Acute massive hemorrhage from gastroduodenal ulceration

Acute Massive Hemorrhage from Gastroduodenal Ulceration FRANK W. SPICER,

M.D., JOHN V.

CARBONE, M.D. AND

San Francicso, From the Departmenls of Surgery and Medicine, Universit,v of California School of Medicine, San Francisco,

G. LYON, M.D.,

CLAYTON

California acutely and massively. The average age of these patients was sixty-five. Our purpose is to present a pIan of management of patients with acute massive hemorrhage and discuss how this plan might influence two controversial issues: the indications for

Cali,fornia. FIVE year study of patients with upper gastrointestinal hemorrhage has been conducted on one of t\vo serivces at the San Francisco General Hospital. The patients have been evaIuated by the resident staffs of both the hledical and Surgical Departments and by one attending staff member from each department. Uniform criteria appIied to acuteness, severity and source of bleeding have been foIlowed in evaluation and treatment. Acute hemorrhage means that the patient has had gross bIeeding kvithin five days prior to examination in our hospital. Actually, al1 but two patients who bled acutely and massiveIy had evidence of active bleeding at the time of admission. Massive bleeding means that the hematocrit value has been Iowered to thirty or less, representing an approximate loss of at least 40 per cent of the circuIating red cell mass. These definitions of acute and massive are patterned after those suggested by Stewart et aI.* The diagnosis of g astroduodenal ulcer has been based on a clearc ut history of ulcer or emergency roentgenog ram of the upper gastrointestinal tract or both. Eight hundred seventy-four patients were admitted for gross upper gastrointestinal hemorrhage. (Table I.)Three hundred sixty-six of these qualified as patients with acute massive bleeding. Since we primarily wished to evaIuate the resuIts in gastroduodenal ulceration with hemorrhage, we have excluded from this discussion the patients with hemorrhage due to variccs. In this report, 304 consecutive patients with and without a diagnosis of ulcer bled

A

BLEEDING

FROM

THE

TABLE I liPPER GASTROINTE$TI\AL TRACT*

Gross BIeeding

Total Number of Patients

874

’ .,hlassivc Bleeding

Minor ,/’ BIeeding

366

508

With /.” Diagnosis of UIcer 196'\

\\

* San Francisco Genera1 to January I, 1961.

\\

Without Diagnosis of Ulcer '99 ,

Varix 01

//

395 Hospital

Jnnu:try

[,

1950

immedrate operation and the dilemma of unexpIained bleeding at the operating table. PLAN

OF

MANAGEMENT

One hundred ninety-six patients were judged to have acute massive hemorrhage from gastroduodenal ulceration; the diagnosis was based on reIiabIe history of ulcer or emergent? roentgenogram of upper gastrointestinal tract or both. These patients were managed in the folIowing fashion: Forty-six patients \vith blecd-

* ~IEWAKT, J. D.. MASSOVER, A. J. and POT-IXH, \2’. I I. Mnssivc hemorrhage from gastroduodenal ulcer .$lreerV, 24: 239, 1948. ‘53

AmeG

un .JournuI

ol Surwrr.

Vdum

,#,2.

Aucurr

ioh,

Spicer, TABLE ACUTE

MASSIVELY

ULCER.

Ig6

GASTRODUODENAL

PATIENTS

WITH

Random 22 Patients: Immediate surgical thera y P * Deaths (9%)

/’

DIAGNOSIS

ULCER* Catgorhy

=~tix;Y, 1 Associated Disease S&&on 24 Patients: Immediate nonsurgical therapy \ \ Dekh (4 %)

Per&nt bleeders

Total 23 Deaths (13 %) 53 Persistent bleeders (30 %)

150 Patients: Immediate nonsurgical therapy / / De:ths (15 vu) 44 Persistent bleeders

c381%)

@*I%)

Delayed operation

Delayed 0peratjOn

I

I

I

1

*January

II

Associatefzl Disease

‘\

Deaths (22 %) I, 1956 to January

I Dk:hs (26 %I I, 1961

Deyths (27 a)

ing uIcer had no critica associated disease and were pIaced in category I. A random seIection of numbered cards decided whether initial treatment wouId be nonsurgica1 or surgica1. One hundred fIft y patients with severe hemorrhage had severe associated disease and were pIaced in category II. InitiaI treatment was nonsurgica1. One hundred nine other patients who were bIeeding acuteIy and massiveIy did not have a diagnosis of ulcer confirmed by history or roentgenogram or both and were placed in category 111. InitiaI treatment was nonsurgical. If the initia1 treatment was nonsurgica1 and active bIeeding persisted, the patient was considered a candidate for delayed surgery when his hematocrit failed to rise above 30 per cent despite g units of bIood. In categories I and II comparisons have been made between the resuits of immediate nonsurgica1 and surgica1 therapy and between immediate and deIayed emergency operation. In category III the results of immediate nonsurgica1 therapy were analyzed. CONTROVERSIAL

and Lyon After immediate surgica1 therapy, the mortaIity in category I was g per cent. FoIIowing immediate nonsurgica1 therapy, the tota mortaIity rate was 13 per cent in categories I and II. Seven out of ten deaths were due to hemorrhage rather than major associated disease. In this group of patients who were treated with immediate nonsurgica1 therapy, an additiona 30 per cent persisted in bIeeding and required surgica1 contro1 after receiving g units of bIood. The mortality rate in the group of fifty-three patients who persisted in bIeeding and eventuaIIy had deIayed emergency operation was 26 per cent. Seventy per cent of the patients had a history of chronic uIcer symptoms averaging ten years. In the majority of cases this, in addition to the compIication of bleeding, was indication for eIective gastrectomy. ApproximateIy haIf of the patients who were operated upon had a proved gastric uIcer. AIthough this evidence seems more rea1 than apparent, it is premature to say that these data justify emergency operation on a11 patients bIeeding acutely and massiveIy from documented gastroduodenal uIcer. It is preferabIe to urge immediate emergency operation, at least in those uIcer patients who have no major associated disease and in whom there is a cIearcut indication for eIective gastrectomy. For most other patients bIeeding massiveIy from uIcer, initial nonsurgica1 therapy may be the proper treatment. However, mortaIity figures need further critica anaIysis. The sobering inffuence of surgica1 mortatity in these eIderIy, debiIitated, weIfare patients must be wiseIy interpreted in view of the significant number of nonsurgical deaths due to hemorrhage, the high incidence of persistent bleeding requiring a deIayed emergency operation, the increased mortaIity rate associated with deIayed operation, and the high incidence of chronic ulcer disease which warrants eIective operation. The decision regarding immediate operation is less of a problem when severe upper gastrointestina1 hemorrhage occurs in a patient in whom there is no history of ulcer and in whom the x-ray examination is negative. Initial treatment in this group of patients shouId be nonsurgical and for these reasons: Exsanguination was rare. A number of these patients bIed from sources other than gastroduodena1 uIcer, such as: esophagitis, esophagogastritis associated with hiatus hernia, or gastritis associated with alcoholism. Most patients in this category

II

BLEEDING OF

Carbone

ISSUES

Indications for Immediate Operation. From these comparisons the question is raised whether there is suffkient evidence to support the statement that the patient who bIeeds acuteIy and massiveIy from documented ulcer, warrants an immediate emergency operation. The foIlowing data seem pertinent. (Table II.)

‘54

Gastroduodenal ‘TABLE ACl TE

314SSIYE

INTI~STIUAL I3Y OPERATlON

HEUORRHAGE

TRACT: OR

X-RAY

Ulceration

IL, FROM

L PI’ER

EXAMINATION

GASTRCb-

FOLLOWED

ALTOPSY~SIXTY-NINE

PATIENTS”

Findings

S-ray

findings confirn~~d.

Normal x-ray incorrtct Superficial ulceration.. Substantial ulceration. Pos’t ive x-ray incorrect

Pathologic findings after initial explomtion (70 Vi,) Pathologic findings obvious nftcr partial resection (27 $;, j No pathologic change (3 (-; )

67 84

j

17 10 h

Total.

stopped bIeeding. OnIy one in ten patients persisted in bleeding and after g units of bIood required surgical control. When deIayed emergency operation was finaIIy necessary, the source of bleeding was usuaIIy gastroduodenal ulcer. In only two patients in category 111 was no explanation of bleeding found at the operating table. The Dilemma qf’ Unexplained Bleeding. The fear of finding no explanation for the bIeeding at the operating table is an additiona reason for the frequent procrastination in surgical management. This is a rare occurrence providing the surgeon eIects to operate upon patients with severe hemorrhage who have a documented diagnosis of ulcer or who have no diagnosis of ulcer but persist in bleeding after receiving g units of blood. The next point in this discussion concerns the accuracy of a diagnosis of gastroduodenal ulcer based on a reliable history of ulcer or x-ray Iindings or both. Most of us agree that a history of ulcer in a bleeding patient is very heIpfu1 in establishing :I diagnosis. Seventy per cent of our patients who were operated upon had a definite history of ulcer. Among these the sole error in diagnosis \vas questionable and concerned a proI)able marginal uker. Not everyone agrees that emergency x-ray examination of the upper gastrointestinal tract is as reliable. Eighty per cent of these 307 patients had an emergency x-ray examination. Operation or autopsy followed x-ray examination in sixty-nine patients. (TabIe III.) The value of this study as an aid in diagnosis can be iudgecl only by comparing the unbiased opinion of preoperative s-ray findings with the immcdiatc opernti\,c or postmortem finding. The

52 I2 1’ Oj

I I

2 20

x-ray findings were confirmed in 67 per cent. The x-ray Mm was incorrectly interpreted as being normal in 27 per cent, but in 17 per cent the x-ray film failed to visualize superficial gastroduodena1 ulcerations which was understandable after inspection of the pathologic findings. In 6 per cent, the x-ray film was interpreted incorrectly as being posrtive. To sum up, the x-ray film showed what we thought it should in 84 per cent of the cases. Anv errors were apt to be ones of omission. In patients operated upon with a preoperative diagnosis of gastroduodenal ulcer based on a history of ulcer or x-ray findings or both, no errors were made in diagnosis lzith the exception of one in the patient with a probable marginal ulcer. It should be emphasized that at the operating table, unexpIained bleeding was a common finding after initial examination. After resection had been performed, however, it ~vas very uncommon even though the patient had no preoperative diagnosis of ulcer. Eighty-five patients have been operated upon for acute, massive upper gastrointestinal bleeding---sixty-five patients had a preoperative diagnosis of ulcer and twenty dicl not. (Table IV.) The pathologic fincling could be identified in 70 per cent of the patients after initial exploration. Ulceration was found in another 27 per cent after gastrotomy and resection. In only two and possibly three patients in this large group was no explanation for bleeding found. The significant facts are these: One of four gastroduodena1 uIcers was not identified after initial exploration. When preoperative diagnosis of ulcer \vas lacking, ulcer Leas usually not identified after initial esploration. Unespl:iincd bleeding occurred rareI!- in this scrks of conIii

Spicer,

Carbone

secutive cases and in patients without a preoperative diagnosis of ulcer. Gastric resection foIIowing an initia1 negative expIoration becomes Iess probIematica1 in view of these figures. When the bIeeding site is not identified at the operating table, there are some who feel gastrotomy shouId be performed for the purpose of diagnosis which wit1 then inff uence the decision whether or not to undertake a resection. In view of the high incidence of smaI1, superficia1 ulceration, gastrotomy must constitute an accurate examination if gastric resection depends upon it. Is this the case? Gastrotomy has been performed in twelve patients with unexplained bIeeding after initia1 examination. On six occasions, this procedure discIosed smaI1 gastric uIcerations. In four other cases, the uIcer was missed but was found in the resected specimen. Gastrotomy failed to show four ulcers out of ten when ulceration was present. This is a high incidence of faiIure. UntiI there is more statistical proof of its value, gastrotomy might be performed in order to controI bIeeding or to aIIow remova of blood cIots, but it probably shouId not be undertaken in order to come to a decision regarding gastric resection. It shouId be pointed out that if pathoIogic findings are not found in the resected specimen, the duodenum and the gastric remnant shouId be expIored after resection and before compIeting the operation. SUMMARY

Immediate emergency gastric resection is preferred treatment in patients with a diagnosis of gastroduodena1 uIcer and acute massive hemorrhage who have no major associated disease and in whom there is a cIear-cut indication for elective gastrectomy. For other patients with acute, massive upper gastrointestinal bIeeding, initial nonsurgica1 therapy may be best. The diIemma of unexplained bIeeding is a rare occurrence providing the surgeon operates upon patients with severe hemorrhage who have a diagnosis of ulcer based on history or x-ray findings or both, or who have no diagnosis of ulcer but who persist in bIeeding after receiving 9 units of bIood. DISCUSSION

VICTOR RICHARDS (San Francisco, Calif.): To my knowledge this is the third definitive study

and Lyon which has been made in an attempt to answer the probIem of what is the best treatment for the person with massive bIeeding ulcer. The first approach to this problem was set in motion in 1948 when Dr. Stewart and his group in Buffalo decided that they would lay down certain rigid criteria for evaluation of patients with bIeeding ulcer. One of the great difficulties in this field is that everyone who writes on the subject uses different criteria for judging what he is doing; I was therefore very pleased to see that Dr. Spicer has adhered rather rigidly to the Stewart criteria, which have become accepted in the evaluation of the bleeding ulcer. These criteria are: first, gross bleeding within a week; second, the patient should have lost at Ieast 40 per cent of his tota circuIating bIood volume; and third, the diagnosis of utter seems reasonably we11 established on a clinical basis. Stewart decided to operate on al1 patients, and in his series of 124 cases he had fourteen deaths, which is approximateIy a 13 per cent mortality rate. His was the first controIIed study which shows what might happen with routine operation on every mas:ive bleeder, but it left open to question the virtue of judgment in the patient who is bleeding. The second definitive study was made by Carlson and Dennis, again in New York, in which they tried to evaIuate this intangibIe eIement that we call in dealing with a patient. They “judgment” decided that the best approach to this was the use of the statistical method of random selection of patients. They started off with Stewart’s criteria, so that they followed pretty closeIy the same concepts of treatment, but they empIoyed absoIute random selection in deciding which patient would be treated by nonoperative treatment, which by immediate operation and which by the third method, defined as using “judgment.” The concept of Dunphy and Hoerr was used to “judge” operative intervention. The interesting thing is that, in their series, the rest&s were the same in all three groups, regardless of the patients’ age. They had a 14 per cent mortality rate in fifty-eight cases foIlowing nonoperative treatment; they had a 14 per cent mortality rate in thirty-nine patients in which they empIoyed immediate operation. This, by the way, coincides well with Stewart’s figures. And, they had a 14 per cent mortality rate when they used “judgment.” It was cIear from Karlson’s study that if you don’t operate, a certain number of patients do bleed to death, and this was true even in those of the very young age group. If you do operate on patients after “judgment” or after random selection, the cause of death generally is not from massive hemorrhage but is from a complication of the surgical procedurr.

Gastroduodenal No\v \\c’ have Di-. Spiccr’s analysis, which is the third dclinitivc stutly, and he has done somcthing diffcrcnt. Hc has cxcrciscd judgment before bcginninp the analysis and, as you heard, he catcgorizcd his patients into those who had no assoc.iatcd disease and those who had associated disease \chich might make operation more likely to be indicatcd. It is again dificult to reach any definitive conclusion. It certainly seems clear that immediate operation carries the lowest mortality rate in any and att of these studies, or at least it is equal in trcatmcnt to anything that we do. Secondly, it seems clear that if a patient has had any previous indication for surgery at any time, the surgeon is probably better off operating before the patient rcachcs the stage of massive bleeding, since prophylactic gastric rrscction or prophylactic therapy certainly would seem well justified in the light of the iresults of these stuclics. The third thing that was of interest to me was I hat Dr. Spicer had so few cases in which the diagnosis was no longer in doubt following the operative procedure. I suppose this fits in we11 with the rigid critcr-ia that hc usecl in selecting the cases. I think Dr. Cohn reported hcrc a year ago on a group of elderly patients who were bleeding and who eventually bled to death, and in 30 per cent of them no cause for bleeding leas ever found even at autopsy. I believe that the aged patient might be treated a little bit differently. It would seem that the best rule to follo\v for such patients would be to give them blood transfusions rather rapidly up to a reasonable blood volume. If they continue to bleed, or if they do not come out of shock, incident to proper transfusion, there should be immediate surgical intcrvcntion.

Ulceration Unfortunately, all of this may bc mc,dilictl in the future as our concept as to what the proper- trcatmcnt for ulcer really is and, of course, if those who perform vagotomies and merely tie off the bleeder come up with the answer that they have a lower mortality rate than that from any other proccdurc, even in acute bleeders, all of this may have to bc moditied. I certainly think that studies of this type are extremely important. We have to establish rigid criteria for what we are talking about; WY have to use some sort of statistical approach in a large group of patients, and random selection seems almost essential. For the majority of us who have to await the answer to this problem, it is best that we continue to exercise judgment. Careful consideration of these bleeding patients and the performance of an from cxccssive operation before he is “moribund” hemorrhage will enable us to save many of these massive bleeders. CLAVTOU G. LYON (San Francisco, Calif.): Bill Spiccr and John Carbone have put in a tremendous amount of time during the last live years, making their study. This probably is the third study, too, at this same institution. A number of years ago Dr. Goldman reviewed such cases, and then a little later Dr. Mathewson reviewed others on two comparable services, and these studies were more or less an r\.aluation of treatment and results. But when Dr. Spicer attempted this study, it was quite obvious it was difficult for a surgeon to know the diagnosis in those cases in which he operates purely on judgment. I think this is an earnest effort to categorize the cases so that we will have a little more exact information to go on when faced with patients with known duodenal ulcer.

157