L'Ipertensione Portale

L'Ipertensione Portale

Emorragie del tratto GI Prof. Paolo Colombo Cattedra di Chirurgia dellApparato Digerente Universit degli Studi di Pavia EMORRAGIA Emorragia la perdita di sangue da una qualsiasi sede dellorganismo. Exanguinazione la perdita totale del sangue dallorganismo. La durata, lentit di sanguinamento, la velocit di transito del sangue nel tubo digerente riflettono la severit di una emorragia GI.

ACUTE GI BLEEDING Acute blood loss into the intestinal tract presents a management challenge and a grave threat to the patient. The lesion which is bleeding cannot be easily visualized at the bedside, nor can it be controlled in this setting. Transport of the patient to an endoscopy clinic, angiography suite or to the operating room is necessary for definitive diagnosis and management. Tipi di emorragie digestive Emorragia del tratto digerente prossimale o superiore (sovramesocoliche) perdita ematica che si ha a monte della flessura duodeno-digiunale o del

legamento di Treitz. Il paziente presenta tipicamente ematemesi, melena e deficienza di ferro, ma anche ematochezia se il sanguinamento rapido e vivace. Emorragia del tratto digerente distale o inferiore (sottomesocoliche) la perdita si ha distalmente al Treitz o alla valvola ileocecale. La presentazione tipica come ematochezia con emissione improvvisa di sangue rosso-vivo dal retto in assenza di materiale ematico nel gastro-aspirato. Emorragie digestive Caratteristiche della ematemesi e

del vomito caffeano Caratteristiche della melena e della ematochezia Come si riconosce la presenza di sangue nel vomito e nelle feci? Sangue rosso-brillante nel vomito ematemesi Colorito caffeano del vomito Sangue rosso-brillante nelle feci ematocheziarettorragia-proctorragia Sangue scuro mischiato alle feci Feci picee-scure o catramose melena Enterorragia termine generico che indica lemissione di sangue rosso-vivo dal retto ed indicativa di emorragie distali al Treitz, in genere oltre

lileo terminale Come si riconosce una emorragia acuta a carico del tratto digestivo? I segni di sanguinamento nel tubo digerente sono correlati alla sede ed alla severit della emorragia. In caso di sanguinamento esofageo, gastrico o duodenale si hanno feci nerastre-picee o di aspetto catramoso e possibile vomito di materiale ematico rosso vivo o caffeano. Il sanguinamento dal retto o dal colon distale si manifesta con emissione dallano di sangue rosso brillante o di sangue frammisto alle feci. Le feci possono apparire commiste a sangue scuro se il sanguinamento ha sede pi prossimale nel colon e nel tratto ileale terminale. In caso di emorragia cronica ed occulta il paziente non

rileva differenze di colore a carico delle feci. Ematemesi E il vomito ematico ed indica una sede di sanguinamento a carico del tratto GI superiore, in genere a monte del legamento di Treitz. Il materiale emesso appare rosso-vivo, indicando un sanguinamento recente od in atto, o appare simile al fondo di caff (vomito caffeano, rossonerastro) per una emorragia non-recente o per un sanguinamento pi lento. Ci dovuto alla conversione dellemoglobina in ematina da parte dellacido cloridrico. Ematochezia (proctorragia-rettorragia) E la fuoriuscita di sangue rosso-vivo dal retto, commisto o non alle feci o la emissione di feci di colorito

marrone-scuro ed indica un sanguinamento da una sorgente del tubo digerente distale o inferiore, ma anche una emorragia severa e vivace del tratto GI prossimale. Se lemorragia ha origine nelle porzioni pi prossimali del colon o nel tratto distale del piccolo intestino le feci possono apparire commiste a sangue pi scuro o di colore marrone scuro. Melena Emissione di feci nere, catramose e con cattivo odore. Melena si pu avere in caso di sanguinamento GI superiore. E causata da perdite di almeno 50 ml di sangue (lacidit gastrica, enzimi ed i batteri intestinali degradano in poche ore lHb in ematina ed altri pigmenti ematici) e non deve essere confusa con le feci scure che si osservano dopo

ingestione di quantit eccessive di ferro o di bismuto (antidiarroico) o di determinati cibi (barbabietole, mirtilli e liquerizia). Un severo episodio emorragico comporta lemissione di feci catramose per diversi giorni sino ad una settimana. Acute Massive GI Bleeding Most cases of gastrointestinal bleeding resolve spontaneously, regardless of the amount of blood lost. The stability of the patient and the rate of bleeding dictate the order in which various diagnostic procedure should be conducted. The goal is to identify and, if necessary, treat the source of bleeding, while mantaining hemodynamic stability.

Manning-Dimmit et al. Am Fam Physician 2005;71:1339-46. Acute Massive Upper Gastrointestinal Bleeding Incidence of 40 to 150 episodes per 100.000 persons annually, with a mortality rate of 6 to 10 per cent. Manning-Dimmit et al. Am Fam Physician 2005;71:1339-46. Cause di emorragia del tratto GI prossimale Ulcera duodenale Ulcera gastrica

Varici esofago Esofagite Erosioni gastriche Cause rare Cause sconosciute Neoplasie Mallory-Weiss Duodenite Extensive , superficial esophageal varices, including one huge varix. Only 50% of patients with varices actually bleed from them.

Varices are sometimes bluish in color, but may be pale, as in this instance. Small red dots, larger red spots or red streaks on the varix correlate with an increased risk of hemorrhage. Tortuous varices are more likely to bleed than straight varices. Large varices bulge into the lumen of the esophagus and may seem to occlude the passage. Varices which extend proximally have a higher risk of bleeding than those confined to the lower one third. The late phases of this mesenteric angiogram show a normal portal vein. There is no distended or variceal coronary vein.

Liver blood flow is about 1500 ml/min, and 60% is from the portal vein which also supplies about the oxygen requirements of the liver. Complete diversion of portal flow from a cirrhotic liver [as in portocaval shunt] is not tolerated, with further deterioration in liver function and encephalopathy. The late phases of this selective mesenteric angiogram show opacification of the portal vein but also demonstrate a torturous, dilated, left coronary vein extending into gastric and esophageal varices. Portal venous pressure will always exceed 10 mmHg once varices have developed. Large penetrating ulcers in the stomach or duodenum are unpredictable and threatening.

If they bleed once vigorously they are very likely to bleed again in a similar manner. Chronic peptic ulcers penetrate deeply, often completely through the gastric or duodenal wall, until they erode into adjacent organs. Very large vessels may eventually be eroded by this process. These include the gastroduodenal artery behind the first part of the duodenum , the splenic artery posterior to the stomach or the left gastric artery on the lesser curve. The duodenum is very edematous and scarred anteriorly. There is a penetrating ulcer on the posterior wall of the duodenum, which is the usual location of lesions that lead to massive hemorrhage. In the central part of this ulceration one can see a thrombus protruding from the eroded vessel,

likely the gastroduodenal. A deeply penetrating ulcer in the posterior wall of the duodenum has been exposed by a longitudinal pyloromyotomy. The bleeding vessel has already been secured. The gastroduodenal artery runs from the 6 0clock to the 12 0clock position across the ulceration. The vessel is imbedded in the scar tissue in the base of the ulcer. The usual strategy is to

under run, and ligate the vessel at the superior and inferior margin of the ulcer, isolating the eroded portion between the two ligatures. Bleeding peptic ulcers are often seen, at endoscopy, to be covered by adherent clot. Active bleed from an esophageal varix demonstrates the arterylike nature of these hemorrhages. The pressure in a varix may be 20-30 mm Hg and blood is still well

oxygenated, having been shunted away from the liver sinusoids. Malignant ulcers lead to encasement of vessels, but do not, as a rule, erode into an artery as acid peptic digestion will. Gastric epitheleal tumors (adenocarcinomas) may cause anemia by a slow loss of blood from neoplastic vessels on the ulcerated surface.

They are very seldom responsible for an acute upper GI hemorrhage. Lower GI Bleeding By definition, the term lower refers to bleeding sites below the duodenojejunal flexure. Hematemesis never occurs. If an N/G tube is inserted, aspiration will yield only gastric contents. If bile is aspirated then bleeding in the duodenal loop is also excluded. Acute Massive Lower GI Bleeding Incidence of 20 to 27 episodes per 100.000

persons annually, with a mortality rate of 4 to 10 per cent. Mortality rate increases in patients with advancing age and increasing number of associated comorbidities (renal and hepatic dysfunction,heart disease, and malignancies). Manning-Dimmit et al. Am Fam Physician 2005;71:1339-46. Causes of Acute Massive Rectal Bleed Cause Prevalence (%) Upper GI tract Peptic ulcer disease 40 to 79

Gastritis/duodenitis 5 to 30 Esophageal varices 6 to 21 Mallory-Weiss tear 3 to 15 Esophagitis 2 to 8 Gastric cancer 2 to 3 Dieulafoys lesions <1 Gastric arteriovenous malformations <1

Portal gastropathy <1 Lower GI tract Small bowel Angiodysplasia 70 to 80 Jejunoileal diverticula Cause Prevalence (%) Meckels diverticulum Neoplasms/lymphomas (benign and malignant) Enteritis/Crohns disease

Aortoduodenal fistula in patient with synthetic vascular graft Large bowel Diverticular disease 17 to 40 A-V malformations 2 to 30 Colitis 9 to 21 Colonic neoplasms/post polypectomy bleeding 11 to 14 Anorectal causes 4 to 10

Colonic tuberculosis Cause di Emorragia Massiva Tratto GI Distale Diverticolosi 60% IBD 13%

Malattie benigne anorettali 11% Neoplasie 9% Coagulopatia e altre 4% Angiodisplasia e malformazioni arterovenose 3% Lower GI Bleeding These bleeds are more difficult to follow, in that the small bowel and colon have a capacity to contain a significant amount of blood before it is passed per rectum. The slower rate of bleeding does not stimulate peristalsis, which would propel evidence of a faster hemorrhage to the rectum. A common clinical scenario in lower GI bleeding is the patient

passing fresh blood and clots per rectum, e.g. 500-1000 mls and then being found to have dropped his/her Hgb level 20-30gms. No change in vital signs had been detected in the prior 12 hours. A bleeding rate of 2ml/min is slow, but it can be relentless and adds up as the hours pass. (2ml/min = 120ml/hr = 720ml in 6 hours = 1440ml in 12 hours). Diverticulosis Fecaliths impacted in the neck of diverticula; in this case of lower GI bleeding, a fecalith in the diverticulum just to right of center in the photo, eroded a small vessel which bled relentlessly.

Arterial bleeding in the colon is rarely rapid enough to pose problems in resuscitation. This selective angiogram [IMA] was performed in an attempt to locate a lower GI bleed. Labeled red blood cell scan. Meckels diverticulum with bleeding ulcerations. The anomaly was first described

by Johann Meckel in 1808. Bleeding is the commonest complication, followed by intestinal obstruction and Meckels diverticulitis. Surprisingly, the lesion has a signifigant mortality rate of 510%. About 50% of Meckels will have ectopic gastric mucosa. The ulceration caused by the secretion of acid will be in the adjacent ileum and not in the diverticulum, so in surgery for a lower GI bleed caused by a Meckels, the diverticulum and a

segment of ileum should be removed. Depending on the rate of blood loss, it may present to the rectum as bright red blood or as a maroon colored stool. Acid secreting gastric mucosa can be labeled with 99mTcpertechnetate. Ulcerative colitis. Patients on chemotherapy regimes are sometimes vulnerable to extensive mucosal ulceration, necrosis and hemorrhage. The pathogenesis of this lesion is unclear but it seems more likely to occur in the proximal colon. Systemic

sepsis and toxemia as well as GI bleeding may result. Cecal cancer Infiltrating carcinomas in the colon very seldom bleed acutely. An erosion of the tumor leads to oozing of blood from these small vessels, which mixes with the stool and may not ever be noticed by the patient. In other instances traces or smudges of blood are seen on the stool or in the toilet water intermittently. A continuous and significant GI bleed is unusual. Liquidi dellorganismo L'acqua totale del corpo (total body water = TBW) rappresenta circa il 60-70% del peso corporeo.

Compartimento Intra-cellulare Extracellulare (liquido interstiziale ) Volume (L) % TBW 23.0 55 8.4 20

Osso Intravascolare (plasma) Cavit del corpo 6.3 15 3.2 7.5 1.1 2.5

42.0 100 Totale Classificazione delle emorragie Classe Quadro clinico % di perdita di volume ematico I

Tachicardia 15 II Ipotensione ortostatica 20-25 III Ipotensione in clinostatismo Oliguria

30-40 IV Obnubilamento del sensorio Collasso cardiocircolatorio oltre 40 Committee on Trauma, American College of Surgeons. Advanced Trauma Life Support ATLS . Early care of the injured patient. 3rd ed. Philadelphia: WB Saunders, 1982. Classificazione delle emorragie Classe

Quadro clinico Riduz. volemia I Modificaz. cardiocircolatorie assenti o minime, Ht >30%, Hb >10 g%, perdita ematica stimata <1000 ml. Non alteraz. dei parametri vitali, non necessaria resuscitaz. con fluidi. fino a 15% modesta

Tachicardia e calo pressorio, vasocostriz. periferica, Ht 20-30%, Grave compens Hb 8-10 g%, perdita ematica stimata 1000-2000 ml. Necessaria ata resuscitaz. con cristalloidi (NaCl o Ringer lattato), non richieste emotrasfusioni se compenso emodinamico agevole. II 20-25%

Classificazione delle emorragie Classe Quadro clinico Shock conclamato (ipotens. Grave marcata, tachicardia, grave scompen deficit perfusione periferica, sata obnubilamento sensorio), Ht <20%, Hb<7 g%, perdita ematica stimata >1500 ml. Necessit di resuscitaz. con cristalloidi e con emotrasfusioni. Compenso

emodinamico difficile o instabile III Riduz. volemia 30-40% Classificazione delle emorragie Classe Quadro clinico Stato di shock grave e Gravissi progressivo per raggiunti limiti di ma, compenso circolatorio.

irreversi Necessit di resuscitazione bile aggressiva morte. IV Riduz. volemia > 40% Quali sono i sintomi classici di una emorragia acuta? Ogni segno di sanguinamento (ematemesi, ematochezia, melena, ecc.) Debolezza e fiacchezza progressiva Perdita del tono muscolare Affaticabilit ingravescente

Senso di languore Capogiro e vertigini Accorciamento del respiro (respiro corto, frequente, superficiale) Dolore addominale crampiforme Diarrea (il sangue un ottimo catartico!) Ipotensione ortostatica ( della PA > a 10 mmHg) Instabilit emodinamica e shock (tachicardia, ipotensione, polipnea, oliguria-anuria, pallore cutaneo) Sintomi di una emorragia acuta del tubo GI Inizialmente Ematemesi Melena Ematochezia Tachicardia (polso piccolo e frequente)

Ipotensione Riduzione della diuresi Cute ed estremit pallide, fredde, sudate Debolezza e fiacchezza (perdita del tono muscolare ) Vertigini Dolore addominale (da iperperistaltismo) Diarrea (il sangue un potente catartico) Se lemorragia persiste o in assenza di trattamento Confusione, disorientamento mentale, sopore Stato di shock Modificazioni fisiologiche nello shock ipovolemico Perdita ematica ml Perdita ematica %

<750 <15% 750-1250 15%-25% 1250-2000 25%-40% > 2000 >40% Frequenza cardiaca Pressione arteriosa Frequenza

respiratoria Entit della diuresi Normale Normale Normale/ Normale

Normale Oliguria Anuria Stato mentale

Minima ansiet Media ansiet Confusione Stato letargico Parametri clinici nello shock Tipo di Cute shock

Ipovol. Cardiog. Settico early Settico late Neurog. Diure si Fredd. pallida Fredd. pallida

Calda rossa Fredd. pallida Caldarossa Turg. Giugul. Indice Pres.ne Resiste cardia polmon. nze co bloccata vascol. Perifer.

Conten. misto di O2

Nova Scotia Canada Quali sono i sintomi di emorragia cronica ? Ogni segno di sanguinamento Debolezza e fiacchezza progressiva Affaticabilit ingravescente Accorciamento del respiro

Pallore Sopore Stato anemico Come si fa diagnosi di emorragia acuta del tratto digestivo? Va identificata la fonte di sanguinamento ! anamnesi esame fisico indagini di laboratorio, strumentali (endoscopia), radiologiche (CT scan, angiografia), scintigrafiche Come si tratta una emorragia acuta del tubo digerente? Applicazione

di sonde emostatiche, infusione di farmaci particolari, sclerosi endoscopica, posizionamento di anelli, clip o agrafes, Laserterapia, embolizzazione selettiva, chirurgia in caso di insuccesso dei provvedimenti elencati. Emorragie del tratto GI. Valutazione iniziale Costante controllo dei parametri vitali (PA e frequenza del polso)

Stato cardiovascolare controllo perfusione periferica (colorito e temperatura cutanea) Stato neurologico (livello di coscienza e stato mentale perfusione cerebrale: letargia, sonnolenza, delirio, incoscienza). In genere il paziente presenta PA< 90mmHg e diuresi oraria<20ml/h o shift 250 ml/8h. Posizionare catetere vescicale Posizionare catetere venoso (14-16 gauge) Ripristinare il volume vascolare con cristalloidi. Monitorizzare la saturazione di O (ossimetro digitale) 2 Trasfondere pappe di GR, plasma fresco, piastrine (se necessario) Treating Shock - ABCDEs Airway clear?

Be careful of suspected cervical spine injury Breathing adequate? Give oxygen and support ventilation Circulation Stop external bleeding I.V. Cannulation Crossmatch sample Resuscitate with IV fluids Diagnose problem

Undress and expose Establish Treatment priorities for definitive care Emorragie del tratto GI. Principi di trattamento Assicurare la perviet delle vie aeree aspirazione di sangue nellalbero tracheobronchiale nel paziente debilitato (stato di shock, sopore/coma,encefalopatia epatica, ematemesi massiva, emorragia attiva da varici esofagee) Intubazione oro-tracheale

Parametri vitali (PA e frequenza del polso) ipotensione e tachicardia in decubito supino ipovolemia severa. Una caduta della Pr sistolica >15 mmHg o un aumento della frequenza del polso >15battiti/min indica ipotensione ortostatica per significativa ipovolemia. Misure immediate in caso di emorragia massiva GI Stabilizzare lemodinamica: Catetere ev ed infusione di soluzioni isotoniche di cristalloidi (sodio cloruro e Ringer lattato) Verificare e mantenere la perviet delle vie aeree Catetere vescicale (diuresi oraria) Porre SNG (sangue nello stomaco?)

Esplorazione rettale (sangue?) Esofago-gastroscopia (diagnostica-terapeutica) Retto-colonscopia (diagnostica-terapeutica) Espansione del volume vascolare Infondere rapidamente un bolo di 500-1000 ml di soluzione salina isotonica o di Ringer lattato (PA e frequenza del polso); ripetere, se necessario, 2 e 3 bolo per mantenere una PA valida (Linfusione rapida nel cardiopatico pu dare edema polmonare !!). Resuscitazione iniziale Ematocrito in fase acuta non parametro affidabile della perdita ematica (equilibrio fra spazio extravascolare ed intravascolare). Ht di 30 nellanziano, fra <20-25 nel giovane. Trasfondere sangue (i cristalloidi espandono il compartimento

extravascolare, ma non hanno oxygen-carrying capacity of blood). Posizionare CVC Monitorizzare la coagulazione Stabilizzato il paziente, precisazione diagnostica e trattamento definitivo della causa di emorragia. EMORRAGIA ACUTA Volume ematico normale Maschi: BV= 70 ml/Kg o 3,2 L/M2 Femmine: BV= 60 ml/Kg o 2,9 L/M2 Fraz. della perdita ematica Perdita (%) Reintegrazione (%)

Non segni clinici <20 20 Ortostasi 20 20 Ipotensione in supinazione 20-35 30 Organ failure >35 50 Deficit di volume Deficit di volume = % della perdita x normale volume ematico Regole di resuscitazione

Sangue intero = 1.0 x deficit volumetrico FIGURE 44-1. Algorithm for the management of upper gastrointestinal bleeding UGIB. NSAID, nonsteroidal anti-inflammatory drug; PPI, proton-pump inhibitor; LGIB, lower gastrointestinal bleeding;

AGML, acute gastric mucosal lesions; OR, operating room. Indications for Emergency Surgery Pre-Endoscopic era Shock on admission Uncontrolled bleeding Onset of bleeding in hospital Endoscopic appearance of ulcer Recurrent episodes of bleeding Over 60 years of age Endoscopic era Failure of therapy Upper GI bleeding

Principles of Emergency Surgery Duodenal ulcer Oversew Ligate vessel Gastric ulcer Ligate vessel Resect or biopsy ulcer Diffuse mucosal lesion Vagotomy (truncal+piloroplasty; highly selective) +/- gastrectomy Upper GI bleeding Resezione Gastrica Billroth I / Billroth II FIGURE 44-3A. Lines mark limits

of gastric resection for antrectomy. For patients with more proximal gastric ulcers, the proximal line of resection can be extended or tailored to include the ulcer in the resection. FIGURE 44-3B. Billroth I reconstruction with

gastroduodenostom y. Note that truncal vagotomy is included in the procedure. Billroth I FIGURE 44-2A. A , During truncal vagotomy, both vagal trunks are divided at the esophageal hiatus. The vagal branches to the

gastric cardia, fundus, antrum, and pylorus are divided, as are the hepatic and celiac branches. A gastric-emptying procedure, either pyloroplasty or gastrojejunostomy, is required because pyloric opening is impaired. Vagotomia Tronculare +piloroplastica-Truncal vagotomy

and parietal cell vagotomy. FIGURE 44-2B. Parietal cell vagotomy denervates only the parietal cell mass. Innervation of the antropyloric region and the hepatic and celiac branches is preserved. Parietal cell vagotomy preserves normal gastric emptying, but the procedure requires considerably longer operative time and

should be used only in stable patients who do not have significant risk factors for poor outcome. Vagotomia selettiva Endoscopic Therapeutic Options in Acute Upper GI Bleeding Injection Thermal Heater probe Bipolar probe Nd:YAG laser

Argon plasma coagulator Mechanical Hemoclips Banding FIGURE 44-4. Algorithm for the management of acute hemorrhage due to portal hypertension. TIPS, transjugular intrahepatic portosystemic shunt. Acute Upper GI Bleed 20%

80% Bleeding stops Survival Bleeding continues or recurs Death 8%

FIGURE 44-5. Diagnostic steps in the evaluation of acute lower gastrointestinal hemorrhage. RBC, red blood cell. Opzioni di trattamento nelle Emorragie Massive del tratto GI Distale Diagnostiche

Anoscopia Sigmoidoscopia Colonscopia Enteroscopia Clisma del tenue Scintigrafia Angiografia Endoscopia intraoperatoria Terapeutiche Endoscopiche Termiche Iniettive Coagulaz. argon

plasma Polipectomia Angiografiche Vasopressina Chirurgiche Endoscopic Therapeutic Options in Acute Lower GI Bleeding Injection Thermal Heater probe Bipolar probe Nd:YAG laser Argon plasma coagulator Mechanical

Hemoclips Banding Endoscopic Therapy in LGI Bleeding Diagnosis Hemorrhoids Radiation proctitis Diverticulosis Polyps Post-polypectomy

Angiodysplasia Therapy Injection, banding Argon plasma coagulator, thermal probe, laser Injection, thermal probe polipectomy Injection, thermal probe, clips

Thermal probe, laser Black Hills ACUTE HEMHORRAGE The maximum infusion rate for intravenous fluids is determined by the size of the catheter and not by the size of the vein that is cannulated. ACUTE HEMHORRAGE The goal of fluid therapy for mild hemorrhage is to fill the interstitial space, not the vascular space. This is the rationale for using saline (sodium chloride) fluids for the

resuscitation of mild hemorrhage. ACUTE HEMHORRAGE Blood transfusion to correct anemia does not ensure that tissue oxygenation is also improved. Therefore, the hemoglobin can be misleading as a guide for blood transfusion therapy. Alaska highway Yukon

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