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Acute Postoperative Peptic Ulceration
Acute Postoperative Peptic Ulceration EDUARDO DAVID, M.D. KEITH A. KELLY, M.D.
Acute postoperative peptic ulceration is a life-threatening complication that usually occurs in patients who are already desperately ill. Progress in understanding and treating this disease has been slow, partly because the occurrence is uncommon and the numbers of such cases studied have not been large. We have undertaken to describe the clinical pattern of acute postoperative ulceration in a series of 95 cases and to correlate the method of treatment with survivorship.
CASE MATERIAL Selection of Cases The records of all patients given a clinical or postmortem diagnosis of upper gastrointestinal bleeding or perforated viscus at the Mayo Clinic during the 7-year period from 1960 through 1966 were reviewed. Ninety-five cases were encountered in which gastric, duodenal, or jejunal ulceration occurred within 30 days after operation. The acute nature of the ulceration was established by either or both of (1) the description by the gastroscopist or surgeon of a soft, pliable, unscarred, usually superficial lesion that was often sharply circumscribed, and (2) the report of the pathologist which revealed no gross or histologic evidence of chronicity. In a few cases, where the patient survived the illness without gastroscopy or operation, no confirmation of the diagnosis was obtained. These cases were included because no other cause for upper-gastrointestinal hemorrhage was present, and the clinical setting was such that the diagnosis of acute postoperative peptic ulceration was highly credible. All patients with a history of earlier peptic ulceration were excluded, except for lOin whom a chronic duodenal ulcer had been demonstrated previously. Two of them had undergone subtotal gastric resection with gastrojejunostomy because of the chronic ulcer. All 10 had been asymptomatic, however, for at least 1 year prior to the operation Surgical Clinics of North America - Vol. 49, No. 5,
Octob~r,
1969
1111
1112
EDUARDO DAVID, KEITH
A.
KELLY
which preceded the acute peptic ulceration, and in every case the ulceration was acute and developed at a site different from that of the earlier chronic ulcer. Description of Cases Of the 95 patients, 67 were male and 28 female. In contrast, among all 193,282 patients operated upon at this clinic during the same 7-year period, the numbers of males and females were virtually equal (males 49.9%, females 50.1%), so the incidence of acute ulcer in the postoperative period was greater in males than in females. Among the 95 cases reviewed, the range in age was wide (4 years to 90), but 70% of the patients were between 50 and 70 years old. A comparison was made between the age distribution of the acute-ulcer patients and that of all patients who underwent operation during the same period (Fig. 1, upper panel). The median age of all patients operated upon was 50 years, and that of the series studied was 58 years. The frequency of acute peptic ulceration changed with age at operation, increasing slowly up to age 60 and sharply during the next decade, then decreasing after age 70 (Fig. 1, lower panel). The interpretation of this change of incidence with age is difficult because the reasons for opera4r-----------------------------,
IOr------------------------------,
8
6
4
2
O~~I~O--~~3~O--~~5~O--~~7~O~~-9~O--~~IIO Age in years
Figure 1. Upper panel, Age distribution of 95 patients with acute postoperative peptic ulcer (dotted line) and of all patients operated upon (193,282 cases) at Mayo Clinic in the same period, 1960-1966 (solid line). Lower panel, Incidence rate of acute peptic ulcer in 'postoperative patients by decade of age (per 10,000 patients operated upon).
1113
ACUTE POSTOPERATIVE PEPTIC ULCERATION
tion, type of operation, criteria of operability, and other factors may have also changed with age. Acute peptic ulcers developed after a wide variety of operations (Table 1). The greatest incidences of the lesion followed abdominal, neurologic, cardiovascular, and thoracic operations. These incidences were not significantly different from one another, but were significantly greater than those which followed operations of other categories. The rarity of the disease was shown by the overall incidence in the postoperative period of just over 0.05%. All patients, of course, had an illness serious enough to warrant the initial operation. In addition, concomitant diseases were present in 65 patients (68% of the series). Cardiovascular lesions, advanced chronic obstructive pulmonary disease, neoplasia, and diabetes mellitus were the conditions most frequently associated. The remaining 30 patients (32%) were considered in good general health prior to the operation. Only three patients had been treated with steroids prior to surgery. None of the patients had received anticoagulants, aspirin, phenylbutazone, or other ulcerogenic medicaments, either before or after the initial operation. In the interval between the initial operation and the development of the acute peptic ulcer, the majority of the patients were extremely ill. Other significant postoperative complications affected 66. Sepsis was verified by culture in 45 cases and 63% of the organisms isolated were gram-negative. Significant pulmonary and respiratory complications occurred in 20 patients. One or more severe hypotensive episodes for which therapy was required were experienced by 14 patients. Water and electrolyte disturbances or azotemia or both were present in 14 cases. Table 1. Incidence of Acute Peptic Ulceration Following Various Categories of Operations (1960 through 1966) PATIENTS WITH ACUTE ULCER CATEGORY OF OPERATION*
General surgical Abdominal Other Neurologic Cardiovascular Thoracic§ Urologic Gynecologic Orthopedic Miscellaneous·' Total
NO.
37 5 19 14 6 6 6 2 0 95
%
38.9 5.3 20.0 14.8 6.3 6.3 6.3 2.1 0 100.0
ALL OPERATIONS IN CATEGORY NO.
20,33lt 18,196 12,010 7,712 4,440 14,248 15,806 25,666 59,699 178,108
%
11.4 10.2 6.8 4.3 2.5 8.0 8.9 14.4 33.5 100.0
ULCER CASES PER 10,000 OPERATIONSt
18.2 2.7 15.8 18.2 13.5 4.2 3.8 0.8 0 5.3
*Excludes endoscopy, biopsy, and diagnostic tests. tValues in italics differ significantly from those without italics, but not from each other (chi square test, P
1114
EDUARDO DAVID, KEITH
A.
KELLY
Eight patients were comatose or semicomatose before the ulcerative lesion developed. Hepatic failure occurred in three cases, pulmonary embolism in two, and myocardial infarction in one. Eighteen of these 66 patients required further surgical treatment (not for the acute ulcer) in the immediate postoperative period. Closure of a dehiscent wound was performed in six cases, tracheostomy in four, drainage of subphrenic abscess in three, and reoperation for control of hemorrhage in two. The remaining 29 patients (31 %) had an uncomplicated postoperative course until the acute ulceration developed.
Symptoms and Signs The onset of symptoms or signs of the acute ulceration occurred most frequently between the fourth and eighth days following the initial operation (range, second to twenty-sixth day) and was noted within the first 12 days in 72 cases (Fig. 2). All cases could be divided readily into two groups according to their symptoms; those with bleeding and those with perforation. Gastrointestinal bleeding was the most common expression of the disease and occurred in 84 cases (almost 90%). Such bleeding was demonstrated by hematemesis or aspiration of blood through a gastric tube in every case in this group, although melena was present also in 81 of the 84. Hypotension resulted from the bleeding in 44 cases. Only two patients with bleeding had epigastric pain. The bleeding itself was the initial manifestation in 66 of the 84 cases in which it occurred. Hypotension preceded it in 16 cases, pain in only two. The lesions tended to bleed massively. Each of the 84 patients required more than 1500 ml of blood before operation, stabilization,or death, and 59 (70%) required more than 3 liters of blood. Among these 84 cases, recurrence of bleeding developed in 13 from 2 to 15 days after the initial episode had been completely arrested. Of 10
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Days after operation Figure 2. Distribution of onset of symptoms within first postoperative month in 95 cases of acute peptic ulceration.
ACUTE POSTOPERATIVE PEPTIC ULCERATION
1115
these 13 patients, 10 died after the second hemorrhagic episode, and 1 died after a third episode. Perforation of an acute peptic ulcer without bleeding occurred in only 11 of the 95 cases. In nine of these it presented first as acute upper abdominal pain. Insidious abdominal pain was the initial symptom of perforation in two cases, and in one of these the correct diagnosis was not determined until autopsy. In addition to these 11 cases, a twelfth patient with perforation was encountered who presented with gastrointestinal bleeding. The perforation was an incidental finding at operation. Laboratory Examinations and Findings ENDOSCOPIC. Gastroscopy was used in diagnostic study of 15 of the 84 hemorrhagic cases during the first 48 hours after the onset of bleeding. The gastroscopist was able to localize the bleeding lesion within the stomach or see blood coming from the duodenum in 13 cases, and subsequent operation in 10 of these confirmed the gastroscopic impression. Medical management was successful in the other three cases, so operative confirmation of the diagnosis was not available. Gastric ulcers were encountered at operation in two cases wherein the gastroscopic report had been negative. RADIOLOGIC. In contrast to the success of gastroscopy in achieving the diagnosis, radiologic examination of the upper gastrointestinal tract with barium, performed in 18 of the 84 hemorrhagic cases within 48 hours of the onset of symptoms, demonstrated a lesion in o-nlyone. Six of these 18 patients subsequently underwent gastroscopy, which revealed the site of bleeding. Neither gastroscopy nor upper-gastrointestinal radiologic examination was performed during the first 48 hours in 57 of the 84 hemorrhagic cases, either because the bleeding was so severe that diagnostic attempts were deemed unwise or because it was so mild that such attempts were thought unwarranted. Radiologic study with barium was done more than 48 hours after the onset of bleeding in 12 of these cases, but the results were negative in all of them. Roentgenograms of the abdomen in the supine, erect, or lateral decubitus position were obtained in 10 of the 12 cases with perforating lesions. Pneumoperitoneum was revealed in seven and pleural effusion in one, but no abnormalities in the other two. Abdominal operations had been performed previously in three of the patients who had intraperitoneal air, so that it was not certain that the air had escaped from a perforated viscus. OVERALL PATHOLOGIC. Acute peptic ulceration was demonstrated in 84 of the 95 patients by gastroscopy, operation, or autopsy. Gastric ulcers were found in more than three fourths of the patients, and multiple lesions in nearly two thirds (Table 2). The ulcers were bleeding in 72 cases, bleeding and perforating in one, and perforating alone in 11. Seven of the perforations were gastric, four duodenal, and one jejunal (at the site of a gastrojejunal anastomosis). No lesion was demonstrated in 11 of the 95 cases. All had upper-
1116
A.
EDUARDO DAVID, KEITH
Table 2.
KELLY
Relation Between Number and Location of Acute Peptic Ulcers (84 Cases) PATIENTS WITH ULCERS IN
ULCERS
STOMACH
Single Multiple In one viscus In two visci Total
18
DUODENUM
6
12*
12* 29*
TOTAL PATIENTS
30
11
36 66'
JEJUNUM
o o 1
42 12 84
*Twelve patients had ulcers in both stomach and duodenum.
gastrointestinal hemorrhage that was controlled successfully by medical therapy. Radiologic examinations with barium were performed in all 11 and gastroscopy on one, from 3 to 20 days after the bleeding had stopped, but no lesions were encountered. None of these patients had a history of peptic ulceration in the past.
RESULTS OF TREATMENT The seriousness of this disease was demonstrated by the fatal outcome in 53% of the 95 cases. However, many factors besides the occurrence of the acute postoperative peptic ulcer influenced the course of the patients. The timing of the onset of symptoms was important. Only four patients survived of the 14 whose ulcers appeared 2 weeks or more after the initial operation. The presence of serious concomitant illness at the time of the initial operation was very unfavorable: -:il (63%) of 65 patients in this situation died, whereas only 9 (30%) of 30 patients who initially were in good general health succumbed. Also, the survivorship among patients who developed one or more additional complications before the onset of the acute peptic ulcer was poor: 47 (71 %) of 66 such patients died, in comparison with only three deaths (10%) among 29 patients who had no additional complications. In an attempt to determine the most successful mode of therapy, the cases were divided into two groups - those with medical treatment only and those with surgical treatment. Sometimes surgical therapy followed unsuccessful medical therapy. Medical Medical therapy alone was given to 52 patients. Nineteen of them were moribund when the acute ulcer developed. Among these '19 patients, seven had undergone neurosurgical operations and were comatose, three had severe hemodynamic complications (low-output syndrome) following open-heart surgery, four had advanced malignant disease, and five were preterminal as a result of multiple severe postoperative complications including sepsis and hypotension. These '19 patients were considered unlikely to respond favorably to any form of
1117
ACUTE POSTOPERATIVE PEPTIC ULCERATION
Table 3.
Results of Medical and Surgical Treatment for Acute Bleeding Peptic Ulcer (65 CasesY SURVIVEDt
TREATMENT Medical Surgical Total
DIED
PATIENTS
NO.
%
NO.
%
32 33 65
14 26 40
44 79 62
18 7 25
56 21 38
"Excludes patients moribund at onset of bleeding. tBleeding arrested. patient dismissed from hospital.
therapy and were not included when the results of medical therapy were assessed. One additional patient, who died from an unrecognized acute perforated ulcer, was also excluded from the group. The remaining 32 cases with only medical therapy were assessed for evaluation of the success of such treatment. There were bleeding lesions in all of these cases. Fourteen of the patients responded favorably to medical treatment, survived, and were discharged from the hospital (Table 3). Bleeding was usually not severe in this group: nine of its members required only 2 liters or less of blood in the first 48 hours, after which time the bleeding ceased. Also, the condition of these patients generally was not precarious when the bleeding began. Only three of them had serious complications other than the acute bleeding peptic ulcer. Eighteen of the 32 patients failed to respond well to medical therapy and died as a direct result of unrelieved upper-gastrointestinal hemorrhage. The majority had massive bleeding and multiple complications. Their general condition was poor, although no case could be considered inoperable. Surgical consultation was obtained in 12 cases, but the decision was against operation, either because the patient appeared to be unable to tolerate operation or because the bleeding apparently had stopped, or both. Regardless of the reason for persisting with medical therapy, the treatment was unsuccessful, and all 18 patients died of hemorrhage. In summary, 56% of the patients who initially had a chance for survival and received medical treatment alone to control hemorrhage died as a consequence of hemorrhage.
Surgical Surgical therapy was employed in 43 of the 95 cases (Tables 4 and 5). The operations were performed to control bleeding in 33 cases and to correct perforation in 10 cases. The promptness of surgical treatment after the onset of symptoms appeared to be important: 8 of the 12 surgical deaths occurred in patients who were operated on 48 hours or more after the onset of symptoms. Vagotomy and pyloroplasty was the only operation used in the 15 cases of acute bleeding duodenal ulcer. The results of operation were good (Table 4): 14 of the 15 patients survived. Hemorrhage recurred in
1118
EDUARDO DAVID, KEITH
Table 4.
A.
KELLY
Results of Operation for Hemorrhage from Acute Peptic Ulcer (33 Cases) DEATHS FROM
LOCATION OF ULCER, TYPE OF OPERATION
CASES
Duodenal ulcer Vagotomy and pyloroplasty Gastric ulcer Vagotomy and pyloroplas ty Vagotomy and hemigastrectomy Subtotal gastrectomy Suture ligation Gastric and duodenal ulcer Vagotomy and pyloroplasty Vagotomy and hemigastrectomy Subtotal gastrectomy Total
POSTOPERATIVE REBLEEDING
BLEEDING
OTHER CAUSES
15
4
o
2
2
2
5
2
3 3
o
1
o o
o
2
2
o
o
o
o
o
o
o
11
5
2
2 33
o o It
"Septicemia, acute renal failure. tPulmonaryembolus. t One patient ,had perforating gastric ulcer as well as bleeding gastric and duodenal ulcers.
four of these cases but did not result in death. In the single patient who died, septicemia and acute renal failure were the causes of death. Vagotomy, pyloroplasty, gastrectomy, and suture ligation were used singly and in various combinations for the treatment of acute bleeding gastric or gastric and duodenal ulcers. All patients treated with vagotomy and pyloroplasty bled again and subsequently died from hemorrhage. Table 5.
Results of Operation for Acute Perforated Peptic Ulcer (10 Cases)
LOCATION OF ULCER, TYPE OF OPERATION
CASES
DEATHS
Duodenal ulcer Simple closure Vagotomy and gastroenterostomy
3 1
1 0
Gastric ulcer Simple closure Vagotomy and gastroenterostomy Subtotal gastrectomy
3 1 1
0 1
10
5
2t
Jejunal ulcer Simple closure Total
"All patients died with peritonitis. tPatients had thrombotic complications as well as peritonitis.
ACUTE POSTOPERATIVE PEPTIC ULCERATION
1119
After gastrectomy, however, only three of 11 patients bled again, and only one of the three died of hemorrhage. Overall, the mortality that followed operation for acute bleeding peptic ulcers was 21 %, whereas that which accompanied nonsurgical treatment was 56% (Table 3). Operations were performed on 10 of 11 patients having acute perforated ulcer. The results were poor: half of these patients died with overwhelming peritonitis (Table 5).
COMMENT
This study of acute postoperative peptic ulcer confirms many earlier reports. Massive bleeding! from acute ulcers that were often gastric and multiple5 usually occurred within 2 weeks4 of various operations7 in patients who were desperately ill with many complications. 5 The overall mortality rate W
1120
EDUARDO DAVID, KEITH
A.
KELLY
It does seem clear that operation should be strongly considered for desperately ill patients who bleed massively from acute ulcers. Of the patients who were in this category and received only medical therapy, few survived. Our survey shows that vagotomy and pyloroplasty was successful as treatment for postoperative acute bleeding peptic ulceration of the duodenum. No patients died of bleeding after this operation. However, our data do not allow a conclusion as to the operation most successful in cases of acute bleeding gastric or gastric and duodenal ulcers, since the employment of the operations was not randomized and the cases in any one group were few. The results do suggest that either gastrectomy, with or without vagotomy, or suture ligation should be used in treatment for these ulcers rather than vagotomy and pyloroplasty. Only one death from bleeding followed the former operations, whereas all four patients treated by vagotomy and pyloroplasty died of continued hemorrhage.
SUMMARY Ninety-five cases of acute postoperative peptic ulceration were reviewed. The frequency of ulceration was greater in males than in females. It was very small in patients under age 20, increased up to age 70, and then decreased slightly. The incidence of acute ulcers was greater after abdominal, neurologic, cardiovascular, and thoracic operations than after others. Typically, the ulcers developed in patients who were extremely ill with associated diseases and additional complications. Two thirds of the ulcers appeared within the first 12 postoperative days. Bleeding-usually massive-was the initial symptom in 84 cases, ~and perforation was the presenting feature in the other 11. Gastroscopy performed within 48 hours after the onset of bleeding established a diagnosis in 90% of the cases in which it was used. Gastric ulcers were present in approximately three fourths of the patients with demonstrable lesions, and multiple ulcers in nearly two thirds. Among all patients who received surgical therapy for bleeding, the survival rate was 79%; among nonmoribund patients who received only medical therapy, it was 44%. Vagotomy and pyloroplasty effectively controlled acute bleeding duodenal ulcer (14 of 15 patients survived) but failed to arrest bleeding in four patients with acute gastric or gastric and duodenal ulcers. Subtotal gastrectomy with or without vagotomy resulted in survival in 10 of 11 patients who had acute bleeding gastric or gastric and duodenal ulcers. In contrast to the favorable results of surgery for bleeding, five of 10 patients operated upon for acute perforated peptic ulcer died. ACKNOWLEDGMENTS
Thanks are expressed to Lila R. Elveback, Ph.D., and Mr. Mark Jereczek for their help.
ACUTE POSTOPERATIVE PEPTIC ULCERATION
1121
REFERENCES 1. Beil, A. R., Jr., Mannix, H., Jr., and Beal, J. M.: Massive upper gastrointestinal hemorrhage after operation. Amer J Surg 108:324-330 (Sept.) 1964. 2. Davis, R. A., Wetzel, N., and Davis, L.: Acute upper alimentary tract ulceration and hemorrhage following neurosurgical operations. Surg Gynec Obstet 100:51-58 (Jan.) 1955. 3. Fletcher, D. G., and Harkins, H. N.: Acute peptic ulcer as a complication of major surgery, stress, or trauma. Surgery 36:212-226 (Aug.) 1954. 4. Fogelman, M. J., and Garvey, J. M.: Acute gastroduodenal ulceration incident to surgery and disease: Analysis and review of eighty-eight cases. Amer J Surg 112:651-656 (Nov.) 1966. 5. Goodman, A. A., and Frey, C. F.: Massive upper gastrointestinal hemorrhage following surgical operations. Ann Surg 167:180-184 (Feb.) 1968. 6. Harjola, P.-T., and Kerminen, T.: Akute Abdominalkomplikationen nach Thoraxoperationen. Thoraxchirurgie 11 :473-482 (Feb.) 1964. 7. Kanar, E. A.: Acute peptic ulcer. In Harkins, H. N., and Nyhus, L. M.: Surgery of the Stomach and Duodenum. Boston, Little, Brown & Company, 1962, pp. 210-223.
Acute postoperative peptic ulceration is a life-threatening complication that usually occurs in patients who are already desperately ill. Progress in understanding and treating this disease has been slow, partly because the occurrence is uncommon and the numbers of such cases studied have not been large. We have undertaken to describe the clinical pattern of acute postoperative ulceration in a series of 95 cases and to correlate the method of treatment with survivorship.
CASE MATERIAL Selection of Cases The records of all patients given a clinical or postmortem diagnosis of upper gastrointestinal bleeding or perforated viscus at the Mayo Clinic during the 7-year period from 1960 through 1966 were reviewed. Ninety-five cases were encountered in which gastric, duodenal, or jejunal ulceration occurred within 30 days after operation. The acute nature of the ulceration was established by either or both of (1) the description by the gastroscopist or surgeon of a soft, pliable, unscarred, usually superficial lesion that was often sharply circumscribed, and (2) the report of the pathologist which revealed no gross or histologic evidence of chronicity. In a few cases, where the patient survived the illness without gastroscopy or operation, no confirmation of the diagnosis was obtained. These cases were included because no other cause for upper-gastrointestinal hemorrhage was present, and the clinical setting was such that the diagnosis of acute postoperative peptic ulceration was highly credible. All patients with a history of earlier peptic ulceration were excluded, except for lOin whom a chronic duodenal ulcer had been demonstrated previously. Two of them had undergone subtotal gastric resection with gastrojejunostomy because of the chronic ulcer. All 10 had been asymptomatic, however, for at least 1 year prior to the operation Surgical Clinics of North America - Vol. 49, No. 5,
Octob~r,
1969
1111
1112
EDUARDO DAVID, KEITH
A.
KELLY
which preceded the acute peptic ulceration, and in every case the ulceration was acute and developed at a site different from that of the earlier chronic ulcer. Description of Cases Of the 95 patients, 67 were male and 28 female. In contrast, among all 193,282 patients operated upon at this clinic during the same 7-year period, the numbers of males and females were virtually equal (males 49.9%, females 50.1%), so the incidence of acute ulcer in the postoperative period was greater in males than in females. Among the 95 cases reviewed, the range in age was wide (4 years to 90), but 70% of the patients were between 50 and 70 years old. A comparison was made between the age distribution of the acute-ulcer patients and that of all patients who underwent operation during the same period (Fig. 1, upper panel). The median age of all patients operated upon was 50 years, and that of the series studied was 58 years. The frequency of acute peptic ulceration changed with age at operation, increasing slowly up to age 60 and sharply during the next decade, then decreasing after age 70 (Fig. 1, lower panel). The interpretation of this change of incidence with age is difficult because the reasons for opera4r-----------------------------,
IOr------------------------------,
8
6
4
2
O~~I~O--~~3~O--~~5~O--~~7~O~~-9~O--~~IIO Age in years
Figure 1. Upper panel, Age distribution of 95 patients with acute postoperative peptic ulcer (dotted line) and of all patients operated upon (193,282 cases) at Mayo Clinic in the same period, 1960-1966 (solid line). Lower panel, Incidence rate of acute peptic ulcer in 'postoperative patients by decade of age (per 10,000 patients operated upon).
1113
ACUTE POSTOPERATIVE PEPTIC ULCERATION
tion, type of operation, criteria of operability, and other factors may have also changed with age. Acute peptic ulcers developed after a wide variety of operations (Table 1). The greatest incidences of the lesion followed abdominal, neurologic, cardiovascular, and thoracic operations. These incidences were not significantly different from one another, but were significantly greater than those which followed operations of other categories. The rarity of the disease was shown by the overall incidence in the postoperative period of just over 0.05%. All patients, of course, had an illness serious enough to warrant the initial operation. In addition, concomitant diseases were present in 65 patients (68% of the series). Cardiovascular lesions, advanced chronic obstructive pulmonary disease, neoplasia, and diabetes mellitus were the conditions most frequently associated. The remaining 30 patients (32%) were considered in good general health prior to the operation. Only three patients had been treated with steroids prior to surgery. None of the patients had received anticoagulants, aspirin, phenylbutazone, or other ulcerogenic medicaments, either before or after the initial operation. In the interval between the initial operation and the development of the acute peptic ulcer, the majority of the patients were extremely ill. Other significant postoperative complications affected 66. Sepsis was verified by culture in 45 cases and 63% of the organisms isolated were gram-negative. Significant pulmonary and respiratory complications occurred in 20 patients. One or more severe hypotensive episodes for which therapy was required were experienced by 14 patients. Water and electrolyte disturbances or azotemia or both were present in 14 cases. Table 1. Incidence of Acute Peptic Ulceration Following Various Categories of Operations (1960 through 1966) PATIENTS WITH ACUTE ULCER CATEGORY OF OPERATION*
General surgical Abdominal Other Neurologic Cardiovascular Thoracic§ Urologic Gynecologic Orthopedic Miscellaneous·' Total
NO.
37 5 19 14 6 6 6 2 0 95
%
38.9 5.3 20.0 14.8 6.3 6.3 6.3 2.1 0 100.0
ALL OPERATIONS IN CATEGORY NO.
20,33lt 18,196 12,010 7,712 4,440 14,248 15,806 25,666 59,699 178,108
%
11.4 10.2 6.8 4.3 2.5 8.0 8.9 14.4 33.5 100.0
ULCER CASES PER 10,000 OPERATIONSt
18.2 2.7 15.8 18.2 13.5 4.2 3.8 0.8 0 5.3
*Excludes endoscopy, biopsy, and diagnostic tests. tValues in italics differ significantly from those without italics, but not from each other (chi square test, P
1114
EDUARDO DAVID, KEITH
A.
KELLY
Eight patients were comatose or semicomatose before the ulcerative lesion developed. Hepatic failure occurred in three cases, pulmonary embolism in two, and myocardial infarction in one. Eighteen of these 66 patients required further surgical treatment (not for the acute ulcer) in the immediate postoperative period. Closure of a dehiscent wound was performed in six cases, tracheostomy in four, drainage of subphrenic abscess in three, and reoperation for control of hemorrhage in two. The remaining 29 patients (31 %) had an uncomplicated postoperative course until the acute ulceration developed.
Symptoms and Signs The onset of symptoms or signs of the acute ulceration occurred most frequently between the fourth and eighth days following the initial operation (range, second to twenty-sixth day) and was noted within the first 12 days in 72 cases (Fig. 2). All cases could be divided readily into two groups according to their symptoms; those with bleeding and those with perforation. Gastrointestinal bleeding was the most common expression of the disease and occurred in 84 cases (almost 90%). Such bleeding was demonstrated by hematemesis or aspiration of blood through a gastric tube in every case in this group, although melena was present also in 81 of the 84. Hypotension resulted from the bleeding in 44 cases. Only two patients with bleeding had epigastric pain. The bleeding itself was the initial manifestation in 66 of the 84 cases in which it occurred. Hypotension preceded it in 16 cases, pain in only two. The lesions tended to bleed massively. Each of the 84 patients required more than 1500 ml of blood before operation, stabilization,or death, and 59 (70%) required more than 3 liters of blood. Among these 84 cases, recurrence of bleeding developed in 13 from 2 to 15 days after the initial episode had been completely arrested. Of 10
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Days after operation Figure 2. Distribution of onset of symptoms within first postoperative month in 95 cases of acute peptic ulceration.
ACUTE POSTOPERATIVE PEPTIC ULCERATION
1115
these 13 patients, 10 died after the second hemorrhagic episode, and 1 died after a third episode. Perforation of an acute peptic ulcer without bleeding occurred in only 11 of the 95 cases. In nine of these it presented first as acute upper abdominal pain. Insidious abdominal pain was the initial symptom of perforation in two cases, and in one of these the correct diagnosis was not determined until autopsy. In addition to these 11 cases, a twelfth patient with perforation was encountered who presented with gastrointestinal bleeding. The perforation was an incidental finding at operation. Laboratory Examinations and Findings ENDOSCOPIC. Gastroscopy was used in diagnostic study of 15 of the 84 hemorrhagic cases during the first 48 hours after the onset of bleeding. The gastroscopist was able to localize the bleeding lesion within the stomach or see blood coming from the duodenum in 13 cases, and subsequent operation in 10 of these confirmed the gastroscopic impression. Medical management was successful in the other three cases, so operative confirmation of the diagnosis was not available. Gastric ulcers were encountered at operation in two cases wherein the gastroscopic report had been negative. RADIOLOGIC. In contrast to the success of gastroscopy in achieving the diagnosis, radiologic examination of the upper gastrointestinal tract with barium, performed in 18 of the 84 hemorrhagic cases within 48 hours of the onset of symptoms, demonstrated a lesion in o-nlyone. Six of these 18 patients subsequently underwent gastroscopy, which revealed the site of bleeding. Neither gastroscopy nor upper-gastrointestinal radiologic examination was performed during the first 48 hours in 57 of the 84 hemorrhagic cases, either because the bleeding was so severe that diagnostic attempts were deemed unwise or because it was so mild that such attempts were thought unwarranted. Radiologic study with barium was done more than 48 hours after the onset of bleeding in 12 of these cases, but the results were negative in all of them. Roentgenograms of the abdomen in the supine, erect, or lateral decubitus position were obtained in 10 of the 12 cases with perforating lesions. Pneumoperitoneum was revealed in seven and pleural effusion in one, but no abnormalities in the other two. Abdominal operations had been performed previously in three of the patients who had intraperitoneal air, so that it was not certain that the air had escaped from a perforated viscus. OVERALL PATHOLOGIC. Acute peptic ulceration was demonstrated in 84 of the 95 patients by gastroscopy, operation, or autopsy. Gastric ulcers were found in more than three fourths of the patients, and multiple lesions in nearly two thirds (Table 2). The ulcers were bleeding in 72 cases, bleeding and perforating in one, and perforating alone in 11. Seven of the perforations were gastric, four duodenal, and one jejunal (at the site of a gastrojejunal anastomosis). No lesion was demonstrated in 11 of the 95 cases. All had upper-
1116
A.
EDUARDO DAVID, KEITH
Table 2.
KELLY
Relation Between Number and Location of Acute Peptic Ulcers (84 Cases) PATIENTS WITH ULCERS IN
ULCERS
STOMACH
Single Multiple In one viscus In two visci Total
18
DUODENUM
6
12*
12* 29*
TOTAL PATIENTS
30
11
36 66'
JEJUNUM
o o 1
42 12 84
*Twelve patients had ulcers in both stomach and duodenum.
gastrointestinal hemorrhage that was controlled successfully by medical therapy. Radiologic examinations with barium were performed in all 11 and gastroscopy on one, from 3 to 20 days after the bleeding had stopped, but no lesions were encountered. None of these patients had a history of peptic ulceration in the past.
RESULTS OF TREATMENT The seriousness of this disease was demonstrated by the fatal outcome in 53% of the 95 cases. However, many factors besides the occurrence of the acute postoperative peptic ulcer influenced the course of the patients. The timing of the onset of symptoms was important. Only four patients survived of the 14 whose ulcers appeared 2 weeks or more after the initial operation. The presence of serious concomitant illness at the time of the initial operation was very unfavorable: -:il (63%) of 65 patients in this situation died, whereas only 9 (30%) of 30 patients who initially were in good general health succumbed. Also, the survivorship among patients who developed one or more additional complications before the onset of the acute peptic ulcer was poor: 47 (71 %) of 66 such patients died, in comparison with only three deaths (10%) among 29 patients who had no additional complications. In an attempt to determine the most successful mode of therapy, the cases were divided into two groups - those with medical treatment only and those with surgical treatment. Sometimes surgical therapy followed unsuccessful medical therapy. Medical Medical therapy alone was given to 52 patients. Nineteen of them were moribund when the acute ulcer developed. Among these '19 patients, seven had undergone neurosurgical operations and were comatose, three had severe hemodynamic complications (low-output syndrome) following open-heart surgery, four had advanced malignant disease, and five were preterminal as a result of multiple severe postoperative complications including sepsis and hypotension. These '19 patients were considered unlikely to respond favorably to any form of
1117
ACUTE POSTOPERATIVE PEPTIC ULCERATION
Table 3.
Results of Medical and Surgical Treatment for Acute Bleeding Peptic Ulcer (65 CasesY SURVIVEDt
TREATMENT Medical Surgical Total
DIED
PATIENTS
NO.
%
NO.
%
32 33 65
14 26 40
44 79 62
18 7 25
56 21 38
"Excludes patients moribund at onset of bleeding. tBleeding arrested. patient dismissed from hospital.
therapy and were not included when the results of medical therapy were assessed. One additional patient, who died from an unrecognized acute perforated ulcer, was also excluded from the group. The remaining 32 cases with only medical therapy were assessed for evaluation of the success of such treatment. There were bleeding lesions in all of these cases. Fourteen of the patients responded favorably to medical treatment, survived, and were discharged from the hospital (Table 3). Bleeding was usually not severe in this group: nine of its members required only 2 liters or less of blood in the first 48 hours, after which time the bleeding ceased. Also, the condition of these patients generally was not precarious when the bleeding began. Only three of them had serious complications other than the acute bleeding peptic ulcer. Eighteen of the 32 patients failed to respond well to medical therapy and died as a direct result of unrelieved upper-gastrointestinal hemorrhage. The majority had massive bleeding and multiple complications. Their general condition was poor, although no case could be considered inoperable. Surgical consultation was obtained in 12 cases, but the decision was against operation, either because the patient appeared to be unable to tolerate operation or because the bleeding apparently had stopped, or both. Regardless of the reason for persisting with medical therapy, the treatment was unsuccessful, and all 18 patients died of hemorrhage. In summary, 56% of the patients who initially had a chance for survival and received medical treatment alone to control hemorrhage died as a consequence of hemorrhage.
Surgical Surgical therapy was employed in 43 of the 95 cases (Tables 4 and 5). The operations were performed to control bleeding in 33 cases and to correct perforation in 10 cases. The promptness of surgical treatment after the onset of symptoms appeared to be important: 8 of the 12 surgical deaths occurred in patients who were operated on 48 hours or more after the onset of symptoms. Vagotomy and pyloroplasty was the only operation used in the 15 cases of acute bleeding duodenal ulcer. The results of operation were good (Table 4): 14 of the 15 patients survived. Hemorrhage recurred in
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EDUARDO DAVID, KEITH
Table 4.
A.
KELLY
Results of Operation for Hemorrhage from Acute Peptic Ulcer (33 Cases) DEATHS FROM
LOCATION OF ULCER, TYPE OF OPERATION
CASES
Duodenal ulcer Vagotomy and pyloroplasty Gastric ulcer Vagotomy and pyloroplas ty Vagotomy and hemigastrectomy Subtotal gastrectomy Suture ligation Gastric and duodenal ulcer Vagotomy and pyloroplasty Vagotomy and hemigastrectomy Subtotal gastrectomy Total
POSTOPERATIVE REBLEEDING
BLEEDING
OTHER CAUSES
15
4
o
2
2
2
5
2
3 3
o
1
o o
o
2
2
o
o
o
o
o
o
o
11
5
2
2 33
o o It
"Septicemia, acute renal failure. tPulmonaryembolus. t One patient ,had perforating gastric ulcer as well as bleeding gastric and duodenal ulcers.
four of these cases but did not result in death. In the single patient who died, septicemia and acute renal failure were the causes of death. Vagotomy, pyloroplasty, gastrectomy, and suture ligation were used singly and in various combinations for the treatment of acute bleeding gastric or gastric and duodenal ulcers. All patients treated with vagotomy and pyloroplasty bled again and subsequently died from hemorrhage. Table 5.
Results of Operation for Acute Perforated Peptic Ulcer (10 Cases)
LOCATION OF ULCER, TYPE OF OPERATION
CASES
DEATHS
Duodenal ulcer Simple closure Vagotomy and gastroenterostomy
3 1
1 0
Gastric ulcer Simple closure Vagotomy and gastroenterostomy Subtotal gastrectomy
3 1 1
0 1
10
5
2t
Jejunal ulcer Simple closure Total
"All patients died with peritonitis. tPatients had thrombotic complications as well as peritonitis.
ACUTE POSTOPERATIVE PEPTIC ULCERATION
1119
After gastrectomy, however, only three of 11 patients bled again, and only one of the three died of hemorrhage. Overall, the mortality that followed operation for acute bleeding peptic ulcers was 21 %, whereas that which accompanied nonsurgical treatment was 56% (Table 3). Operations were performed on 10 of 11 patients having acute perforated ulcer. The results were poor: half of these patients died with overwhelming peritonitis (Table 5).
COMMENT
This study of acute postoperative peptic ulcer confirms many earlier reports. Massive bleeding! from acute ulcers that were often gastric and multiple5 usually occurred within 2 weeks4 of various operations7 in patients who were desperately ill with many complications. 5 The overall mortality rate W
1120
EDUARDO DAVID, KEITH
A.
KELLY
It does seem clear that operation should be strongly considered for desperately ill patients who bleed massively from acute ulcers. Of the patients who were in this category and received only medical therapy, few survived. Our survey shows that vagotomy and pyloroplasty was successful as treatment for postoperative acute bleeding peptic ulceration of the duodenum. No patients died of bleeding after this operation. However, our data do not allow a conclusion as to the operation most successful in cases of acute bleeding gastric or gastric and duodenal ulcers, since the employment of the operations was not randomized and the cases in any one group were few. The results do suggest that either gastrectomy, with or without vagotomy, or suture ligation should be used in treatment for these ulcers rather than vagotomy and pyloroplasty. Only one death from bleeding followed the former operations, whereas all four patients treated by vagotomy and pyloroplasty died of continued hemorrhage.
SUMMARY Ninety-five cases of acute postoperative peptic ulceration were reviewed. The frequency of ulceration was greater in males than in females. It was very small in patients under age 20, increased up to age 70, and then decreased slightly. The incidence of acute ulcers was greater after abdominal, neurologic, cardiovascular, and thoracic operations than after others. Typically, the ulcers developed in patients who were extremely ill with associated diseases and additional complications. Two thirds of the ulcers appeared within the first 12 postoperative days. Bleeding-usually massive-was the initial symptom in 84 cases, ~and perforation was the presenting feature in the other 11. Gastroscopy performed within 48 hours after the onset of bleeding established a diagnosis in 90% of the cases in which it was used. Gastric ulcers were present in approximately three fourths of the patients with demonstrable lesions, and multiple ulcers in nearly two thirds. Among all patients who received surgical therapy for bleeding, the survival rate was 79%; among nonmoribund patients who received only medical therapy, it was 44%. Vagotomy and pyloroplasty effectively controlled acute bleeding duodenal ulcer (14 of 15 patients survived) but failed to arrest bleeding in four patients with acute gastric or gastric and duodenal ulcers. Subtotal gastrectomy with or without vagotomy resulted in survival in 10 of 11 patients who had acute bleeding gastric or gastric and duodenal ulcers. In contrast to the favorable results of surgery for bleeding, five of 10 patients operated upon for acute perforated peptic ulcer died. ACKNOWLEDGMENTS
Thanks are expressed to Lila R. Elveback, Ph.D., and Mr. Mark Jereczek for their help.
ACUTE POSTOPERATIVE PEPTIC ULCERATION
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REFERENCES 1. Beil, A. R., Jr., Mannix, H., Jr., and Beal, J. M.: Massive upper gastrointestinal hemorrhage after operation. Amer J Surg 108:324-330 (Sept.) 1964. 2. Davis, R. A., Wetzel, N., and Davis, L.: Acute upper alimentary tract ulceration and hemorrhage following neurosurgical operations. Surg Gynec Obstet 100:51-58 (Jan.) 1955. 3. Fletcher, D. G., and Harkins, H. N.: Acute peptic ulcer as a complication of major surgery, stress, or trauma. Surgery 36:212-226 (Aug.) 1954. 4. Fogelman, M. J., and Garvey, J. M.: Acute gastroduodenal ulceration incident to surgery and disease: Analysis and review of eighty-eight cases. Amer J Surg 112:651-656 (Nov.) 1966. 5. Goodman, A. A., and Frey, C. F.: Massive upper gastrointestinal hemorrhage following surgical operations. Ann Surg 167:180-184 (Feb.) 1968. 6. Harjola, P.-T., and Kerminen, T.: Akute Abdominalkomplikationen nach Thoraxoperationen. Thoraxchirurgie 11 :473-482 (Feb.) 1964. 7. Kanar, E. A.: Acute peptic ulcer. In Harkins, H. N., and Nyhus, L. M.: Surgery of the Stomach and Duodenum. Boston, Little, Brown & Company, 1962, pp. 210-223.