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CE for Nurses: Nursing Assessment of Intraluminal and Intraperitoneal Hemorrhage Following Bariatric Surgery

| June 1, 2016

*This is a Complimentary Clinical Nursing Education Activity*

Nurses: Earn 1 Contact Hour.


Complimentary Continuing Education Course: Nursing Assessment of Intraluminal and Intraperitoneal Hemorrhage Following Bariatric Surgery

TemplateTake the test at http://tinyurl.com/BTCEJune2016

Participants must read the designated article and take, submit, and pass the post-test by June 1, 2017. Participants must answer at least 70% of the post-test questions correctly to pass and receive credit for the activity. Upon successful completion of the post-test, participants will receive a certificate of completion. NOTE: Hard copy responses will not be accepted.

Course Overview: Anastomotic leaks, anastomotic strictures, and internal hernias are more commonly described in bariatric educational courses and literature. However, hemorrhage, both intra-abdominal and intra-peritoneal, can be more challenging due to the infrequency of their occurrence, and yet a very life threatening postoperative complication following bariatric surgery. This educational program will describe the etiology, signs and symptoms, nursing assessment, and interventions to address intraluminal versus intraperitoneal hemorrhage.

Course Description: This educational program is designed to educate, through independent study, nursing clinicians who care for the post-operative bariatric surgical patient on assessment and nursing interventions for the postoperative patient with intraluminal and intraperitoneal hemorrhage following bariatric surgery.

Course Objectives: Upon completion of this program, the participant should be able to:
1.) List the differentiating symptoms between intraluminal and intraperitoneal hemorrhage.
2.) Explain the common causes associated with intraluminal and intraperitoneal hemorrhage following bariatric surgery.
3.) Identify the essential nursing assessments skills when assessing a patient for a postoperative bleeding complication.
4.) Discuss the appropriate nursing interventions for a patient with postoperative intraluminal and intraperitoneal hemorrhage.

Completion Time: This educational activity is accredited for a total of 1.0 contact hour.

Target Audience: This accredited program is intended for nurses who treat patients with obesity.

Provider: This educational program is provided by Matrix Medical Communications. Provider approved by the California Board of Registered Nursing, Provider Number 14887, for 1.0 contact hour.

About the Instructor: Dr. Wittgrove is Medical Director of Wittgrove Bariatric Center in La Jolla, California. He is a board certified bariatric surgeon who has been performing bariatric surgery for over 30 years. He performed the first laparoscopic gastric bypass in November 1993. He performs gastric bypass, sleeve gastrectomy, revision surgery in a multi-disciplinary setting in Del Mar, California. He is the past president of the American Society for Metabolic and Bariatric Surgery. Disclosures: Dr. Wittgrove is a consultant for Ethicon Inc. (Cincinnati, Ohio).

Support for this educational activity is provided by Ethicon

Provider Contact Information: Angela M. Saba, Matrix Medical Communications, 1595 Paoli Pike,Suite 201, West Chester, PA 19380; E-mail: asaba@matrixmedcom.com


Complimentary Continuing Education Course: Nursing Assessment of Intraluminal and Intraperitoneal Hemorrhage Following Bariatric Surgery

by Alan C. Wittgrove MD, FACS, FAMBS
Dr. Wittgrove is Medical Director of Wittgrove Bariatric Center in La Jolla, California. He is also a past president of the American Society for Metabolic and Bariatric Surgery.

ABSTRACT
Anastomotic leaks, anastomotic strictures, and internal hernias are more commonly described in bariatric educational courses and literature. However, hemorrhage, both intra-abdominal and intra-peritoneal, can be more challenging due to the infrequency of their occurrence, and yet a very life-threatening postoperative complication following bariatric surgery. This educational program will describe the etiology, signs and symptoms, nursing assessment, and interventions to address intraluminal versus intraperitoneal hemorrhage.

Bariatric Times. 2016;13(6):10–17.


Introduction
Although the complication rate following bariatric surgery is low, complications may still occur in even the most experienced hands. Most patients undergoing surgical treatment for their obesity have numerous other comorbidities that can further aggravate postoperative complications. Diligent nursing assessment is imperative for a prompt medical response and accurate interventions to promote the best chance of patient recovery and survival. Bleeding after bariatric surgery is not common, however, it can be life threatening and challenging to assess and manage. Nurses play an extremely important role postoperatively because they are with the patient more than any other team member during the acute postoperative phase, the hospital stay. As importantly, since the length of stay for patients is one or two days, the clinical staff in the office setting are often fielding and triaging patient calls.

Overview
Most complications from bariatric surgery require identification and treatment, but many are not urgent or emergent. Postoperative bleeding (or hemorrhage) requires urgent, if not emergent recognition and treatment. This article will outline how the patient usually presents but it should be understood that not every patient has classic signs and symptoms. The classic signs and symptoms of a postoperative bleed are pallor, hypotension, orthostatic changes inducing dizziness, mental confusion, tachycardia, hematemesis (if intraluminal), bright red blood per rectum (if intraluminal), drop in the hematocrit/hemoglobin level, increased bloody fluid from the abdominal drains, and low urine output.[1] Since bariatric patients in general have at least some degree of metabolic disease burden, it is incumbent on the healthcare professional to be attentive and compulsive about their approach to the postoperative patient. Early identification of complications begins with well-trained nursing staff. Routine care pathways, which aid in timely and keen assessment, often can be the difference between a complication that was an inconvenience to the patient and one that is life-threatening to the patient. If we design the care pathway with the classic presentation of the patient presenting with a postoperative bleed, we would include frequent and early vital signs, documentation of the urine output (more often than once a shift), and obtaining a hematocrit every 12 hours for the first 24 hours. Together with these signs, an overall assessment of the general progression of the patient through the first 24 hours following surgery will give the practitioner a good understanding as to whether this is a complicated postoperative case.

Staple Line Bleeding
Over the years, bariatric surgery has shifted from open laparotomy cases to primarily laparoscopic cases. With this change we have found a higher incidence of postoperative bleeding.[2] During a standard laparoscopic gastric bypass, multiple staple lines are created (Figure 1). These include about 60cm of everted or visible staple lines as well as about 70cm of intraluminal staple lines. Bleeding from these staple lines may either occur from the transected tissue edges or at the sites where the staples penetrate the mucosa of the bowel wall. During the primary surgery, it is important for the surgeon to use the appropriate staple load size and height based on the case details and the patient’s anatomy. There are several different types of staples available to the surgeon. The main difference is the length of the staple leg height. This becomes important because if a short staple is used, for example, in very thick tissue, the staple leg might not be long enough to bend into the proper configuration to adequately compress the tissue. Through the years of staple technology development, the various manufacturers have produced guidelines for their product’s use. If these recommendations are not followed, there may be a higher incidence of postoperative bleeding.  Recommendations include the following: holding pressure on the device for 30 seconds before firing the stapler to allow extrusion of tissue fluid, resisting the temptation to force more tissue into the jaws of the stapler, eliminating torque on the instrument, and using a larger stapler load when using buttress material.[3]

Several authors have reviewed this topic and postulated the following: there are more surgeons using antithrombotics for deep venous thrombosis prophylaxis in the laparoscopic era,[2] the learning curve is involved with the incidence, changes in stapling products and techniques have been involved in the transition and therefore may play a role and a variance in reporting techniques. Though there have been several postulated reasons for this increased incidence,[4,5] the exact explanation is unknown. Two patient variables have been identified with a higher incidence of postoperative bleeding: 1) prior bariatric surgery and 2) diabetes.1 Though the risk of postoperative bleeding is higher with the use of antithrombotic agents, this risk appears to be an acceptable tradeoff for most bariatric surgeons as the risk of deep vein thrombosis/pulmonary embolism with a bad outcome is more profound than that of a bleed.[3] Interestingly, the incidence of postoperative bleeding seems to be decreasing more recently.[6] This may be related to change in staple design, improved surgeon technique, use of more sophisticated energy sources (e.g., harmonic scalpel), hemostatic products, such as “fibrin glue,” and staple-line reinforcement products.[7,8]

Intraluminal and Intraperitoneal Hemorrhage
There are two types of postoperative hemorrhage, or bleeding, which occur following bariatric surgery: 1) intraperitoneal or 2) intraluminal. Intraperitoneal bleeding (IPB) is bleeding into the abdominal cavity from either dissected tissues; trocar sites; or staple lines at the gastrojejunostomy, the gastric pouch, the enteroenterostomy, or the excluded stomach (Figure 2 and Figure 3). Intraluminal bleeding (ILB) is bleeding into the lumen of the bowel. ILB can occur for a number of medical or surgical reasons, either early or late in the patient’s course. Late ILB is usually from ulcer disease in the gastric bypass and is much less common in the sleeve gastrectomy procedure. The etiology of these ulcers can stem from ischemia, tension, Helicobacter pylori, tobacco use, use of nonsteroidal anti-inflammatory drugs (NSAIDs), high acidity, fistula formation, and various suture material. This article is mainly focused on the acute postoperative phase and the etiology of ILB is at the staple lines of the afore-noted sites.

It is important to note that these bleeding episodes are generally either one or the other, meaning that the patient presents with bleeding and the healthcare provider is tasked with determining if the etiology is intraluminal or intraperitoneal. On rare occasions, the patient will present with both and intraluminal and an intraperitoneal hemorrhage. This is almost always associated with a leak (bleeding on both sides of the bowel wall would lead one to assume there is discontinuity of the bowel wall). In these situations, early re-exploration should be strongly considered.

Diagnosis: Assessing the signs and symptoms
The diagnosis of postoperative bleeding can, at times, be quite challenging.6 Often the clinician has determined there is bleeding, but it may be difficult to determine if the source is intraluminal or intraperitoneal (Table 1). If the patient is experiencing hematemesis or melena, the etiology would be clearly ILB even though the specific location may not be delineated. The patient might even pass bright red blood per rectum with an upper GI bleeding source postoperatively. This generally indicates brisk bleeding. If the surgeon uses intraperitoneal drains and a significant amount of bloody drainage is seen in the drain, the diagnosis is less difficult as well. The difficulty lies in the bariatric patient’s body habitus and anatomic changes that were created surgically. The classic sign of IPB of distention, for example, is not helpful in this population. A large portion of the stomach is sectioned off in a gastric bypass and therefore is not readily available for endoscopic evaluation. We must rely more on the signs and symptoms noted previously and further explore.

Tachycardia is defined in different ways depending on the situation. In general, tachycardia is defined as a pulse greater than 100 beats per minute. In the postoperative bariatric case, most authors use greater than 120 beats per minute as the definition of tachycardia. Tachycardia is often a very helpful indicator when trying to determine if there is a postoperative complication. Again, it must be emphasized that there is a significant number of bariatric patients who use beta blockers and this usage will clearly modify this response. It should also be noted that the tachycardia from bleeding is often more cyclical in nature as opposed to the more sustained tachycardia seen with a leak or sepsis. A pulse greater than 120 bpm is an indicator that this is a patient who needs to be evaluated more closely. In sepsis, there is often a sustained tachycardia where the pulse rate is constantly over 120 bpm on each reading for hours. With bleeding, there may be a reading of 120 bpm and an hour later the pulse maybe 115 bpm. This nonsustained curve can pacify the clinician, but one needs to stay alert and look for other signs or symptoms earlier rather than later in the patient’s course.

The specific staple line location responsible for the ILB (in the gastric bypass patient) has been reported by several authors and, although the “majority” of bleeds have been assigned to different locations by the different authors, the bleeding sites are essential;y equally divided between three locations: gastric pouch, gastric remnant, and the enteroenterostomy.[1,6,9,10] In the sleeve gastrectomy, there is one staple line, but it is the longest staple line created in general surgery.

Treatment
Once it is determined that the patient has experienced a postoperative bleed, it is important to begin treatment quickly (Table 2). Often, a significant amount of blood is already lost before it becomes clinically apparent, so time can be critical. The surgeon should be called immediately. Since blood loss is the main issue, fluid resuscitation must begin quickly and the patient’s response needs close monitoring. Early resuscitation and subsequent monitoring are imperative to insure best possible outcomes. Oxygen supplementation should be considered early in the course of treatment and all staff members should emotionally support the patient. These situations often involve times where obvious blood is seen and it is understandable that this is upsetting to most individuals.  Care might be given at a rapid rate and clinicians should keep mindful that there is a patient at the end of the blood pressure cuff that needs reassurance. Next, remember to stop all medications that can continue to aggravate the issue. Stop all anticoagulants; any medications which can alter the clotting mechanism or prolong the bleeding time. More frequent monitoring will be required and, in some institutions, that means transfer to another unit with higher acuity. The patient requires more frequent vital signs to determine hemodynamic stability and assess the response to resuscitation. Blood for type and screen/cross should be ordered acutely when the diagnosis is questioned. A Foley catheter should be inserted since urine output is a very sensitive screen by which the response to resuscitation can be detected. Serial hemograms are needed as well. If the patient is hemodynamically stable, further testing can be ordered. In the unstable patient, emergent surgical exploration may be required. Endoscopy can be performed at the bedside and can be diagnostic as well as therapeutic for an ILB. The endoscopist might be able to identify the location of the ILB, apply clips, and inject or coagulate the area to stop the bleeding. Endoscopy is limited, however, to the proximal stomach and usually cannot visualize the enteroenterostomy or the defunctionalized gastric remnant. Endoscopy is only therapeutic for ILB and therefore the differentiation between IPB and ILB again becomes important.

The vast majority of early postoperative bleeds stop without operative intervention (over 80%).[1] Though this is important to remember, it should not allow the healthcare provider to become complacent because this still represents a potentially life-threatening process. The statistics of good outcomes without re-operation are built within a system that institutes early resuscitation and monitors the patient’s response.

In a review of this topic, it was found of acute bleeding after laparoscopic gastric bypass that 89 of 2,895 total patients had clinically significant postoperative hemorrhage, and only 20 percent required reoperation.[3] The majority of patients were successfully managed with observation, resuscitation with fluid and/or blood, and, in some cases, endoscopy.[9] Of the patients who were managed nonoperatively, 20 percent did not require a blood transfusion.[3] It must be pointed out that these patients remain clinically stable and since the bleeding stopped spontaneously, no site of bleeding was determined. Fifty-five percent of patients required fluid and blood replacement, but did not undergo diagnostic or therapeutic interventions. In 15 percent of the patients, clinical evidence prompted urgent endoscopy, which was diagnostic in five cases, therapeutic in six cases, and used to guide operative intervention in two cases.[3]

Postoperative bleeding occurring within six hours after the primary surgery usually indicates a situation which requires emergent re-operation.[8,11,12] The patient can present with hematemesis or bright red blood per rectum, rapidly falling hematocrit (Hct), and hemodynamic instability. Abdominal re-exploration is indicated either laparoscopically or open. The surgical approach is determined by the surgeon but is influenced by degree of hemodynamically instability. The laparoscopic approach may be relatively contraindicated as the pneumoperitoneum and resultant increased intra-abdominal pressure may worsen the hemodynamic picture.

Differentiation between Intraluminal and Intraperitoneal Bleeding
Once it is determined that the patient is bleeding and resuscitation has begun, the next task is to determine whether it is IPB or ILB and intervention is required. Although many patients’ bleeding stops before determining the etiology of the bleed, it is important to know what diagnostic tools are available when you are treating a patient with a falling Hct, low urine output, and tachycardia. Diagnostic tools are determined by the patient’s hemodynamic stability. Most studies in the literature do not recommend tagged red cell studies, and angiographic embolization may place a fresh anastomosis at risk, so that modality is generally not used either.[2,3,6] Computed tomography (CT) scan can be used in the stable patient and can be important in differentiating between the locations. In the case of the IPB, the CT can visualize a fluid collection in an extra luminal location; whereas, in the ILB there may be clot seen in the lumen of the bowel or distention of the remnant stomach.[13]

It is important to fully assess the clinical picture as this may point to the etiology of the bleed. In general blood is an irritant to the bowel. If the bleeding is within the lumen of the bowel, this irritation causes more bowel activity or hyperactive bowel movements. Typically, the bowel movement is black to maroon (or even bright red if the bleeding is fast enough). If the blood is on the outside of the bowel (i.e., extra luminal), the irritation causes an ileus picture or a slowdown of GI function.
The following common scenarios may help the clinician determine the source of the postoperative hemorrhage.
•    Hematemesis suggests bleeding from the gastrojejunostomy or gastric pouch in a gastric bypass.
•    Severe left upper quadrant pain, back and shoulder pain, hiccups (indicating diaphragmatic irritation from the expanding stomach), or severe nausea with retching and melena suggests bleeding in the remnant stomach.6
•    Bright red blood per rectum or melena suggests bleeding from the enteroenterostomy but this can occur from any intraluminal site.
•    Bright red blood from the surgical drain indicates IPB, but don’t be misled by no bloody drain output. Remember, clots cannot go through most surgical drains. Multiple bleeding sites are also possibly creating a mixed clinical picture.

Surgical Intervention
The primary goals of surgical intervention are to evacuate the majority of the clot and attempt to identify and control the site of hemorrhage. Often, on re-exploration, the hemorrhage appears to have stopped. Evacuation of the clot is still important since intraperitoneal blood can cause an ileus pattern. If the site of bleeding is apparent, the surgeon can use sutures or hemostatic devices or topical agent to achieve hemostasis. If the patient is hemodynamically unstable or a bleeding site is not identifiable, the preferred surgical technique is to oversew all staple lines.[6] It is important to determine if the defunctionalized stomach is distended with clot during the exploration. If this scenario is found, the surgeon should evacuate the clot and place a gastrostomy tube.

Conclusion
Early postoperative bleeding can occur in up to four percent of primary bariatric cases. The etiology of these bleeds can be either intraluminal or intra peritoneal. A significant amount of blood is lost before clinical signs change and therefore all healthcare professionals need to be vigilant and compulsive in the care of these patients to best insure successful outcomes. Rapid resuscitation and monitoring are imperative. Studies show that the majority of these patients can be managed non-operatively. The patients who require re-operation are generally those who manifest bleeding within the first 6 to 12 hours postoperatively.

References
1.    Rabl C, Peeva S, Prado K, Campos GM. Early and late abdominal bleeding after Roux-en-Y gastric bypass: sources and tailored therapeutic strategies. Obes Surg. 2011;21(4):413–420.
2.    Nguyen N, Longoria M, Chalifoux S, Wilson S. Gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg. 2004;14(10):1308–1312.
3.    Spaw A, Husted J. Bleeding after laparoscopic gastric bypass: Case report and literature review. Surg Obes Relat Dis. 2005;1(2):99–103.
4.    Shin R. Evaluation of the learning curve for laparoscopic Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis. 2005;1(2):91–94.
5.    Ballantyne G, Ewing D, Capella R, et al. The learning curve measured by operating times for laparoscopic and open gastric bypass: roles of surgeons experience, institutional experience, body mass index, and fellowship training. Obes Surg. 2005;15(2)172–182.
6.    Mehran A, Szomstein S, Zundel N, Rosenthal R. Management of acute bleeding after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2003;13(6):842–847.
7.    Lee M, Provost D, Jones D. Use of fibrin sealant in laparoscopic gastric bypass for the morbidly obese. Obes Surg. 2004;14(10):1321–136.
8.    Nguyen N, Rivers R, Wolf B. Early gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg. 2003;13(1):62–65.
9.    Fernandez-Esparrach G, Bodas J, Pellise M, et al. Endoscopic management of early GI hemorrhage after laparoscopic gastric bypass. Gastrointest Endosc. 2008;67(3):5525.
10.    Heneghan HM, Meron-Eldar S, Yenumula P, Rogula T, Brethauer SA, Schauer PR. Incidence and management of bleeding complications after gastric bypass surgery in the morbidly obese. Surg Obes Relat Dis. 2012 Nov-Dec;8(6):729-35.
11.    Acquafresca PA, Palermo M, Rogula T, Duza GE, Serra E. Early surgical complications after gastric by-pass: a literature review. Arq Bras Cir Dig. 2015;28(1):74–80.
12.    Griffith PS, Birch DW, Sharma AM, Karmali S.Managing complications associated with laparoscopic Roux-en-Y gastric bypass for morbid obesity. Can J Surg. 2012;55(5):329–336.
13.    Blachar A, Federle MP. Gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass surgery in patients who are morbidly obese: findings on radiography and CT. AJR Am J Roentgenol. 2002;179:1437–1442.

FUNDING: No funding was provided.

DISCLOSURES: Dr. Wittgrove is a consultant for Ethicon Inc. (Cincinnati, Ohio).

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