicos: Puestow Colecistectomia + coledocoduodenostomia Reparación eventración * HDA: ulcus bulbar (1995) * HDB: hemorroides interna (1998)

5 CASO CLINICO: Acude por HD (rectorragias) + deterioro estado general dos días después de la diálisis. Encefalopatía hepática grado III Pruebas complementarias: Analítica: Hb: 6,4 gr/dl; Hto: 19%. Plaq: /mm3 Esofagogastroscopia: varices esofágicas pequeño tamaño y gastropatia hipertensiva H.D.A. Sin repercusión hemodinámica pero con necesidad de transfusión (5 concentrados de Hematies)

6 CASO CLINICO: Ingreso en UCSI (27/10/03)
Rectorragias + inestabilización hemodinámica (Hto: 22%; Hb: 7,7 gr/dl) Encefalopatia hepática grado IV. Transfusión 3 concentrado Hematíes; estabilización hemodinámica Esofagogastroscopia: Varices grado I Gastropatía hipertensiva Arteriografía: malformación: conglomerado venoso pericecal que drena hacia la pélvis No candidato a TIPS

7 CASO CLINICO Arteriografía:

8 CASO CLINICO

9 CASO CLINICO Ingreso en UVI (28/10/03) 29/10/03:
Melenas y rectorragias  Hb: 5 gr/dl; Hto: 27% Transfusión Preparación colonoscopia  Normal Hemorragia masiva en la noche del 29 al 30: 10 concentrados de Hematies 16 unidades de Plasma 3 unidades de plaquetas

10 CASO CLINICO: Opciones terapéuticas
No endoscópicas: no se objetivó el punto de sangrado Arteriografía: No TIPS: riesgo inaceptable de encefalopatía hepática No embolización: No se objetiva el punto de sangrado Imposibilidad de embolización circulación venosa aberrante Cirugía: Ligadura del plexo varicoso pericecal Hemicolectomía derecha Transplante hepático

11 CASO CLINICO: Cirugía Laparotomía exploradora (30/10/03)
Gran Sd. Adherencial Varices importantes a nivel de la pared y entre esta y asas de Intestino delgado adheridas Varices a nivel del mesenterio del yeyuno

12 CASO CLINICO: Cirugía

13 H.D.B. Mortalidad del 10-20% Factores predisponentes:
Edad > 60 años Fallo multiorgánico Necesidades de transfusión mayores de 5 unidades Necesidad de cirugía Situaciones de stress reciente: cirugía, trauma, sepsis La HDB continua siendo importante, con unas tasas de mortalidad del 10-20% y que depende de una serie de factores: ·         Edad > 60 años ·         Fallo multiorgánico ·         Necesidades de transfusión mayores de 5 unidades ·         Necesidad de cirugía ·         Situaciones de stress reciente: cirugía, trauma, sepsis

14 H.D.B. 1,5 % de las urgencias quirúrgicas
En el 80% ceden espontáneamente No hay protocolos de actuación La HDB continua siendo importante, con unas tasas de mortalidad del 10-20% y que depende de una serie de factores: ·         Edad > 60 años ·         Fallo multiorgánico ·         Necesidades de transfusión mayores de 5 unidades ·         Necesidad de cirugía ·         Situaciones de stress reciente: cirugía, trauma, sepsis

15 H.D.B. Tres aspectos fundamentales en el tratamiento de la HDB Determinar la severidad de la hemorragia Establecer la etiología y localización del sangrado Tratamiento específico Localización: Colon, recto y ano- 80%; Estómago y duodeno-15%; Intestino delgado-5% Etiología: Niños y adultos jóvenes: Divertículo de Meckel, Polipos, Enfermedad Inflamatoria intestinal Adultos menores de 60 años: Diverticulosis, Enfermedad inflamatoria intestinal, Malformaciones AV, Neoplasias Adults mayores 60 años: Angiodisplasia, Diverticulosis, Neoplasias, Colitis isquémica Haemorrhoidal disease

16 Etiología y Localización
H.D.B. Etiología y Localización 10-20% de los pacientes no se demuestra el punto sangrante a pesar de las mejoras de los métodos diagnósticos

17 Tratamiento especifico
H.D.B. Tratamiento especifico Localización conocida: Resección segmentaria Localización desconocida: No Colectomía segmentaria: Resangrado 75% Morbilidad 83% Mortalidad 60% Colectomía subtotal Resangrado 3% Morbilidad 32% Mortalidad 19% A pesar de las mejoras en los métodos diagnósticos y terapéuticos, entre el 10-20% de los pacientes con HDB no se objetiva el punto de sangrado.

18 H.D.B. y CIRROSIS HEPATICA
¿Cuáles son las causas de HD en el paciente cirrótico? Rotura de varices esofágicas y gástricas Esofagitis por reflujo LAMG Ulcera péptica Disminución de los factores de coagulación What Causes Gastrointestinal Bleeding in Cirrhotic Liver Disease? In advanced stage of cirrhotic liver disease, upper gastrointestinal bleeding is the most serious and life-threatening complication and must be treated immediately. For those patients already found to have varices in the esophagus and stomach, prevention of bleeding is very important. In order to prevent this serious complication, we must know what the major causes are. The following is a general list: 1. Rupture of varices in the esophagus and stomach - When this happens, the level of bleeding can be quite severe and ensue in large quantities. The physical sign that often occurs is a sudden vomiting of blood and stools becomes a shiny black color. The patient may experience hypotensive shock and hepatic encephalopathy. Without immediate medical attention, the condition can turn fatal. Some preventive measures for a patient with varices are to eat soft foods, eat slowly, and chew very thoroughly before swallowing. In addition, avoid excessive coughing, sudden increases of pressure in the stomach, and keep regular bowel movements. 2. Refluxing esophagitis - The sphincters in the lower end of the esophagus can become loose during ascitic cirrhotic disease. As a result, refluxing esophagitis is a common complication of cirrhotic liver disease and inflammation of the esophagus can trigger varices bleeding. To prevent this condition, ascites and acid reflux must be actively treated. 3. Acute stomach membrane lesion (AGML) - AGML is an acute erosive inflammation of the stomach membrane and cirrhotic liver disease can often cause this condition. When there is hypertension in the portal vein, there are excessive H+ ions that diffuse to the lower end of esophagus that can cause rupture of the varices. It is very important to actively treat AGML to prevent the possibility of bleeding. 4. Peptic ulceration - Portal hypertension changes the microcirculation and dynamics of blood circulation in the stomach membrane. These changes cause blood stagnancy in the stomach membrane as the inflow of blood from the arteries become greater than the outflow through veins in the stomach membrane. This stagnancy of blood can cause thrombosis, swelling, and ischemia. Stomach acids and infectious agents can then attack and erode the membrane, causing ulceration and bleeding. 5. Reduction in blood coagulation factors - Damaged liver functions can interfere with the synthesis of blood coagulation factors. As a result, blood coagulation factors such as factor VII and VIII will drop in number and prolong the PT and PTT. An enlarged spleen causes a decrease in platelet count and even minor bleeds can lead to severe bleeding, as the coagulation mechanism cannot function properly. Since bleeding is a serious condition, the patient should be rushed to the nearest hospital for emergency care. For preventative care, we use Yunan Paiyao Capsule for general gum and nose bleeds. For bleeds in the esophagus and stomach, we use Rhubarba (Rhei Rhizoma

19 H.D.B. y CIRROSIS HEPATICA
Bleeding intestinal varices associated with portal hypertension and previous abdominal surgery. Patients with portal hypertension may develop portasystemic communication in adhesions formed after earlier surgery. This condition causes localized mesenteric and intestinal varices which may lead to significant gastrointestinal hemorrhage. Two patients with this disease spectrum are discussed. The recommended treatment was resection of the involved intestine and formation of a portacaval shunt to eliminate recurrence of the varices and subsequent hemorrhage. Fee. Am Surg Nov;43(11):760-2 Scintigraphic demonstration of gastrointestinal bleeding due to mesenteric varices. Mesenteric varices can appear as massive, acute lower gastrointestinal bleeding. The small bowel or colon may be involved, varices usually developing at sites of previous surgery or inflammation in patients with portal hypertension. Hansen; Clin Nucl Med Jul;15(7): What Causes Gastrointestinal Bleeding in Cirrhotic Liver Disease? In advanced stage of cirrhotic liver disease, upper gastrointestinal bleeding is the most serious and life-threatening complication and must be treated immediately. For those patients already found to have varices in the esophagus and stomach, prevention of bleeding is very important. In order to prevent this serious complication, we must know what the major causes are. The following is a general list: 1. Rupture of varices in the esophagus and stomach - When this happens, the level of bleeding can be quite severe and ensue in large quantities. The physical sign that often occurs is a sudden vomiting of blood and stools becomes a shiny black color. The patient may experience hypotensive shock and hepatic encephalopathy. Without immediate medical attention, the condition can turn fatal. Some preventive measures for a patient with varices are to eat soft foods, eat slowly, and chew very thoroughly before swallowing. In addition, avoid excessive coughing, sudden increases of pressure in the stomach, and keep regular bowel movements. 2. Refluxing esophagitis - The sphincters in the lower end of the esophagus can become loose during ascitic cirrhotic disease. As a result, refluxing esophagitis is a common complication of cirrhotic liver disease and inflammation of the esophagus can trigger varices bleeding. To prevent this condition, ascites and acid reflux must be actively treated. 3. Acute stomach membrane lesion (AGML) - AGML is an acute erosive inflammation of the stomach membrane and cirrhotic liver disease can often cause this condition. When there is hypertension in the portal vein, there are excessive H+ ions that diffuse to the lower end of esophagus that can cause rupture of the varices. It is very important to actively treat AGML to prevent the possibility of bleeding. 4. Peptic ulceration - Portal hypertension changes the microcirculation and dynamics of blood circulation in the stomach membrane. These changes cause blood stagnancy in the stomach membrane as the inflow of blood from the arteries become greater than the outflow through veins in the stomach membrane. This stagnancy of blood can cause thrombosis, swelling, and ischemia. Stomach acids and infectious agents can then attack and erode the membrane, causing ulceration and bleeding. 5. Reduction in blood coagulation factors - Damaged liver functions can interfere with the synthesis of blood coagulation factors. As a result, blood coagulation factors such as factor VII and VIII will drop in number and prolong the PT and PTT. An enlarged spleen causes a decrease in platelet count and even minor bleeds can lead to severe bleeding, as the coagulation mechanism cannot function properly. Since bleeding is a serious condition, the patient should be rushed to the nearest hospital for emergency care. For preventative care, we use Yunan Paiyao Capsule for general gum and nose bleeds. For bleeds in the esophagus and stomach, we use Rhubarba (Rhei Rhizoma

20 H.D.B. y CIRROSIS HEPATICA
Idiopathic mesenteric varices causing lower gastrointestinal bleeding. ……. Mesenteric varices are a rare cause of lower gastrointestinal bleeding, almost always associated with portal hypertension. Schilling Eur J Gastroenterol Hepatol Feb;8(2):177-9. Characterization of the syndrome of small and large intestinal variceal bleeding. Massive bleeding from jejunal varices in a young alcoholic with cirrhosis and portal hypertension ceased following a portocaval shunt. Although rare, bleeding from small or large bowel varices has a high mortality. In 62 cases, small or large bowel varices are almost always associated with a predisposing condition including previous abdominal surgery and portal hypertension from cirrhosis or other causes. Hematochezia without hematemesis and nonbleeding esophageal varices generally occur. Angiography is the best diagnostic test. Cappell Dig Dis Sci Apr;32(4):422-7 What Causes Gastrointestinal Bleeding in Cirrhotic Liver Disease? In advanced stage of cirrhotic liver disease, upper gastrointestinal bleeding is the most serious and life-threatening complication and must be treated immediately. For those patients already found to have varices in the esophagus and stomach, prevention of bleeding is very important. In order to prevent this serious complication, we must know what the major causes are. The following is a general list: 1. Rupture of varices in the esophagus and stomach - When this happens, the level of bleeding can be quite severe and ensue in large quantities. The physical sign that often occurs is a sudden vomiting of blood and stools becomes a shiny black color. The patient may experience hypotensive shock and hepatic encephalopathy. Without immediate medical attention, the condition can turn fatal. Some preventive measures for a patient with varices are to eat soft foods, eat slowly, and chew very thoroughly before swallowing. In addition, avoid excessive coughing, sudden increases of pressure in the stomach, and keep regular bowel movements. 2. Refluxing esophagitis - The sphincters in the lower end of the esophagus can become loose during ascitic cirrhotic disease. As a result, refluxing esophagitis is a common complication of cirrhotic liver disease and inflammation of the esophagus can trigger varices bleeding. To prevent this condition, ascites and acid reflux must be actively treated. 3. Acute stomach membrane lesion (AGML) - AGML is an acute erosive inflammation of the stomach membrane and cirrhotic liver disease can often cause this condition. When there is hypertension in the portal vein, there are excessive H+ ions that diffuse to the lower end of esophagus that can cause rupture of the varices. It is very important to actively treat AGML to prevent the possibility of bleeding. 4. Peptic ulceration - Portal hypertension changes the microcirculation and dynamics of blood circulation in the stomach membrane. These changes cause blood stagnancy in the stomach membrane as the inflow of blood from the arteries become greater than the outflow through veins in the stomach membrane. This stagnancy of blood can cause thrombosis, swelling, and ischemia. Stomach acids and infectious agents can then attack and erode the membrane, causing ulceration and bleeding. 5. Reduction in blood coagulation factors - Damaged liver functions can interfere with the synthesis of blood coagulation factors. As a result, blood coagulation factors such as factor VII and VIII will drop in number and prolong the PT and PTT. An enlarged spleen causes a decrease in platelet count and even minor bleeds can lead to severe bleeding, as the coagulation mechanism cannot function properly. Since bleeding is a serious condition, the patient should be rushed to the nearest hospital for emergency care. For preventative care, we use Yunan Paiyao Capsule for general gum and nose bleeds. For bleeds in the esophagus and stomach, we use Rhubarba (Rhei Rhizoma

21 H.D.B. y CIRROSIS HEPATICA
Gastrointestinal hemorrhage from adhesion-related mesenteric varices. As a result of this retrospective analysis of hemorrhage from a porta-systemic venous shunt occurring within the small intestine, we believe that the early diagnosis of the syndrome is strongly suggested by the presence of varices in unusual locations demonstrated by the venous phase of mesenteric arteriography. In all patients portal hypertension was present, and in all the affected bowel was adherent to postoperative adhesions on old suture lines. The syndrome was treated variously with lysis of adhesions, bowel resection, or portal-systemic shunt. Those patients with excellent hepatic reserve survived and had no further gastrointestinal bleeding. Moncure Ann Surg Jan;183(1):24-9 Mesenteric varices: a source of mesosystemic shunts and gastrointestinal hemorrhage. The presence of mesenteric varices was demonstrated angiographically in 7 patients with portal hypertension. In 4 of these cases the mesenteric varices were the source of lower gastrointestinal bleeding which was successfully controlled by intra-arterial infusion of vasopressin. The radiological diagnosis and management of mesenteric varices is discussed and the pertinent literature is briefly reviewed. Federle Gastrointest Radiol Nov 15;4(4):331-7 What Causes Gastrointestinal Bleeding in Cirrhotic Liver Disease? In advanced stage of cirrhotic liver disease, upper gastrointestinal bleeding is the most serious and life-threatening complication and must be treated immediately. For those patients already found to have varices in the esophagus and stomach, prevention of bleeding is very important. In order to prevent this serious complication, we must know what the major causes are. The following is a general list: 1. Rupture of varices in the esophagus and stomach - When this happens, the level of bleeding can be quite severe and ensue in large quantities. The physical sign that often occurs is a sudden vomiting of blood and stools becomes a shiny black color. The patient may experience hypotensive shock and hepatic encephalopathy. Without immediate medical attention, the condition can turn fatal. Some preventive measures for a patient with varices are to eat soft foods, eat slowly, and chew very thoroughly before swallowing. In addition, avoid excessive coughing, sudden increases of pressure in the stomach, and keep regular bowel movements. 2. Refluxing esophagitis - The sphincters in the lower end of the esophagus can become loose during ascitic cirrhotic disease. As a result, refluxing esophagitis is a common complication of cirrhotic liver disease and inflammation of the esophagus can trigger varices bleeding. To prevent this condition, ascites and acid reflux must be actively treated. 3. Acute stomach membrane lesion (AGML) - AGML is an acute erosive inflammation of the stomach membrane and cirrhotic liver disease can often cause this condition. When there is hypertension in the portal vein, there are excessive H+ ions that diffuse to the lower end of esophagus that can cause rupture of the varices. It is very important to actively treat AGML to prevent the possibility of bleeding. 4. Peptic ulceration - Portal hypertension changes the microcirculation and dynamics of blood circulation in the stomach membrane. These changes cause blood stagnancy in the stomach membrane as the inflow of blood from the arteries become greater than the outflow through veins in the stomach membrane. This stagnancy of blood can cause thrombosis, swelling, and ischemia. Stomach acids and infectious agents can then attack and erode the membrane, causing ulceration and bleeding. 5. Reduction in blood coagulation factors - Damaged liver functions can interfere with the synthesis of blood coagulation factors. As a result, blood coagulation factors such as factor VII and VIII will drop in number and prolong the PT and PTT. An enlarged spleen causes a decrease in platelet count and even minor bleeds can lead to severe bleeding, as the coagulation mechanism cannot function properly. Since bleeding is a serious condition, the patient should be rushed to the nearest hospital for emergency care. For preventative care, we use Yunan Paiyao Capsule for general gum and nose bleeds. For bleeds in the esophagus and stomach, we use Rhubarba (Rhei Rhizoma

22 H.D.B. y CIRROSIS HEPATICA
Jejunal varices as a cause of massive gastrointestinal bleeding. Jejunal varices are not a common manifestation of portal hypertension. This report describes a 46-yr-old man with recurrent massive gastrointestinal bleeding from jejunal varices arising in an area of adhesions between the intestine and the omentum. The bleeding site was identified by exploratory laparotomy. Medical therapy, including vasopressin infusion via the superior mesenteric artery, was of limited success for controlling acute variceal bleeding. However, jejunal resection and anastomosis resulted in complete resolution of the bleeding, and the patient has experienced no recurrent bleeding over a 3-yr follow-up period. A review of the literature shows that this syndrome is characterized by portal hypertension, generally due to liver cirrhosis; frequently, there is a history of abdominal surgery, and the syndrome presents with hematochezia but without hematemesis. Accurate preoperative diagnosis is often difficult. We propose that bleeding from jejunal varices, though uncommon, should be considered under such clinical conditions. Yuki Am J Gastroenterol Apr;87(4):514-7 What Causes Gastrointestinal Bleeding in Cirrhotic Liver Disease? In advanced stage of cirrhotic liver disease, upper gastrointestinal bleeding is the most serious and life-threatening complication and must be treated immediately. For those patients already found to have varices in the esophagus and stomach, prevention of bleeding is very important. In order to prevent this serious complication, we must know what the major causes are. The following is a general list: 1. Rupture of varices in the esophagus and stomach - When this happens, the level of bleeding can be quite severe and ensue in large quantities. The physical sign that often occurs is a sudden vomiting of blood and stools becomes a shiny black color. The patient may experience hypotensive shock and hepatic encephalopathy. Without immediate medical attention, the condition can turn fatal. Some preventive measures for a patient with varices are to eat soft foods, eat slowly, and chew very thoroughly before swallowing. In addition, avoid excessive coughing, sudden increases of pressure in the stomach, and keep regular bowel movements. 2. Refluxing esophagitis - The sphincters in the lower end of the esophagus can become loose during ascitic cirrhotic disease. As a result, refluxing esophagitis is a common complication of cirrhotic liver disease and inflammation of the esophagus can trigger varices bleeding. To prevent this condition, ascites and acid reflux must be actively treated. 3. Acute stomach membrane lesion (AGML) - AGML is an acute erosive inflammation of the stomach membrane and cirrhotic liver disease can often cause this condition. When there is hypertension in the portal vein, there are excessive H+ ions that diffuse to the lower end of esophagus that can cause rupture of the varices. It is very important to actively treat AGML to prevent the possibility of bleeding. 4. Peptic ulceration - Portal hypertension changes the microcirculation and dynamics of blood circulation in the stomach membrane. These changes cause blood stagnancy in the stomach membrane as the inflow of blood from the arteries become greater than the outflow through veins in the stomach membrane. This stagnancy of blood can cause thrombosis, swelling, and ischemia. Stomach acids and infectious agents can then attack and erode the membrane, causing ulceration and bleeding. 5. Reduction in blood coagulation factors - Damaged liver functions can interfere with the synthesis of blood coagulation factors. As a result, blood coagulation factors such as factor VII and VIII will drop in number and prolong the PT and PTT. An enlarged spleen causes a decrease in platelet count and even minor bleeds can lead to severe bleeding, as the coagulation mechanism cannot function properly. Since bleeding is a serious condition, the patient should be rushed to the nearest hospital for emergency care. For preventative care, we use Yunan Paiyao Capsule for general gum and nose bleeds. For bleeds in the esophagus and stomach, we use Rhubarba (Rhei Rhizoma