1. Andrew Young March 22, 2012

2.  Diagnosis:  Bleeding duodenal ulcer  Procedures:  Pyloroplasty, Truncal Vagotomy, G/J tube  Transverse colectomy, Abthera placement  Complication:  Death

3.  64yo woman with chronic back pain and large opiod requirement found down by EMS.  Resuscitated and transferred to MRICU from OSH  Acute renal failure  Unspecified liver disease (NAFLD?)  Respiratory failure

4. Past Medical History  Chronic kidney disease  Hypertension  Diabetes  Spinal stenosis  Anemia  Chronic back pain  Morbid obesity Past Surgical History  Cholecystectomy (open)  Hysterectomy  Tubal ligation

5.  STICU Consult – 11:30 pm  bleeding duodenal ulcer on EGD earlier that day.  Received 6 units of PRBC and still hypotensive  Intubated and sedated  Pale and diaphoretic  Vitals: 36.9 141 116/63 Ventilator 75%  Levophed at 150; Vasopressin at 0.04  Abd: obese, soft, NG with clear output

6.  Procedure:  Pyloroplasty  Truncal vagotomy  G/J tube  Findings:  2 duodenal ulcers

7.  2am: Hgb 7.2 (from 8.1 day prior)  4am: confused, nausea, & coffee ground emesis  8am:  Hgb 5.1 INR 1.6  1L NS, Levophed begun, 2 units PRBC, 2 FFP  10am: intubated for airway control  11am:  EGD two duodenal ulcers at bulb, one with clot  Bronchoscopy: thin secretions  2pm: extubated

8.  6pm:  unresponsive; hypotensive; Levophed at 65mcg  Intubated  7pm: aline; Levophed at 90mcg; 1L NS  8pm: 1L NS  9pm:  CT abd/pelvis  Levophed at 140mcg; Vasopressin begun; 1L NS  11pm: 3 units PRBC; Surgery consulted.

9.  Procedure:  Pyloroplasty  Truncal vagotomy  G/J tube  Findings:  2 duodenal ulcers

10.  6am: 2 units of PRBC, 2 FFP, 1 Plt, 1 cryo  10am:  4 units PRBC, 5 FFP  To OR for rexploration ▪ Bleeding omental vessel ligated ▪ Transverse colon ischemic - resected ▪ 1.6L of clot evacuated; abdomen packed ▪ Temporary abdominal closure device placed  Family meeting post op – care withdrawn.

11.  Pyloroplasty  Truncal Vagotomy  Other options:  Pylorus sparing duodenotomy  HSV

13.  Judgement  Offer operative intervention at all? ▪ CKD, Liver disease, pulmonary disease ▪ DM & Age

14.  Retrospective review: Demark  1998 to 2002: 7k patients  Bleeding ulcers: 30 day mortality  Mortality (P = 0.003):  DM: 16%  Without: 10%

15.  Judgement  Offer operative intervention at all?  Better resuscitation prior to going to OR

16. “…the most frequently overlooked aspect of the initial management of the patient with upper GI bleeding…is the need to immediately attempt to establish hemodynamic stability and adequately resuscitate the patient.” -Bruce Schirmer,Charlottesville, VA Mastery of Surgery, 5 th Ed. 2007

17.  Judgement  Offer operative intervention at all?  Better resuscitation prior to going to OR  Technique  1.6L of blood in abdomen with “bleeding vessel”

18.  Patients and families must be counseled on risk given comorbidities.  Bleeding ulcer:  Resuscitate adequately  EGD for first bleed  Surgery for second bleed ~ 10%