Overview
Definition:
Bariatric internal bleeding refers to hemorrhage occurring within the gastrointestinal tract or abdominal cavity following bariatric surgical procedures, often necessitating prompt diagnosis and management, frequently involving laparoscopic re-exploration to identify and control the bleeding source.
Epidemiology:
Post-operative bleeding is a significant complication of bariatric surgery, with reported rates varying from 1% to 10% depending on the specific procedure (e.g., Roux-en-Y gastric bypass, sleeve gastrectomy) and surgical technique
Early bleeding (within 24-48 hours) is more common and often severe, while later bleeding can occur up to several weeks post-operatively.
Clinical Significance:
Untreated bariatric internal bleeding can lead to hypovolemic shock, organ ischemia, need for blood transfusions, prolonged hospital stays, increased morbidity, and mortality
Prompt recognition and intervention, particularly with minimally invasive techniques like laparoscopic re-exploration, are crucial for favorable outcomes in DNB and NEET SS preparation.
Clinical Presentation
Symptoms:
Tachycardia
Hypotension
Abdominal pain, often severe
Hematemesis (vomiting blood), which can be bright red or coffee-ground
Melena (black, tarry stools)
Hematochezia (bright red blood per rectum) is less common but can indicate massive upper GI bleeding or lower GI source
Dizziness
Syncope (fainting)
Weakness
Signs of hypovolemia.
Signs:
Hypotension (low blood pressure)
Tachycardia (rapid heart rate)
Pallor
Cool, clammy skin
Abdominal distension and tenderness
Guarding or rigidity may indicate intra-abdominal hemorrhage or perforation
Decreased urine output
Altered mental status in severe cases.
Diagnostic Criteria:
No specific formal diagnostic criteria exist, but a diagnosis is strongly suspected in any patient post-bariatric surgery presenting with signs and symptoms suggestive of significant gastrointestinal or intra-abdominal bleeding, especially with hemodynamic instability
Hemoglobin drop is a key indicator.
Diagnostic Approach
History Taking:
Detailed surgical history: type of bariatric procedure, date of surgery, surgeon, operative findings, any intra-operative complications
Onset and character of symptoms: timing, severity, associated factors
Fluid intake and output
Medications (anticoagulants, NSAIDs)
Past medical history (peptic ulcer disease, bleeding disorders)
Red flags: sudden onset of severe pain, hemodynamic instability, large volume of hematemesis or melena.
Physical Examination:
Focused abdominal examination: inspection for distension, scars
auscultation for bowel sounds
palpation for tenderness, rigidity, masses
percussion for tympany or dullness
Assess for signs of shock (pallor, cool extremities, poor capillary refill)
Digital rectal examination to assess for melena or hematochezia
Careful assessment of vital signs: BP, HR, RR, SpO2, temperature.
Investigations:
Laboratory: Complete Blood Count (CBC) to assess hemoglobin and hematocrit levels (serial monitoring is crucial)
Coagulation profile (PT, INR, aPTT)
Liver function tests
Renal function tests
Electrolytes
Imaging: Abdominal X-ray (may show free air if perforation is present)
CT angiography is the gold standard for identifying active bleeding or pseudoaneurysms
contrast-enhanced CT is essential
Upper GI endoscopy (EGD) can be diagnostic and therapeutic if bleeding is accessible and patient is stable enough
Angiography with embolization is both diagnostic and therapeutic for arterial bleeding.
Differential Diagnosis:
Anastomotic leak with secondary bleeding
Marginal ulcer
Marginal ulcer perforation
Gastric staple line dehiscence
Pseudoaneurysm formation
Retained surgical instrument
Gastric pouch distension with erosion
Hematoma compression of visceral structures
Acute gastritis or erosive esophagitis
Esophageal varices (rare in bariatric patients unless other risk factors)
Pancreatitis (can mimic abdominal pain and cause retroperitoneal bleeding).
Management
Initial Management:
Immediate resuscitation: intravenous fluid resuscitation (crystalloids, colloids) to maintain hemodynamic stability
Blood transfusion: Packed Red Blood Cells (PRBCs) to maintain adequate hemoglobin levels (target >7-8 g/dL, higher if cardiac comorbidities)
Oxygen therapy
Nasogastric tube (NGT) placement to decompress the stomach and assess for ongoing bleeding (though less useful in Roux-en-Y bypass)
Hemodynamic monitoring: continuous vital signs, urine output
Consult surgery urgently.
Medical Management:
Proton Pump Inhibitors (PPIs): Intravenous PPIs (e.g., pantoprazole, omeprazole) are administered to reduce gastric acidity and promote healing, especially if gastric or duodenal origin is suspected
Vasopressors may be needed in refractory shock.
Surgical Management:
Laparoscopic Re-exploration: This is often the preferred approach for suspected internal bleeding post-bariatric surgery due to its minimally invasive nature, faster recovery, and reduced complications compared to open surgery
Indications include hemodynamic instability not responding to resuscitation, gross bleeding, or a clear source identified on imaging
The goal is to locate the bleeding site (e.g., staple line, anastomosis, ulcer, pseudoaneurysm), achieve hemostasis (suturing, cautery, clips, stapling), and if necessary, revise or repair compromised areas
Laparotomy may be necessary if the bleeding source cannot be controlled laparoscopically or if the patient is too unstable for a prolonged laparoscopic procedure.
Supportive Care:
Continuous monitoring of vital signs, fluid balance, and laboratory parameters
Nutritional support: Total Parenteral Nutrition (TPN) may be required in severe cases or if oral intake is compromised
Pain management
Antibiotics may be indicated if there is suspicion of infection or leak.
Complications
Early Complications:
Hemorrhagic shock
Organ ischemia due to hypotension
Need for repeated transfusions
Anemia
Complications of resuscitation (fluid overload, electrolyte imbalance)
Extended hospital stay
Conversion to open surgery.
Late Complications:
Bleeding from marginal ulcers
Bleeding from pseudoaneurysms
Stricture formation at the site of repair
Adhesions leading to bowel obstruction
Incisional hernia (if laparotomy was performed)..
Prevention Strategies:
Meticulous surgical technique: careful identification and control of all bleeding vessels during the primary procedure
Use of appropriate stapling devices and techniques
Careful handling of tissues
Prophylactic proton pump inhibitors post-operatively
Careful patient selection and optimization pre-operatively
Close post-operative monitoring for early signs of bleeding
Education of patients on warning signs.
Prognosis
Factors Affecting Prognosis:
Severity of bleeding
Promptness of diagnosis and intervention
Patient's hemodynamic stability
Presence of comorbidities
Location and nature of the bleeding source
Surgeon's experience with laparoscopic re-exploration.
Outcomes:
With timely and effective management, including laparoscopic re-exploration, outcomes for bariatric internal bleeding are generally good
Mortality rates are significantly higher in patients who are hemodynamically unstable or have delayed treatment
Successful control of bleeding usually leads to recovery and allows continuation of the weight loss journey.
Follow Up:
Close monitoring of hemoglobin levels and vital signs post-operatively
Follow-up appointments to assess for recurrent bleeding or other complications
Endoscopic surveillance may be indicated for high-risk patients or those with a history of marginal ulcers
Long-term adherence to PPIs if indicated.
Key Points
Exam Focus:
Recognize the common sources of bleeding post-bariatric surgery: staple lines, anastomoses, marginal ulcers, pseudoaneurysms
Understand the diagnostic algorithm: initial resuscitation, labs, imaging (CT angiography is key)
Laparoscopic re-exploration is the preferred surgical approach for most stable patients
Know the indications for conversion to laparotomy.
Clinical Pearls:
Suspect bleeding in any hemodynamically unstable patient post-bariatric surgery, even without overt GI symptoms
Serial hemoglobin monitoring is more sensitive than a single value
CT angiography is crucial for localizing the bleeding source
Don't delay surgical intervention if there is ongoing significant bleeding or hemodynamic compromise.
Common Mistakes:
Delaying resuscitation while awaiting imaging
Performing endoscopy in an unstable patient without securing airway
Underestimating the volume of blood loss
Failing to consider pseudoaneurysm as a cause of late bleeding
Not adequately preparing for potential conversion to laparotomy during laparoscopic re-exploration.