Why was an open abdominal exploration performed instead of an endoscopy (upper GI scope) for a patient with severe vomiting and gastrointestinal bleeding?

Why Open Abdominal Exploration Was Performed Instead of Endoscopy

The provider likely performed open abdominal exploration because the patient was hemodynamically unstable despite aggressive resuscitation, making immediate surgical hemostasis mandatory to prevent death. 1

Clinical Decision Algorithm for Vomiting and GI Bleeding

Hemodynamic Status Determines the Approach

For unstable patients (shock index >1 after resuscitation):

• Diagnostic laparotomy with surgical hemostasis is mandatory when patients remain unstable despite aggressive fluid resuscitation. 1
• The shock index is calculated as heart rate divided by systolic blood pressure; a value >1 indicates critical instability. 1
• Endoscopy requires hemodynamic stability and airway protection—unstable patients cannot safely tolerate the procedure. 1

For stable patients:

• Endoscopy is the first-line diagnostic and therapeutic tool for GI bleeding. 1
• CT angiography should precede endoscopy if the patient has a shock index >1 but responds to initial resuscitation. 1, 2

Specific Scenarios Requiring Surgery Over Endoscopy

When Endoscopy Is Contraindicated or Has Failed

Immediate surgical exploration is indicated when:

• The patient remains hemodynamically unstable after initial resuscitation (systolic BP <90 mmHg, heart rate >100 bpm despite 1-2 liters crystalloid). 3
• Endoscopic hemostasis has failed and bleeding persists. 1
• CT angiography is negative but clinical signs of ongoing bleeding continue in an unstable patient. 1
• Angioembolization has failed to control intraperitoneal or extra-luminal bleeding. 1

Vomiting as a Complicating Factor

Severe vomiting creates specific risks:

• Active vomiting with hemodynamic instability increases aspiration risk during endoscopy, even with endotracheal intubation. 1
• Vomiting may indicate gastric outlet obstruction from conditions like gastric volvulus, which requires surgical correction rather than endoscopic management. 4
• The combination of vomiting and bleeding suggests potential mechanical obstruction or perforation that endoscopy cannot address. 4

Upper vs. Lower GI Source Considerations

The provider must first localize the bleeding source:

• Hematemesis or coffee-ground vomiting indicates an upper GI source requiring upper endoscopy if the patient is stable. 3, 5
• However, 10-15% of patients with bright red rectal bleeding and hemodynamic instability actually have an upper GI source. 2, 3
• If CT angiography identifies no source in an unstable patient with vomiting and bleeding, immediate upper endoscopy should be performed—but only if the patient can be stabilized. 1, 2
• When stabilization is impossible, surgery cannot be delayed for diagnostic procedures. 1

Critical Pitfalls That Lead to Surgery

Common scenarios where endoscopy is bypassed:

• Delaying surgery while attempting bowel preparation in an unstable patient is dangerous and contraindicated. 1, 2
• Attempting endoscopy without adequate resuscitation (hemoglobin <7 g/dL, ongoing hypotension) risks cardiovascular collapse. 1, 3
• Failure to recognize that vomiting with bleeding may indicate a surgical emergency like volvulus, perforation, or ischemic bowel. 4
• In patients with prior bariatric surgery, internal hernia or anastomotic complications may require immediate surgical exploration. 1

Intraoperative Endoscopy Option

If surgery is performed, intraoperative endoscopy can be utilized:

• The surgeon can perform endoscopy during laparotomy to localize the bleeding site if not immediately visible. 1
• This approach combines the life-saving benefits of surgical hemostasis with diagnostic precision. 1
• A surgical gastrostomy may be created to access difficult areas like the gastric remnant in post-bariatric patients. 1

Bottom Line

The decision to proceed directly to open exploration rather than endoscopy hinges on one critical factor: whether the patient's hemodynamic status allows time for diagnostic procedures. When shock persists despite resuscitation, mortality risk from continued bleeding outweighs the benefits of endoscopic diagnosis, making immediate surgical control of hemorrhage the only appropriate intervention. 1, 3