O. N. M. Panton, MB, BS, FRCSC, FACS, Head, UBC Division of General Surgery, VGH/UBCH

 HAEMORRHAGE  SEPSIS

 Upper GI  Small Bowel  Colorectal  Solid organ

 Gastric or duodenal ulcer  Varices  Mallory-Weiss tear  Oesophageal ulcer

 Varices  Mallory-Weiss tear  Esophagitis/ulcer – acid reflux, infection  Neoplasia  Trauma

 Gastritis  Superficial  Stress ulceration  Mechanical

 Gastric Ulcer  Benign or malignant (10%)  Initial biopsy if safe  Repeat OGD to assess healing & repeat bx  Benign: drug-induced, hypersecretors +/- H. pylori infection

 Duodenitis  Benign ulcer  Crohn’s  Neoplasia  Vascular Malformation  Dieulafoy

 Haemobilia  Aortoduodenal fistula

 Benign ulcer  May have all the same etiology as stomach  Major bleeding usually gastroduodenal artery

 32 year old male found at home in a pool of blood & still vomiting blood  VGH ER pulse140 BP 60/0  Hb 32  Massive resuscitation/transfusion protocol  Codes x 2 in ER  OGD bleeding ++++

 OR STAT laparotomy  Codes shortly after laparotomy  Duodenotomy/gastrotomy  Watermelon stomach torrential haemorrhage  Blood gushing from duodenum  Died on table

 Angiodysplasia  Diverticular disease  Neoplasia: Adenocarcinoma, GIST’s  Ischemia  Hemmorhoids  IBD  Infection: Campylobacter, Shigella, Salmonella, Enteropathogenic E. coli

 Acute bleeding occurs in cases/100,000 annually  20-30% of GI bleeds

 67 year old female found down at home in a pool of blood passed per rectum  VGH ER pulse 156 BP 50/0 Hb 36  Resuscitated/massive transfusion protocol  Previous LAR/TME rectal ca neoadjuvant short course radiorx  Leak/Hartmann

 STAT OR  Pre-sacral ulcer communicating with rectal stump  Packed/controlled  ICU plan for IR angio/embolization  DIC ICU & died

 56 year old male presents VGH ER sudden (R) flank pain  Pulse 148 BP 210/110 Hb 88  Resuscitated then STAT laparotomy  (R) suprarenal ruptured tumour

 Perforated appendicitis  Colonic perforations  Gasrtro-duonenal perforations  Mesenteric ischaemia with infarcted gut  Gangrenous cholecystitis  Necrotizing pancreatitis  Ascending cholangitis

 47 male HIV + 24 hour hx severe abdominal pain  CT dx terminal ileitis Rx IV antibiotics  GS consulted next night  Temp 39 pulse 120 BP 115/68  Generalized peritonitis WBC 18 creatinine

 DL RLQ abscess  Laparotomy: gangrenous appendicitis/faecolith  Appendectomy & drainage of abscess