The management of upper gastro-intestinal tract haemorrhage

Abstract

SUMMARYTwo hundred successive patients with upper gastro-intestinal tract haemorrhage were admitted to a surgical unit for management. One hundred and thirty-five patients (67.5 per cent) had a chronic peptic ulcer, 33 patients (16.5 per cent) had acute lesions (either an erosive gastritis or an acute gastric ulcer), and 32 patients (16 per cent) were a mixture of other diagnoses, of which 13 (6.5 per cent) were simple conditions but 19 (9.5 per cent) were conditions with a bad prognosis, e.g., carcinoma of the stomach, oesophageal varices, aortic aneurysm. Surgery was undertaken for massive, continuing, or recurrent bleeding and was as ' conservative'as thought possible.I n duodenal ulcer this consisted of suture of the ulcer with vagotomy and pyloroplasty, and suture of the ulcer with vagotomy where possible in cases of anastomotic ulcer. I n gastric ulcer onIy those less than 2 cm. in diameter were treated by suture with vagotomy and pyloroplasty. Ulcers greater than 2 cm. in size requiring surgery were treated by gastrectomy.I n the 181 patients whose underlying condition had a good prognosis there were 7 deaths (4 per cent).I n this group 81 operations were carried out; 61 were ' conservative' operations for peptic ulcer, 2 were for repair of a hiatus hernia, and there were 18 gastrectomies, usually for a large gastric ulcer. There were z deaths among the operated patients; I after gastrectomy and I after a ' conservative' operation.There were 5 deaths among the IOO patients in the group which was treated non-operatively. There were 8 deaths among the 19 patients with underlying conditions of grave prognosis. T h e case for the admission of patients with upper gastro-intestinal tract bleeding to a surgical unit is fully discussed and it is advocated together with a selective policy for operation. Where operation is necessary this should be as conservative as possible for bleeding duodenal ulcer, chronic gastric ulcer less than 2 cm. in size (ulcers of larger size may well respond but the method was not assessed for such ulcers), solitary acute gastric ulcer, and anastomotic ulcer. Gastric resection should be retained for the few patients with diffuse erosive gastritis requiring surgery and possibly for patients with a very large chronic peptic ulcer.UPPER gastro-intestinal tract haemorrhage can be a life-threatening emergency, which it has been * Present address : Manchester Royal Infirmary, Oxford t Present address : Stepping Hill Hospital, Stockport.

Survey of Management in Acute upper Gastrointestinal Haemorrhage1

“…The respondents choice of surgical procedure reflects published advice (Ward-McQuaid et al 1960, Clark 1968, Cocks et al 1972, Hegarty et al 1973. It is widely recognized that emergency surgery carries a higher mortality than a semi-elective procedure (Ward-McQuaid et al 1960, Schiller et al 1970, Crook et al 1972, Johnston et al 1973, Heideman et al 1977, but this also reflects the fact that emergency surgery will be chosen more often when patients are bleeding most heavily.…”

Surgery for bleeding peptic ulceration in a district general hospital: morbidity and mortality in one year

“…Physicians emphasise that the majority of ulcers stop bleeding spontaneously and concomitant medical diseases are better treated on medical wards 13 . Some surgeons feel that patients requiring early surgery are more readily identified if all cases are admitted to surgical wards 14 , though the ideal environment is surely a combined gastrointestinal unit 4 , 5 , 6 . Wherever the patient resides, it is surely essential that the surgical registrar on call assesses the situation shortly after admission and ensures that he or a colleague follows the patient's progress in case surgery is called for.…”

Effect of Intravenous Infusion of Propantheline Bromide on Gastric Secretion

“…Surgical vagotomy has a good effect in some patients with massive upper gastro-intestinal bleeding (2,9). However, the operation mortality at emergency operation is high, especially in patients with haemorrhagic gastritis (5).…”