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Management of massive hemorrhage from peptic ulcer
Management of Massive Hemorrhage from Peptic Ulcer EDWARDN. SNYDER, JR., M.D. ANDCLARENCE J. BERNE, M.D., Los Angeles, From tbe Department of Surgery, University of Soutbern California School of Medicine and tbe Los Angeles County Hospital, Los Angeles, California.
of our cases in order to report results presently being obtained, and have attempted to identify potentia1 means of improving our future results.
T that
HERE is no more diffrcuIt judgment than required of the cIinician when he must evaIuate the inherent Iethality of an acute, severe, hemorrhage from a peptic uIcer. For adequate orientation regarding the probIem he must be provided with careful anaIyses of significant numbers of such situations. These studies shouId include all patients with acutely bleeding peptic uIcer who enter the hospita1, whether or not they are operated upon. Further, rigid criteria of massive hemorrhage must be appIied in order to excIude a11 instances of Iesser degrees of bleeding. AdditionaIIy, because of the extreme infIuence of the patient’s age and the presence of serious associated disease on this outcome, these factors must be cIearIy presented. In order to appraise the vahdity of existing indications for surgery it is admittedIy desirabIe to have the most exact data obtainabIe regarding a given patient. However, since many of the precise technics are not avaiIabIe in the average hospital a study using generahy avaiIabIe methods shouId have specia1 vaIue. It is our purpose to report such an anaIysis of consecutive cases of massive hemorrhage from gastric or duodena1 uIcer, incIuding all patients admitted to the University of Southern CaIifornia MedicaI and SurgicaI Services at the Los AngeIes County HospitaI over a period of one year from JuIy, 1954 to JuIy, 1955. Another phase of this study of massive hemorrhage from peptic uIcer has to do with estimating the present benefits of operative therapy based on utiIization of the knowIedge gained from the reports of studies such as those of Stewart [I], WeIch [3], Dunphy [61, and Mathewson [2]. We have made such an anaIysis American Journal of Surgery,
Volume 94. August,
1937
Calijornia
CRITERIA OF MASSIVE HEMORRHAGE In order to define massive hemorrhage it is necessary to establish criteria that eliminate all instances of acute bIeeding that were of moderate degree and wouId have recovered spontaneousIy, or with reIativeIy conservative therapeutic efforts. Only when such cases are excIuded can the effectiveness of therapy be measured. No cases are inchided in our series unIess they were of such severity as to fuIfiI1 the foIIowing criteria. Acute hemorrhage accompanied by either: Acute hypovolemic shock SystoIic bIood pressure of 90 mm. Hg or Iess CoId skin Sweating PaIIor, and/or
_. 368
A hemogIobin of 7.5 gm. or Iess per IOOcc. Sixty-three of the seventy-three patients in this series had acute hypovoIemia productive of the signs of shock. The circuIatory disturbance of the remaining ten patients had stabiIized when admitted, but the bIeeding was severe enough to reduce the hemoglobin IeveI to 7.5 gm. or Iess. The IeveI of 7.5 gm. was chosen because at this IeveI of hemogIobin, with the usua1 associated reduction in bIood voIume, ischemic renaI injury was imminent. We beIieve that the foregoing criteria of massive hemorrhage are appIicabIe under aImost any circumstances. Our cases of massive bIeeding from duodena1 or gastric uIcer met these criteria and, excIuding a11 cases with unproved diagnoses of gastric or duodena1 ulcer, seventy-three cases
Massive
Hemorrhage
occurred during the one year. The causative presence of gastric or duodena1 ulcer was proved in each case by x-ray studies, surgery or autopsy. Erythrocyte counts have not been included since it has been we11 estabIished that such counts are subject to an error of pIus to minus 20 per cent. Likewise, hematocrit determinations were not incIuded since a high speed centrifuge is not avaiIabIe in many institutions. However, the results of this determination are accurate within I per cent [y]. BASIC
TABLE I SUMMARYOF MANAGEMENTOF Data
CASES
AND
Cases
-___
MANAGEMENT
FOR OPERATIVE
UIcer
if the patient had signs and symptoms of shock despite the administration of 1,000 to 1,500 cc. of blood. With this indication it may be that the uIcer actuaIIy is bIeeding intermittently, instead of continuousIy. FrequentIy under these conditions, active bleeding n-ill not be present
AI1 patients were treated initially with aggressive nonoperative means. These consisted of vigorous ulcer therapy and rapid restoration of blood voIume. The former included the IiberaI use of parasympatholytic drugs, sedation, Levin tube with suction if vomiting was present, alternate hourIy feedings day and night, and ora antiacid drugs if nausea and vomiting were absent. Because re-bleeding is probably due to peptic digestion of the cIot, it is of the greatest importance that the feedings be continued during the night. This is equally true of the substances used to reduce acidity and thereby to inhibit pepsin activity. The bIood deficit was restored with whoIe blood, each transfusion consisting of goo cc. of whoIe blood and 120 cc. of anticoaguIant solution. The goal with transfusion therapy was to restore the hemogIobin to near normal levels rather than mereIy to aIIeviate the symptoms and signs of shock. Roentgenographic examination was not performed routinely during the period of active bIeeding. Our decisions were made primarily on the basis of the patient’s history, physica examination, Iaboratory data, and the changes in these whiIe the patient was under treatment. The prob1em of diagnosis is not considered in this report. INDICATIONS
from Peptic
RESULTS
Deaths ______-.
Duodenal ulcer : Operation. No operation..
I0 4g
2 (20%) 6 (12.3%)
Gastric uIcer: Operation. No operation.
I0 4
2 (20%) 3 (75%)
73
TotaI..
/
_
13 (17.8%)
~
at the time of surgery. However, the cIot usuaIIy can be easily disIodged. The second indication, one episode of severe re-bIeeding, is more precise. FundamentaIIy, these indications are based on the Iarge mass of evidence that, even with generous bIood replacement, patients with repeated hemorrhages become progressive1y poorer risks [4,6,7,8]. Two gastric uIcer patients and three of the duodena1 ulcer patients had emergencv operations because of continued bIeeding. Eight of the patients with gastric ulcer and seven of the patients with duodena1 ulcer were operated upon because of severe re-bleeding. Major re-bIeeding nearIy aIways occurred within three to four days after hospitaIization. This observation is simiIar to that made by Mathewson [2] and Welch [j] in simi1ar groups of patients. REVIEW
OF CASES
TabIe I shows a summary of the management of these cases. It is quite obvious that the morta1ity rate from bIeeding gastric u1cers is much higher, and that emergency surgery is more often necessary, than is the case in bIeeding duodenal uIcers. Mathewson and WeIch suggest that this is due to the fact that gastric uIcers are more prone to erode into major arteries while duodena1 uIcers more often cause bleeding from smaI1 vessels [2,3]. Another factor may be the reIativeIy Iow acid vaIues in gastric uIcer compared to those in duodena1
TREATMENT
Two indications for surgery were used during the year that these patients were treated. The analysis to be presented was carried out mainly to determine the vaIidity of these indications as a basis for surgical intervention in massive bIeeding from peptic uIcer. These two indications were: continued bleeding, or one episode of major rebleeding. Continued bIeeding necessitating surgery was considered to be present 369
Snyder
and Berne
TABLE CORRELATION
OF AGE,
II
RACE AND
SEX
WITH
Gastric Ulcer
MORTALITY
DuodenaI UIcer
Total
Data Cases
Deaths
Cases
17
20-49......................................
I
Age p-59 ......................................
0
Race
4 4 I
Sex
60-88 ...................................... Caucasian* ................................. { Negro ...................................... Males ...................................... FemaIes ....................................
Deaths
18
3
24 45 ‘4 48
2
11
Cases
Deaths
‘9
1
20
2
34 57 16 56 17
IO I2
I II 2 I
* IncIudes Mexicans
ulcer. These Iower acid vaIues very possibIy reduce the effects of medica treatment of the acid pepsin mechanism. In this series of cases, ten of fourteen patients with gastric uIcers were over sixty years of age and four of the ten patients died. By contrast, onIy twenty-four of the fifty-nine patients with duodena1 uIcer were over sixty years of age and six of the twenty-four patients died. It is IikeIy that the more advanced age of the patients with gastric uIcer is the major determining factor in the mortaIity difference between the two groups of patients. A more detaiIed study of the age distribution of a11 cases (TabIe II) reveaIs that aImost three-fourths of the patients were over fifty years of age. Ten of the thirteen deaths occurred in the thirty-four patients over sixty; two deaths occurred in the twenty patients m their fifties; and only one death occurred in the group under fifty years of age. These mortality figures cIearIy indicate the grave danger associated with massive hemorrhage in the oIder age groups, as has been emphasized by AIIen [9] and WeIch [3,4]. However, this shouId not be interpreted as impIying a high degree of safety in younger patients with massiveIy bIeeding peptic uIcer, because only nineteen of our seventy-three cases were under fifty years of age. There may be a high correIation between the age of the uIcer and the seriousness of the bIeeding. Thus, a Iong standing, deepIy eroded uIcer in a younger patient may present a very grave danger. Such uIcers probabIy increase in frequency in oIder age groups and further condition the increased seriousness of their bIeeding episodes. The great majority of the cases, and a11 but
one of the deaths, occurred in Caucasians. During the period of this study, the average daiIy patient census of the Los AngeIes County Genera1 Hospital incIuded about 31 per cent Negroes and 20 per cent Mexicans; yet of these massive bIeeders, onIy 22 per cent were Negroes and only 4 per cent were of Mexican descent. A study of TabIe II aIso confirms the great prediIection of duodena1 uIcer disease for males. However, the gastric uIcers were aImost evenIy divided among the sexes, and the two deaths among the femaIe patients occurred in patients with gastric uIcer. NevertheIess, femaIes and Negroes had a very Iow mortality rate. A critica evaIuation was made of each patient’s history, physica examination, and Iaboratory data in an attempt to eIicit some factors of prognostic vaIue. WhiIe the facts are informative, IittIe of statistica prognostic significance is apparent. (TabIe III). The mortaIity rate in those patients who had previousIy suffered pain or bIeeding from an uIcer was not significantIy different from that of those who had not had these symptoms. Furthermore, the presence of shock at the time of admission, the occurrence of hematemesis, or the previous demonstration of an uIcer by x-ray, did not correIate with an increased mortaIity rate. The occurrence of shock from re-bIeeding after the initiation of hospita1 treatment, was of major and ominous prognostic significance. Of the thirty-two patients in whom this occurred, tweIve died. BLOOD
REPLACEMENT
Of the 544 transfusions given to these pa168 were given to the fourteen patients
tients,
370
Massive
Hemorrhage
from Peptic
TABLE CORRELATION
OF SIGNS
AND
Data
III SYMPTOMS
I
UIcer
Gastric
WITH
UIcer
MORTALITY
Duodenal
Totals
Ulcer
-1
I--
Deaths
Cases
Cases
Deaths
Cases
Deaths __~
__~~ ;-
Previous uIcer pain.. Previous ulcer hemorrhage.. Acute hematemesis. Shock on admission., Shock after treatment. UIcer on oId x-rays
I / I i .I
2 I
44 27
6 6
II
4 3 4 0
36 45 21 ‘3
4 7 8 2
IO II 2
52 37 47 55 32 IS
8 7 8 IO I2 2
i
I
with gastric ulcers, an average of twelve transfusions per patient. One hundred twenty-eight transfusions, 12.8 per patient, were received by the ten patients with duodena1 ulcer who had had emergency surgery. The forty-nine patients with duodena1 uIcers who were not
8 IO
duodena1 uIcer. Summaries are presented in TabIe v of 183 patients with duodenal uIcer and forty-nine with gastric uIcer. There was no difference in the bIood type between the groups with or without massive hemorrhage. Here aIso, is shown the incidence of these bIood TABLE v DISTRIBUTION OF BLOOD TlPES
TABLE IV NUMBER OF TRANSFUSIONS
I I );&a
Gastric ulcer. DuodenaI uIcer (operated). DuodenaI ulcer (not operated)
~Cases
14 IO 49
Average No. Transfusions/ Patient
I2 12.8 5.1
~
Total
.I~“. ,I A- ~” ~imAB
DuodenaI uIcer.. .._. ., 65.5i26.81 6.41 1.3 (Los Angeles County Genera1 ~ I HospitaI 183 cases1 I Gastric ulcer 47 8,43 51 4 3( 4 : (Los Angeles County General ~ / HospitaI 4g cases) Los AngeIes Red Cross donors.. 44.g138.7 12.3~ 4.3 Los AngeIes County General Hosi pita1 donors (10,199). .,51 ~34 ~12 ~3
168 128 248
operated upon averaged sIightIy more than five transfusions each; onIy fourteen in this group received more than five. (Table IV.) In the entire group there was no patient who subsequentIy returned with hepatitis. AIso, there was no recognized instance of hemoIytic transfusion reaction, or of overtransfusion. Furthermore, there was no incident from which it couId be concIuded that restoration of norma bIood pressure had been responsibIe for disIodgment of the cIot from a vesse1. Evidence against such an effect has been provided by Stewart’s cIinica1 study [I] and by the experimenta study of Mayo [IO].
types obtained from the Los Angeles Red Cross BIood Bank, and aIso from the bIood bank of the Los Angeles County HospitaI. There is evidence of a highly disproportionate percentage of patients with duodenal uIcer who are bIood type 0. The variations shown in our cases are in agreement with those reported from England by Koster [II] and Brown [ 121. No anaIysis was made of the Rh factor. However, this factor, when negative in an uIcer patient with type B or AB bIood, may invoIve major procurement probIems if massive hemorrhage occurs. There are times in the city of Los AngeIes when AB negative and B negative bIood cannot be found in any quantity. Therefore, it is possibIe that a patient with chronic peptic uIcer, who is a B or AB Rh negative,
IMPORTANCE OF BLOOD TYPE In conjunction with this anaIysis of massive bIeeding, the bIood types were recorded in an additiona group of patients with gastric or 371
Snyder
and Berne In evaIuating the deaths in our cases, a decision has been made in every instance as to the inevitabiIity of death. These decisions were made after exhaustive review and discussion of each record. If it was decided that a death might have been prevented by surgical intervention. This decision was based on whether or not there existed one of the indications previousIy stated (continued bleeding or one severe re-bIeeding episode). If the death was considered to be due to some other error, the analysis indicates this, and the death is considered preventabIe. OnIy by such an analysis can the adequacy of the indications be investigated and other errors be revealed.
presents a reIative indication for eIective surgery on the basis of this ditEcuIty. In addition the indication for emergency surgery IogicaIIy wiI1 be much Iess rigid with an individua1 who is an AB Rh negative or B Rh negative. These considerations are of importance even in AB and B types who are Rh positive. TABLE VI MAJOR
ASSOCIATED
ILLNESSES
(46 Patients) Chronic alcoholism, Cirrhosis.................................... Hypertensive cardiovascular disease. ArterioscIerotic heart disease. Chronic renaI disease.. Cancer....................................... Psychosis..................................... Neurosyphihs. Diabetic coma................................
I4 4 13 7 4 3 2
DUODENAL
2 I
AIthough massive bIood repIacement was used in many of the patients in our group, no coaguIopathies were noted except in one case which is to be mentioned Iater. This Iack of tendency to induced bleeding may be reIated to the high rate of turnover and the resuItant freshness of bIood in the Los Angeles County HospitaI BIood Bank. However, in private hospitaIs where blood is procured from a central faciIity, the bIood supplied to patients is frequentIy more than ten days oId. The physician ordering bIood for his patient generally IS unaware of this fact. If massive transfusion therapy becomes necessary, every effort shouId be made to assure the use of recentIy drawn blood. We have consistentIy found bIood drawn two weeks previous to use to have a high serum potassium content and to be very thrombopenic. ANALYSIS
ULCER
Operation. Ten patients with duodenal uIcer had emergency operations, resuhing in two deaths. Of these, one death might have been avoided and one was unavoidable. The avoidable death occurred in a sixty-four year old man who was aIIowed to re-bleed twice, necessitating tweIve transfusions before surgery. This was in vioIation of the previously stated poIicy. Postoperatively, signs and symptoms of peritonitis deveIoped, and he died despite intensive treatment. An autopsy was not performed. This death is considered to be avoidabIe for two reasons: (I) The patient should have been operated upon earIier and (2) there was apparently some technica faiIure productive of the postoperative abdomina1 signs and symptoms. The unavoidabIe death occurred in a seventy-seven year oId man who continued to bIeed after surgica1 intervention. He had very serious heart disease, diagnosed as severe aortic stenosis, and regurgitation with congestive faiIure. A pyIoropIasty with suture ligation of the bIeeding vesseIs was performed. The patient died of cardiac faiIure three days postoperativeIy, and at necropsy there was no evidence of gastrointestinal bleeding. Varied technica procedures were utiIized in the ten duodenal uIcer cases in which operations were performed. Four patients had subtota1 gastric resections with gastrojejuna1 anastomoses; two patients had vagotomy, pyloropIasty and sleeve gastric resections; two had vagotomy and pyIoropIasty, one patient had a subtota1 gastric resection with a gastroduodenal anastomosis; and one patient had a pyIoropIasty onIy. Suture Iigation of the bIeeding vesseIs was done in-al1 cases.
OF DEATHS
Forty-six of the seventy-three patients had at Ieast one very serious compIicating iIIness, (TabIe VI), heart disease and aIcohoIism being the most prevaIent. In three patients (sIightIy over 4 per cent of the tota cases) the primary cause of death was a compIicating iIIness. It seems reasonabIe to postuIate that in any simiIar group of patients, possibIy 4 to 5 per cent wouId be so seriousIy III from associated disease or moribundity, that they wouId die soon after admission or, at least, wouId not be acceptabIe candidates for surgica1 intervention. 372
Massive
Hemorrhage
from
UIcer
be in heart failure and finally died on the fifth postoperative day. At no time was there any evidence of recurrent bIeeding. The second unavoidabIe death was in a sixty-one year old man who had two separate bleeding episodes and two operations. After the first massive hemorrhage he re-bled and had a wedge excision of a high-Iying lesser curvature gastric ulcer about z cm. in diameter. His condition was satisfactorv for two months, after which he returned w?th another massive bleeding episode. This time he continued to bieed after admission and underwent an emergency Iaparotomy, at which time he was found to have a juxtaesophagea1, posterior wall gastric ulcer, 6 cm. in diameter, which had eroded 2 cm. into the pancreas. During the operation signs of a coaguIopathy deveIoped which were determined to be due to hypofibrinoginemia. The patient received twenty-nine transfusions, intravenous fibrinogen and underwent a subtotal gastric resection, despite which he died on the third postoperative day- in irreversible shock. AIthough his death was considered to be unavoidabIe at the time of his second admission, the death might we11 have been prevented by a subtotal gastrectomy at the first operation. The operative procedures used on these ten patients were wedge excision in three cases and subtotal gastrectomy with gastrojejunostomy in one case. The remainder were treated by subtotal gastrectomy with gastroduodenostomy. Except for three wound infections, the morbidity among the surviving patients was not sign&ant. No Surger_v. The death of one of the patients with gastric uIcer who was not operated upon shouId have been avoided. He was a forty-eight year old man who had a massive hemorrhage after being admitted and re-bIed twice. Each time he recovered very quickly with the treatment that was utilized and, despite our estabIished policy, he was not operated upon. He exsanguinated in his sIeep on the fifth night after admission; necropsy showed a gastric ulcer with erosion into a vesse1 with the gastrointestinal tract fuI1 of bIood. The last two patients whose deaths were unavoidabIe (using our operative indications) were a sixty-three year oId woman and a seventy year oId man. Both had severe hypertensive cardiovascuIar disease and were under cardiac therapy when they had their massive hemorrhages. Both patients made .a rapid
The morbidity in this group of cases was small, with no evidence of anastomotic Ieaks or stoma1 maIfunction. One patient had a severe wound infection fo1Iowed by an incisiona1 hernia. No Surgery. There were forty-nine patients with duodena1 uIcer who were not operated upon. In this group there were six deaths, two avoidabIe and four unavoidabIe. .The first of the two avoidabIe deaths occurred in a fifty year o1d man with Iong standing hypertensive cardiovascuIar disease. He had a hemipIegia as the resuIt of an oId cerebrovascu1ar accident but he was able to care for himseIf. He had been hospitaIized because of Iobar pneumonia from which he had recovered satisfactoriIy. Despite massive hemorrhage with continued bIeeding, he was treated medicaIIy. The surgeons were never caIIed in to see him. He died five days after the onset of hemorrhage and, at autopsy, there was an opening in a duodenal vesse1 from which he had exsanquinated. The second death in this group was of a seventy-six year old man who had mild arteriosclerotic heart disease and re-bIed under therapy, but who was not operated upon. He succumbed to the second bIeeding episode. Using our indications, both of these patients shouId have had emergency surgery and are therefore cIassified as potentiaI1y preventabIe deaths. In the unavoidabIe death group was a seventy-eight year o1d man who refused to undergo an operation. The second unavoidable death occurred in an eighty-two year oId man who entered the hospita1 moribund. The third fataIity was a fifty year oId chronic aIcohoIic, with severe cirrhosis and a bIeeding ulcer, who was aIso moribund upon admission. The Iatter two patients died within an hour of arriva1 at the hospita1. The fourth patient was suffering from severe congestive heart faiIure. He re-bIed and died very quick1y. GASTRIC
Peptic
ULCER
Surgery. Of the fourteen patients with gastric uIcers, ten had emergency operations resu1ting in two unavoidable deaths, and four patients were not operated upon, with one avoidab1e death and two unavoidabIe deaths. The first unavoidabIe death postoperativeIy occurred in an eighty-eight year oId woman with hypertensive cardiovascuIar disease and congestrve faiIure, who was operated upon after she re-bled. PostoperativeIy she continued to 373
Snyder
and
Berne CONCLUSIONS
and satisfactory response to non-operative treatment initiaIIy and were considered to be out of danger. About twelve hours after admission in each case, torrentia1 hematemesis suddenIy deveIoped and the patient exsanguinated within twenty or thirty minutes.
We have defined massive hemorrhage from peptic uIcer as acute hemorrhage accompanied by hypovoIemic shock with a systoIic bIood pressure of go mm. Hg or Iess and/or productive of a faI1 of hemogIobin to 7.5 gm. per 100 cc. or Iess. GeneraIIy usabIe criteria shouId be deveIoped for a11 who attempt to evaIuate resuIts in the treatment of massive hemorrhage from duodena1 or gastric ulcer. It is desirabIe that medica and surgica1 cases be reported, showing thk tota hospita1 mortaIity. On the basis of the data presented, it is our intention to maintain our present indications of continued bleeding or one severe re-bIeeding for emergency surgica1 intervention, with emphasis on severe re-bIeeding as an almost absoIute indication for immediate surgery. The successfu1 treatment of patients with massive hemorrhage from duodena1 or gastric ulcer requires Iarge voIumes of bIood (2,500 to 6,000 cc.). Since ten of the thirteen deaths in this series were in patients over sixty years of age, it is suggested that without exception, everyone who has a known active peptic uIcer, and especiaIIy if it be gastric, shouId have appropriate surgica1 treatment before his or her sixtieth birthday. Furthermore, the duration of an uIcer should become a factor in determining the need for eIective surgery. FinaIIy, uIcer patients with AB or B type bIood, especiaIIy if Rh negative, are candidates for earIier eIective and emergency surgery.
COMMENTS
Utilizing a poIicy of treatment for massive gastroduodena1 hemorrhage consisting of vigorous uIcer therapy and restoration of blood voIume, with emergency surgery being reserved for those patients who continued to bleed or who re-bIed, we had a mortaIity rate of 17.8 per cent. If the four deaths we considered avoidabIe could have been prevented, we would have had a mortality rate of 12.3 per cent (nine unavoidable deaths in seventy-three cases). This wouId then indicate a maximal possibIe saIvage of 87.7 per cent of cases, under the conditions presented and using the operative indications that we described. What wouId have been the theoretic optimal mortaIity rate if, during this period, a poIicy had been foIlowed of immediate emergency surgery for a11 patients with massive bIeeding who were not rendered inoperabIe because of severe systemic disease or moribundity? In this series, nearly 5 per cent of the patients were inoperabIe for these latter reasons, and it seems vaIid to assume that this would be true in any simiIar series. If we couId postulate an operative mortaIity rate of 5 per cent, which seems Iower than it probabIy wouId be in a group such as ours, the tota mortality rate we beIieve wouId be IO per cent. Therefore that the difference between the two theoretic mortaIity rates (12.3 per cent versus I0 per cent) and our actua1 mortality rate of 17.8 per cent is not significant enough to justify a change in our policy. In the hands of a seIect group of very skiIIfu1 surgeons, under idea1 hospital conditions, the more radica1 poIicy might be successfuIIy empIoyed. In contempIating the operative procedure to be used in these cases, it seems to us that the surgeon must assume that his primary objective is to stop the hemorrhage in order to save the patient’s life. Therefore, the most expeditious technic,aI procedure possibIe should be utilized to contro1 hemorrhage and to prevent recurrence. This means that frequentIy, a procedure Iess radica1 than a 75 or 80 per cent subtota1 gastric resection is justified.
REFERENCES
S. M., POTTER, W. H. and MASOVER, A. J. Management of massively bleeding peptic ulcer. Ann. Surg., 128: 791, 1948. 2. MATHEWSON, C., JR. and SUGAR, B. Surgical significance of gastro-intestina1 bleeding. Am. J. Surg., 89: 1177, 1955. 3. WELCH, C. E. Treatment of acute, massive gastroduodenaI hemorrhage. -1. A. M. A., r4r : I I I 3, I. STEWART, J. D., SCHAER,
1949. 4. WELCH, C. E., ALLEN, A. W. and DONALDSON,G. A. SurgicaI management of massive acute upper gastro-intestinal hemorrhage. New England J. Med., 252: gzx, 1955. 5. WINTROBE, M. M. Anemia. Arch. Int. Med., 54: 256, 1934. 6. DUNPHY. J. E. and HOERR. S. 0. The indications for emergency operation- in severe hemorrhage from gastric or duodenal uIcer. Surgery, 24: 231, 1948. 7. HEWER, G. J. The surgicaI aspects of hemorrhage from peptic uIcer. New England J. Med., 235: 7779 194.6. 8. LEVEEN, H. H., MULDER, A. G. and PROFOF, F,
374
Massive
Hemorrhage
Physiological mechanism for death in massivety bIeeding peptic uker. Surg., Gynec. Ed Ok., 94: 433, 1952. 9. ALLEN, A. W. Acute massive hemorrhage from the upper gastro-intestina1 tract. Surgery, 2: 7 13, ‘937. IO. MAYO, H. W. Blood transfusion in hemorrhage from a severed artery-an experimenta study. Arch. Surg., 66: 137, 1953. I I. KOSTER, K. H., SINRUP, E. and SEELVE, V. AB-0 blood groups and gastric acidity. Lancet, 2: 52, 1955. 12. BROWN, D. A. P. and MELROSE, A. G. BIood groups in peptic ulceration. &it. M. J., 2: 135,
1956. 13. CHINN, A. B., LITTELL, A., BODGER, C. F. and BEAMS, A. J. Acute hemorrhage from peptic ulcer: a foIIow up study of 310 patients. New England J. Med., 255: 973, 1956. DISCUSSION HERBERT J. MOVIUS (Long agree with the authors on several
Beach,
CaIif.):
I
important points. CertainIy the necessity for a set of rigid criteria, defining massive hemorrhage, is mandatory if anything of value is to come out of the great mass of hospital charts being perused by surgeons throughout the country. The authors’ definition of massive hemorrhage is excellent and is particularly vaIuabIe in that no out-of-the-ordinary clinical Iaboratory test is needed. Few if any patients wouId be erroneousIy incIuded as having “massive hemorrhage” if these criteria were adhered to. It would be a real step forward if some such simpIe set of criteria could be nationaIIy adopted, at Ieast for future cIinica1 analyses. I certainly agree that the bIood voIume should be restored to approximateIy norma in the patient having recently manifested severe hemorrhage and that mere correction of hypovoIemic signs and symptoms should not be the stopping point for bIood replacement. Re-bleeding, as was emphasized by the authors, shouId be a positive indication for surgica1 intervention. This is one condition which certainIy shouId jar the physician into action and shouId end any procrastination on the part of the surgeon concerning when to operate. It is unfortunate, however, that internists and some surgeons alIow re-bIeeding to continue on medical therapy, as evidenced in this manuscript by the report of thirty-two patients who manifested re-bleeding and only twenty of whom were operated upon. At the Long Beach Veterans Administration HospitaI we have vigorousIy taught the residents that the prime concern of the surgeon operating upon a patient for massive hemorrhage is to stop that bIeeding. CertainIy there can be no brief with the authors when they state that many times these patients may not be candidates for more extensive defmitive uIcer procedures. At the Long Beach Veterans Administration Hospital we have fre-
375
from Peptic
UIcer
quently used the procedure of transfixion suture of the bleeding utter and supplemented this with vagotomy and pyIoropIasty. In twenty-six consecutive cases we have had but one death. This is too smaI1 a number from which to draw concIusions, but if the phrase may be used in a non-election year, “it shows a trend.” FinaIIy, I was pleased to see the authors’ suggestion that patients with chronic gastroduodena1 uIcer be submitted to eIective surgical management prior to their attaining the age of sixty. This, I believe, is a true forward step in the over-a11 management of patients with peptic uIcer and I wonder if we shouId not adopt a far more IiberaI set of indications for surgical intervention in the management of al1 patients with peptic uIcer than the now “ we11 accepted criteria.” It is, of c&rse, dificult to state the mortality rate of patients with peptic uIcer for the lifetime of the patient on a medica regimen, but it certainly must be close to 5 per cent. In addition, the regimen is confining, it does not alIow many of the patients to freeIy participate in what is considered to be a we11 rounded socia1 scheme, the regimen is highIy atherogenic (although this might be splitting hairs) and, finaIIy, it is expensive and time consuming when considered over a period of years. If a definitive operation to combat the ulcer diathesis can be accompIished with a mortality rate of one-half of I per cent, and this has been the mortaIity figure for vagotomy and pyIoropIasty in over 1,000 cases at the Long Beach Veterans HospitaI, than why should not such an operation be offered to the patient with peptic ulcer before he bleeds, perforates, obstructs or becomes totaIIy refractory to vigorous medica management. I disagree with the authors on a few trivial points. We have found the use of an upper gastrointestina1 series, with or without the Hampton technic, to be very valuable in al1 massive upper gastrointestina1 hemorrhage, except those patients in shock. The roentgenogram may revea1 a gastric uIcer or a giant duodenal uIcer, which in either case should call for surgica1 intervention without delay. I aIso question the wisdom of attempting to cIassify deaths as avoidable. This couId open avenues for conflicting statistica analyses and may tend to negate other well accepted rigid criteria. FinaIIy, the statement “surgery is indicated as bIeeding continues ” is ambiguous. I personaIIy have no formula or method for determining when surgery is indicated and how to determine when bIeeding is, in fact, continuing. We have a11 had experiences that show that a fairly high percentage of patients who are operated upon for continued bleeding, are in truth, not actively bIeeding at the time the uIcer is viewed. Therefore, I wouId appreciate, but have no suggestion myself, an accurate end point in the cIinica1 titration of the patient who is admitted
Snyder
and Berne The other thing which interested me in Drs. Berne and Snyder’s report was that our use of bIood paraIIeIed theirs quite cIoseIy. It varied in the surgica1 patients from three to thirty-one units, with an average of eight. The Medical Service suppIied their patients, in the range from one to thirty-three units, with an average of 3.2 units of bIood. EDWARD N. SNYDER, JR. (ctosing): In answer to the remark by Dr. Movius about continued bleeding, to a certain extent we left the term because continued bIeeding means ambiguous various things to various people. I do not see how anyone can say for certain that a given patient has a continued minor hemorrhage. Of the total group of patients who were operated upon for what was considered to be continued or recurrent bleeding, that is a11 twenty patients, tweIve were found to have arteria1 hemorrhage at the time of surgery. Of the peopIe who were operated upon for what was thought to be just continued bIeeding only, three had arteria1 hemorrhage at the time of surgery.
with active bleeding. When do we make the decision to operate? EDWARD B. SPEIR (Seattle, Wash.): I thought it might be of some interest to let you know that one of the residents and I recentIy went over the statistics at the Swedish HospitaI for a two-year period. We grouped the patients who were coded and diagnosed on entering the hospita1 as having gastrointestina1 hemorrhage. Three hundred three patients were seen during the two-year period. Seventy-eight per cent of the patients were treated medicaIIy, with a mortaIity rate of I 1.s per cent. Eighteen per cent were treated surgicaIIy, which meant sixty-eight patients, with a mortality of II.7 per cent. The other interesting fact was that of the over-a11 303 patients, tweIve continued to bIeed and were operated upon, as far as we couId determine, whiIe stiI1 bIeeding. Of these twelve patients, three died, giving for that particuIar group a 25 per cent mortality rate. We teII the medical people, of course, that there is a 75 per cent salvage rate, but it only points out the seriousness of the disease.
376
of our cases in order to report results presently being obtained, and have attempted to identify potentia1 means of improving our future results.
T that
HERE is no more diffrcuIt judgment than required of the cIinician when he must evaIuate the inherent Iethality of an acute, severe, hemorrhage from a peptic uIcer. For adequate orientation regarding the probIem he must be provided with careful anaIyses of significant numbers of such situations. These studies shouId include all patients with acutely bleeding peptic uIcer who enter the hospita1, whether or not they are operated upon. Further, rigid criteria of massive hemorrhage must be appIied in order to excIude a11 instances of Iesser degrees of bleeding. AdditionaIIy, because of the extreme infIuence of the patient’s age and the presence of serious associated disease on this outcome, these factors must be cIearIy presented. In order to appraise the vahdity of existing indications for surgery it is admittedIy desirabIe to have the most exact data obtainabIe regarding a given patient. However, since many of the precise technics are not avaiIabIe in the average hospital a study using generahy avaiIabIe methods shouId have specia1 vaIue. It is our purpose to report such an anaIysis of consecutive cases of massive hemorrhage from gastric or duodena1 uIcer, incIuding all patients admitted to the University of Southern CaIifornia MedicaI and SurgicaI Services at the Los AngeIes County HospitaI over a period of one year from JuIy, 1954 to JuIy, 1955. Another phase of this study of massive hemorrhage from peptic uIcer has to do with estimating the present benefits of operative therapy based on utiIization of the knowIedge gained from the reports of studies such as those of Stewart [I], WeIch [3], Dunphy [61, and Mathewson [2]. We have made such an anaIysis American Journal of Surgery,
Volume 94. August,
1937
Calijornia
CRITERIA OF MASSIVE HEMORRHAGE In order to define massive hemorrhage it is necessary to establish criteria that eliminate all instances of acute bIeeding that were of moderate degree and wouId have recovered spontaneousIy, or with reIativeIy conservative therapeutic efforts. Only when such cases are excIuded can the effectiveness of therapy be measured. No cases are inchided in our series unIess they were of such severity as to fuIfiI1 the foIIowing criteria. Acute hemorrhage accompanied by either: Acute hypovolemic shock SystoIic bIood pressure of 90 mm. Hg or Iess CoId skin Sweating PaIIor, and/or
_. 368
A hemogIobin of 7.5 gm. or Iess per IOOcc. Sixty-three of the seventy-three patients in this series had acute hypovoIemia productive of the signs of shock. The circuIatory disturbance of the remaining ten patients had stabiIized when admitted, but the bIeeding was severe enough to reduce the hemoglobin IeveI to 7.5 gm. or Iess. The IeveI of 7.5 gm. was chosen because at this IeveI of hemogIobin, with the usua1 associated reduction in bIood voIume, ischemic renaI injury was imminent. We beIieve that the foregoing criteria of massive hemorrhage are appIicabIe under aImost any circumstances. Our cases of massive bIeeding from duodena1 or gastric uIcer met these criteria and, excIuding a11 cases with unproved diagnoses of gastric or duodena1 ulcer, seventy-three cases
Massive
Hemorrhage
occurred during the one year. The causative presence of gastric or duodena1 ulcer was proved in each case by x-ray studies, surgery or autopsy. Erythrocyte counts have not been included since it has been we11 estabIished that such counts are subject to an error of pIus to minus 20 per cent. Likewise, hematocrit determinations were not incIuded since a high speed centrifuge is not avaiIabIe in many institutions. However, the results of this determination are accurate within I per cent [y]. BASIC
TABLE I SUMMARYOF MANAGEMENTOF Data
CASES
AND
Cases
-___
MANAGEMENT
FOR OPERATIVE
UIcer
if the patient had signs and symptoms of shock despite the administration of 1,000 to 1,500 cc. of blood. With this indication it may be that the uIcer actuaIIy is bIeeding intermittently, instead of continuousIy. FrequentIy under these conditions, active bleeding n-ill not be present
AI1 patients were treated initially with aggressive nonoperative means. These consisted of vigorous ulcer therapy and rapid restoration of blood voIume. The former included the IiberaI use of parasympatholytic drugs, sedation, Levin tube with suction if vomiting was present, alternate hourIy feedings day and night, and ora antiacid drugs if nausea and vomiting were absent. Because re-bleeding is probably due to peptic digestion of the cIot, it is of the greatest importance that the feedings be continued during the night. This is equally true of the substances used to reduce acidity and thereby to inhibit pepsin activity. The bIood deficit was restored with whoIe blood, each transfusion consisting of goo cc. of whoIe blood and 120 cc. of anticoaguIant solution. The goal with transfusion therapy was to restore the hemogIobin to near normal levels rather than mereIy to aIIeviate the symptoms and signs of shock. Roentgenographic examination was not performed routinely during the period of active bIeeding. Our decisions were made primarily on the basis of the patient’s history, physica examination, Iaboratory data, and the changes in these whiIe the patient was under treatment. The prob1em of diagnosis is not considered in this report. INDICATIONS
from Peptic
RESULTS
Deaths ______-.
Duodenal ulcer : Operation. No operation..
I0 4g
2 (20%) 6 (12.3%)
Gastric uIcer: Operation. No operation.
I0 4
2 (20%) 3 (75%)
73
TotaI..
/
_
13 (17.8%)
~
at the time of surgery. However, the cIot usuaIIy can be easily disIodged. The second indication, one episode of severe re-bIeeding, is more precise. FundamentaIIy, these indications are based on the Iarge mass of evidence that, even with generous bIood replacement, patients with repeated hemorrhages become progressive1y poorer risks [4,6,7,8]. Two gastric uIcer patients and three of the duodena1 ulcer patients had emergencv operations because of continued bIeeding. Eight of the patients with gastric ulcer and seven of the patients with duodena1 ulcer were operated upon because of severe re-bleeding. Major re-bIeeding nearIy aIways occurred within three to four days after hospitaIization. This observation is simiIar to that made by Mathewson [2] and Welch [j] in simi1ar groups of patients. REVIEW
OF CASES
TabIe I shows a summary of the management of these cases. It is quite obvious that the morta1ity rate from bIeeding gastric u1cers is much higher, and that emergency surgery is more often necessary, than is the case in bIeeding duodenal uIcers. Mathewson and WeIch suggest that this is due to the fact that gastric uIcers are more prone to erode into major arteries while duodena1 uIcers more often cause bleeding from smaI1 vessels [2,3]. Another factor may be the reIativeIy Iow acid vaIues in gastric uIcer compared to those in duodena1
TREATMENT
Two indications for surgery were used during the year that these patients were treated. The analysis to be presented was carried out mainly to determine the vaIidity of these indications as a basis for surgical intervention in massive bIeeding from peptic uIcer. These two indications were: continued bleeding, or one episode of major rebleeding. Continued bIeeding necessitating surgery was considered to be present 369
Snyder
and Berne
TABLE CORRELATION
OF AGE,
II
RACE AND
SEX
WITH
Gastric Ulcer
MORTALITY
DuodenaI UIcer
Total
Data Cases
Deaths
Cases
17
20-49......................................
I
Age p-59 ......................................
0
Race
4 4 I
Sex
60-88 ...................................... Caucasian* ................................. { Negro ...................................... Males ...................................... FemaIes ....................................
Deaths
18
3
24 45 ‘4 48
2
11
Cases
Deaths
‘9
1
20
2
34 57 16 56 17
IO I2
I II 2 I
* IncIudes Mexicans
ulcer. These Iower acid vaIues very possibIy reduce the effects of medica treatment of the acid pepsin mechanism. In this series of cases, ten of fourteen patients with gastric uIcers were over sixty years of age and four of the ten patients died. By contrast, onIy twenty-four of the fifty-nine patients with duodena1 uIcer were over sixty years of age and six of the twenty-four patients died. It is IikeIy that the more advanced age of the patients with gastric uIcer is the major determining factor in the mortaIity difference between the two groups of patients. A more detaiIed study of the age distribution of a11 cases (TabIe II) reveaIs that aImost three-fourths of the patients were over fifty years of age. Ten of the thirteen deaths occurred in the thirty-four patients over sixty; two deaths occurred in the twenty patients m their fifties; and only one death occurred in the group under fifty years of age. These mortality figures cIearIy indicate the grave danger associated with massive hemorrhage in the oIder age groups, as has been emphasized by AIIen [9] and WeIch [3,4]. However, this shouId not be interpreted as impIying a high degree of safety in younger patients with massiveIy bIeeding peptic uIcer, because only nineteen of our seventy-three cases were under fifty years of age. There may be a high correIation between the age of the uIcer and the seriousness of the bIeeding. Thus, a Iong standing, deepIy eroded uIcer in a younger patient may present a very grave danger. Such uIcers probabIy increase in frequency in oIder age groups and further condition the increased seriousness of their bIeeding episodes. The great majority of the cases, and a11 but
one of the deaths, occurred in Caucasians. During the period of this study, the average daiIy patient census of the Los AngeIes County Genera1 Hospital incIuded about 31 per cent Negroes and 20 per cent Mexicans; yet of these massive bIeeders, onIy 22 per cent were Negroes and only 4 per cent were of Mexican descent. A study of TabIe II aIso confirms the great prediIection of duodena1 uIcer disease for males. However, the gastric uIcers were aImost evenIy divided among the sexes, and the two deaths among the femaIe patients occurred in patients with gastric uIcer. NevertheIess, femaIes and Negroes had a very Iow mortality rate. A critica evaIuation was made of each patient’s history, physica examination, and Iaboratory data in an attempt to eIicit some factors of prognostic vaIue. WhiIe the facts are informative, IittIe of statistica prognostic significance is apparent. (TabIe III). The mortaIity rate in those patients who had previousIy suffered pain or bIeeding from an uIcer was not significantIy different from that of those who had not had these symptoms. Furthermore, the presence of shock at the time of admission, the occurrence of hematemesis, or the previous demonstration of an uIcer by x-ray, did not correIate with an increased mortaIity rate. The occurrence of shock from re-bIeeding after the initiation of hospita1 treatment, was of major and ominous prognostic significance. Of the thirty-two patients in whom this occurred, tweIve died. BLOOD
REPLACEMENT
Of the 544 transfusions given to these pa168 were given to the fourteen patients
tients,
370
Massive
Hemorrhage
from Peptic
TABLE CORRELATION
OF SIGNS
AND
Data
III SYMPTOMS
I
UIcer
Gastric
WITH
UIcer
MORTALITY
Duodenal
Totals
Ulcer
-1
I--
Deaths
Cases
Cases
Deaths
Cases
Deaths __~
__~~ ;-
Previous uIcer pain.. Previous ulcer hemorrhage.. Acute hematemesis. Shock on admission., Shock after treatment. UIcer on oId x-rays
I / I i .I
2 I
44 27
6 6
II
4 3 4 0
36 45 21 ‘3
4 7 8 2
IO II 2
52 37 47 55 32 IS
8 7 8 IO I2 2
i
I
with gastric ulcers, an average of twelve transfusions per patient. One hundred twenty-eight transfusions, 12.8 per patient, were received by the ten patients with duodena1 ulcer who had had emergency surgery. The forty-nine patients with duodena1 uIcers who were not
8 IO
duodena1 uIcer. Summaries are presented in TabIe v of 183 patients with duodenal uIcer and forty-nine with gastric uIcer. There was no difference in the bIood type between the groups with or without massive hemorrhage. Here aIso, is shown the incidence of these bIood TABLE v DISTRIBUTION OF BLOOD TlPES
TABLE IV NUMBER OF TRANSFUSIONS
I I );&a
Gastric ulcer. DuodenaI uIcer (operated). DuodenaI ulcer (not operated)
~Cases
14 IO 49
Average No. Transfusions/ Patient
I2 12.8 5.1
~
Total
.I~“. ,I A- ~” ~imAB
DuodenaI uIcer.. .._. ., 65.5i26.81 6.41 1.3 (Los Angeles County Genera1 ~ I HospitaI 183 cases1 I Gastric ulcer 47 8,43 51 4 3( 4 : (Los Angeles County General ~ / HospitaI 4g cases) Los AngeIes Red Cross donors.. 44.g138.7 12.3~ 4.3 Los AngeIes County General Hosi pita1 donors (10,199). .,51 ~34 ~12 ~3
168 128 248
operated upon averaged sIightIy more than five transfusions each; onIy fourteen in this group received more than five. (Table IV.) In the entire group there was no patient who subsequentIy returned with hepatitis. AIso, there was no recognized instance of hemoIytic transfusion reaction, or of overtransfusion. Furthermore, there was no incident from which it couId be concIuded that restoration of norma bIood pressure had been responsibIe for disIodgment of the cIot from a vesse1. Evidence against such an effect has been provided by Stewart’s cIinica1 study [I] and by the experimenta study of Mayo [IO].
types obtained from the Los Angeles Red Cross BIood Bank, and aIso from the bIood bank of the Los Angeles County HospitaI. There is evidence of a highly disproportionate percentage of patients with duodenal uIcer who are bIood type 0. The variations shown in our cases are in agreement with those reported from England by Koster [II] and Brown [ 121. No anaIysis was made of the Rh factor. However, this factor, when negative in an uIcer patient with type B or AB bIood, may invoIve major procurement probIems if massive hemorrhage occurs. There are times in the city of Los AngeIes when AB negative and B negative bIood cannot be found in any quantity. Therefore, it is possibIe that a patient with chronic peptic uIcer, who is a B or AB Rh negative,
IMPORTANCE OF BLOOD TYPE In conjunction with this anaIysis of massive bIeeding, the bIood types were recorded in an additiona group of patients with gastric or 371
Snyder
and Berne In evaIuating the deaths in our cases, a decision has been made in every instance as to the inevitabiIity of death. These decisions were made after exhaustive review and discussion of each record. If it was decided that a death might have been prevented by surgical intervention. This decision was based on whether or not there existed one of the indications previousIy stated (continued bleeding or one severe re-bIeeding episode). If the death was considered to be due to some other error, the analysis indicates this, and the death is considered preventabIe. OnIy by such an analysis can the adequacy of the indications be investigated and other errors be revealed.
presents a reIative indication for eIective surgery on the basis of this ditEcuIty. In addition the indication for emergency surgery IogicaIIy wiI1 be much Iess rigid with an individua1 who is an AB Rh negative or B Rh negative. These considerations are of importance even in AB and B types who are Rh positive. TABLE VI MAJOR
ASSOCIATED
ILLNESSES
(46 Patients) Chronic alcoholism, Cirrhosis.................................... Hypertensive cardiovascular disease. ArterioscIerotic heart disease. Chronic renaI disease.. Cancer....................................... Psychosis..................................... Neurosyphihs. Diabetic coma................................
I4 4 13 7 4 3 2
DUODENAL
2 I
AIthough massive bIood repIacement was used in many of the patients in our group, no coaguIopathies were noted except in one case which is to be mentioned Iater. This Iack of tendency to induced bleeding may be reIated to the high rate of turnover and the resuItant freshness of bIood in the Los Angeles County HospitaI BIood Bank. However, in private hospitaIs where blood is procured from a central faciIity, the bIood supplied to patients is frequentIy more than ten days oId. The physician ordering bIood for his patient generally IS unaware of this fact. If massive transfusion therapy becomes necessary, every effort shouId be made to assure the use of recentIy drawn blood. We have consistentIy found bIood drawn two weeks previous to use to have a high serum potassium content and to be very thrombopenic. ANALYSIS
ULCER
Operation. Ten patients with duodenal uIcer had emergency operations, resuhing in two deaths. Of these, one death might have been avoided and one was unavoidable. The avoidable death occurred in a sixty-four year old man who was aIIowed to re-bleed twice, necessitating tweIve transfusions before surgery. This was in vioIation of the previously stated poIicy. Postoperatively, signs and symptoms of peritonitis deveIoped, and he died despite intensive treatment. An autopsy was not performed. This death is considered to be avoidabIe for two reasons: (I) The patient should have been operated upon earIier and (2) there was apparently some technica faiIure productive of the postoperative abdomina1 signs and symptoms. The unavoidabIe death occurred in a seventy-seven year oId man who continued to bIeed after surgica1 intervention. He had very serious heart disease, diagnosed as severe aortic stenosis, and regurgitation with congestive faiIure. A pyIoropIasty with suture ligation of the bIeeding vesseIs was performed. The patient died of cardiac faiIure three days postoperativeIy, and at necropsy there was no evidence of gastrointestinal bleeding. Varied technica procedures were utiIized in the ten duodenal uIcer cases in which operations were performed. Four patients had subtota1 gastric resections with gastrojejuna1 anastomoses; two patients had vagotomy, pyloropIasty and sleeve gastric resections; two had vagotomy and pyIoropIasty, one patient had a subtota1 gastric resection with a gastroduodenal anastomosis; and one patient had a pyIoropIasty onIy. Suture Iigation of the bIeeding vesseIs was done in-al1 cases.
OF DEATHS
Forty-six of the seventy-three patients had at Ieast one very serious compIicating iIIness, (TabIe VI), heart disease and aIcohoIism being the most prevaIent. In three patients (sIightIy over 4 per cent of the tota cases) the primary cause of death was a compIicating iIIness. It seems reasonabIe to postuIate that in any simiIar group of patients, possibIy 4 to 5 per cent wouId be so seriousIy III from associated disease or moribundity, that they wouId die soon after admission or, at least, wouId not be acceptabIe candidates for surgica1 intervention. 372
Massive
Hemorrhage
from
UIcer
be in heart failure and finally died on the fifth postoperative day. At no time was there any evidence of recurrent bIeeding. The second unavoidabIe death was in a sixty-one year old man who had two separate bleeding episodes and two operations. After the first massive hemorrhage he re-bled and had a wedge excision of a high-Iying lesser curvature gastric ulcer about z cm. in diameter. His condition was satisfactorv for two months, after which he returned w?th another massive bleeding episode. This time he continued to bieed after admission and underwent an emergency Iaparotomy, at which time he was found to have a juxtaesophagea1, posterior wall gastric ulcer, 6 cm. in diameter, which had eroded 2 cm. into the pancreas. During the operation signs of a coaguIopathy deveIoped which were determined to be due to hypofibrinoginemia. The patient received twenty-nine transfusions, intravenous fibrinogen and underwent a subtotal gastric resection, despite which he died on the third postoperative day- in irreversible shock. AIthough his death was considered to be unavoidabIe at the time of his second admission, the death might we11 have been prevented by a subtotal gastrectomy at the first operation. The operative procedures used on these ten patients were wedge excision in three cases and subtotal gastrectomy with gastrojejunostomy in one case. The remainder were treated by subtotal gastrectomy with gastroduodenostomy. Except for three wound infections, the morbidity among the surviving patients was not sign&ant. No Surger_v. The death of one of the patients with gastric uIcer who was not operated upon shouId have been avoided. He was a forty-eight year old man who had a massive hemorrhage after being admitted and re-bIed twice. Each time he recovered very quickly with the treatment that was utilized and, despite our estabIished policy, he was not operated upon. He exsanguinated in his sIeep on the fifth night after admission; necropsy showed a gastric ulcer with erosion into a vesse1 with the gastrointestinal tract fuI1 of bIood. The last two patients whose deaths were unavoidabIe (using our operative indications) were a sixty-three year oId woman and a seventy year oId man. Both had severe hypertensive cardiovascuIar disease and were under cardiac therapy when they had their massive hemorrhages. Both patients made .a rapid
The morbidity in this group of cases was small, with no evidence of anastomotic Ieaks or stoma1 maIfunction. One patient had a severe wound infection fo1Iowed by an incisiona1 hernia. No Surgery. There were forty-nine patients with duodena1 uIcer who were not operated upon. In this group there were six deaths, two avoidabIe and four unavoidabIe. .The first of the two avoidabIe deaths occurred in a fifty year o1d man with Iong standing hypertensive cardiovascuIar disease. He had a hemipIegia as the resuIt of an oId cerebrovascu1ar accident but he was able to care for himseIf. He had been hospitaIized because of Iobar pneumonia from which he had recovered satisfactoriIy. Despite massive hemorrhage with continued bIeeding, he was treated medicaIIy. The surgeons were never caIIed in to see him. He died five days after the onset of hemorrhage and, at autopsy, there was an opening in a duodenal vesse1 from which he had exsanquinated. The second death in this group was of a seventy-six year old man who had mild arteriosclerotic heart disease and re-bIed under therapy, but who was not operated upon. He succumbed to the second bIeeding episode. Using our indications, both of these patients shouId have had emergency surgery and are therefore cIassified as potentiaI1y preventabIe deaths. In the unavoidabIe death group was a seventy-eight year o1d man who refused to undergo an operation. The second unavoidable death occurred in an eighty-two year oId man who entered the hospita1 moribund. The third fataIity was a fifty year oId chronic aIcohoIic, with severe cirrhosis and a bIeeding ulcer, who was aIso moribund upon admission. The Iatter two patients died within an hour of arriva1 at the hospita1. The fourth patient was suffering from severe congestive heart faiIure. He re-bIed and died very quick1y. GASTRIC
Peptic
ULCER
Surgery. Of the fourteen patients with gastric uIcers, ten had emergency operations resu1ting in two unavoidable deaths, and four patients were not operated upon, with one avoidab1e death and two unavoidabIe deaths. The first unavoidabIe death postoperativeIy occurred in an eighty-eight year oId woman with hypertensive cardiovascuIar disease and congestrve faiIure, who was operated upon after she re-bled. PostoperativeIy she continued to 373
Snyder
and
Berne CONCLUSIONS
and satisfactory response to non-operative treatment initiaIIy and were considered to be out of danger. About twelve hours after admission in each case, torrentia1 hematemesis suddenIy deveIoped and the patient exsanguinated within twenty or thirty minutes.
We have defined massive hemorrhage from peptic uIcer as acute hemorrhage accompanied by hypovoIemic shock with a systoIic bIood pressure of go mm. Hg or Iess and/or productive of a faI1 of hemogIobin to 7.5 gm. per 100 cc. or Iess. GeneraIIy usabIe criteria shouId be deveIoped for a11 who attempt to evaIuate resuIts in the treatment of massive hemorrhage from duodena1 or gastric ulcer. It is desirabIe that medica and surgica1 cases be reported, showing thk tota hospita1 mortaIity. On the basis of the data presented, it is our intention to maintain our present indications of continued bleeding or one severe re-bIeeding for emergency surgica1 intervention, with emphasis on severe re-bIeeding as an almost absoIute indication for immediate surgery. The successfu1 treatment of patients with massive hemorrhage from duodena1 or gastric ulcer requires Iarge voIumes of bIood (2,500 to 6,000 cc.). Since ten of the thirteen deaths in this series were in patients over sixty years of age, it is suggested that without exception, everyone who has a known active peptic uIcer, and especiaIIy if it be gastric, shouId have appropriate surgica1 treatment before his or her sixtieth birthday. Furthermore, the duration of an uIcer should become a factor in determining the need for eIective surgery. FinaIIy, uIcer patients with AB or B type bIood, especiaIIy if Rh negative, are candidates for earIier eIective and emergency surgery.
COMMENTS
Utilizing a poIicy of treatment for massive gastroduodena1 hemorrhage consisting of vigorous uIcer therapy and restoration of blood voIume, with emergency surgery being reserved for those patients who continued to bleed or who re-bIed, we had a mortaIity rate of 17.8 per cent. If the four deaths we considered avoidabIe could have been prevented, we would have had a mortality rate of 12.3 per cent (nine unavoidable deaths in seventy-three cases). This wouId then indicate a maximal possibIe saIvage of 87.7 per cent of cases, under the conditions presented and using the operative indications that we described. What wouId have been the theoretic optimal mortaIity rate if, during this period, a poIicy had been foIlowed of immediate emergency surgery for a11 patients with massive bIeeding who were not rendered inoperabIe because of severe systemic disease or moribundity? In this series, nearly 5 per cent of the patients were inoperabIe for these latter reasons, and it seems vaIid to assume that this would be true in any simiIar series. If we couId postulate an operative mortaIity rate of 5 per cent, which seems Iower than it probabIy wouId be in a group such as ours, the tota mortality rate we beIieve wouId be IO per cent. Therefore that the difference between the two theoretic mortaIity rates (12.3 per cent versus I0 per cent) and our actua1 mortality rate of 17.8 per cent is not significant enough to justify a change in our policy. In the hands of a seIect group of very skiIIfu1 surgeons, under idea1 hospital conditions, the more radica1 poIicy might be successfuIIy empIoyed. In contempIating the operative procedure to be used in these cases, it seems to us that the surgeon must assume that his primary objective is to stop the hemorrhage in order to save the patient’s life. Therefore, the most expeditious technic,aI procedure possibIe should be utilized to contro1 hemorrhage and to prevent recurrence. This means that frequentIy, a procedure Iess radica1 than a 75 or 80 per cent subtota1 gastric resection is justified.
REFERENCES
S. M., POTTER, W. H. and MASOVER, A. J. Management of massively bleeding peptic ulcer. Ann. Surg., 128: 791, 1948. 2. MATHEWSON, C., JR. and SUGAR, B. Surgical significance of gastro-intestina1 bleeding. Am. J. Surg., 89: 1177, 1955. 3. WELCH, C. E. Treatment of acute, massive gastroduodenaI hemorrhage. -1. A. M. A., r4r : I I I 3, I. STEWART, J. D., SCHAER,
1949. 4. WELCH, C. E., ALLEN, A. W. and DONALDSON,G. A. SurgicaI management of massive acute upper gastro-intestinal hemorrhage. New England J. Med., 252: gzx, 1955. 5. WINTROBE, M. M. Anemia. Arch. Int. Med., 54: 256, 1934. 6. DUNPHY. J. E. and HOERR. S. 0. The indications for emergency operation- in severe hemorrhage from gastric or duodenal uIcer. Surgery, 24: 231, 1948. 7. HEWER, G. J. The surgicaI aspects of hemorrhage from peptic uIcer. New England J. Med., 235: 7779 194.6. 8. LEVEEN, H. H., MULDER, A. G. and PROFOF, F,
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Physiological mechanism for death in massivety bIeeding peptic uker. Surg., Gynec. Ed Ok., 94: 433, 1952. 9. ALLEN, A. W. Acute massive hemorrhage from the upper gastro-intestina1 tract. Surgery, 2: 7 13, ‘937. IO. MAYO, H. W. Blood transfusion in hemorrhage from a severed artery-an experimenta study. Arch. Surg., 66: 137, 1953. I I. KOSTER, K. H., SINRUP, E. and SEELVE, V. AB-0 blood groups and gastric acidity. Lancet, 2: 52, 1955. 12. BROWN, D. A. P. and MELROSE, A. G. BIood groups in peptic ulceration. &it. M. J., 2: 135,
1956. 13. CHINN, A. B., LITTELL, A., BODGER, C. F. and BEAMS, A. J. Acute hemorrhage from peptic ulcer: a foIIow up study of 310 patients. New England J. Med., 255: 973, 1956. DISCUSSION HERBERT J. MOVIUS (Long agree with the authors on several
Beach,
CaIif.):
I
important points. CertainIy the necessity for a set of rigid criteria, defining massive hemorrhage, is mandatory if anything of value is to come out of the great mass of hospital charts being perused by surgeons throughout the country. The authors’ definition of massive hemorrhage is excellent and is particularly vaIuabIe in that no out-of-the-ordinary clinical Iaboratory test is needed. Few if any patients wouId be erroneousIy incIuded as having “massive hemorrhage” if these criteria were adhered to. It would be a real step forward if some such simpIe set of criteria could be nationaIIy adopted, at Ieast for future cIinica1 analyses. I certainly agree that the bIood voIume should be restored to approximateIy norma in the patient having recently manifested severe hemorrhage and that mere correction of hypovoIemic signs and symptoms should not be the stopping point for bIood replacement. Re-bleeding, as was emphasized by the authors, shouId be a positive indication for surgica1 intervention. This is one condition which certainIy shouId jar the physician into action and shouId end any procrastination on the part of the surgeon concerning when to operate. It is unfortunate, however, that internists and some surgeons alIow re-bIeeding to continue on medical therapy, as evidenced in this manuscript by the report of thirty-two patients who manifested re-bleeding and only twenty of whom were operated upon. At the Long Beach Veterans Administration HospitaI we have vigorousIy taught the residents that the prime concern of the surgeon operating upon a patient for massive hemorrhage is to stop that bIeeding. CertainIy there can be no brief with the authors when they state that many times these patients may not be candidates for more extensive defmitive uIcer procedures. At the Long Beach Veterans Administration Hospital we have fre-
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quently used the procedure of transfixion suture of the bleeding utter and supplemented this with vagotomy and pyIoropIasty. In twenty-six consecutive cases we have had but one death. This is too smaI1 a number from which to draw concIusions, but if the phrase may be used in a non-election year, “it shows a trend.” FinaIIy, I was pleased to see the authors’ suggestion that patients with chronic gastroduodena1 uIcer be submitted to eIective surgical management prior to their attaining the age of sixty. This, I believe, is a true forward step in the over-a11 management of patients with peptic uIcer and I wonder if we shouId not adopt a far more IiberaI set of indications for surgical intervention in the management of al1 patients with peptic uIcer than the now “ we11 accepted criteria.” It is, of c&rse, dificult to state the mortality rate of patients with peptic uIcer for the lifetime of the patient on a medica regimen, but it certainly must be close to 5 per cent. In addition, the regimen is confining, it does not alIow many of the patients to freeIy participate in what is considered to be a we11 rounded socia1 scheme, the regimen is highIy atherogenic (although this might be splitting hairs) and, finaIIy, it is expensive and time consuming when considered over a period of years. If a definitive operation to combat the ulcer diathesis can be accompIished with a mortality rate of one-half of I per cent, and this has been the mortaIity figure for vagotomy and pyIoropIasty in over 1,000 cases at the Long Beach Veterans HospitaI, than why should not such an operation be offered to the patient with peptic ulcer before he bleeds, perforates, obstructs or becomes totaIIy refractory to vigorous medica management. I disagree with the authors on a few trivial points. We have found the use of an upper gastrointestina1 series, with or without the Hampton technic, to be very valuable in al1 massive upper gastrointestina1 hemorrhage, except those patients in shock. The roentgenogram may revea1 a gastric uIcer or a giant duodenal uIcer, which in either case should call for surgica1 intervention without delay. I aIso question the wisdom of attempting to cIassify deaths as avoidable. This couId open avenues for conflicting statistica analyses and may tend to negate other well accepted rigid criteria. FinaIIy, the statement “surgery is indicated as bIeeding continues ” is ambiguous. I personaIIy have no formula or method for determining when surgery is indicated and how to determine when bIeeding is, in fact, continuing. We have a11 had experiences that show that a fairly high percentage of patients who are operated upon for continued bleeding, are in truth, not actively bIeeding at the time the uIcer is viewed. Therefore, I wouId appreciate, but have no suggestion myself, an accurate end point in the cIinica1 titration of the patient who is admitted
Snyder
and Berne The other thing which interested me in Drs. Berne and Snyder’s report was that our use of bIood paraIIeIed theirs quite cIoseIy. It varied in the surgica1 patients from three to thirty-one units, with an average of eight. The Medical Service suppIied their patients, in the range from one to thirty-three units, with an average of 3.2 units of bIood. EDWARD N. SNYDER, JR. (ctosing): In answer to the remark by Dr. Movius about continued bleeding, to a certain extent we left the term because continued bIeeding means ambiguous various things to various people. I do not see how anyone can say for certain that a given patient has a continued minor hemorrhage. Of the total group of patients who were operated upon for what was considered to be continued or recurrent bleeding, that is a11 twenty patients, tweIve were found to have arteria1 hemorrhage at the time of surgery. Of the peopIe who were operated upon for what was thought to be just continued bIeeding only, three had arteria1 hemorrhage at the time of surgery.
with active bleeding. When do we make the decision to operate? EDWARD B. SPEIR (Seattle, Wash.): I thought it might be of some interest to let you know that one of the residents and I recentIy went over the statistics at the Swedish HospitaI for a two-year period. We grouped the patients who were coded and diagnosed on entering the hospita1 as having gastrointestina1 hemorrhage. Three hundred three patients were seen during the two-year period. Seventy-eight per cent of the patients were treated medicaIIy, with a mortaIity rate of I 1.s per cent. Eighteen per cent were treated surgicaIIy, which meant sixty-eight patients, with a mortality of II.7 per cent. The other interesting fact was that of the over-a11 303 patients, tweIve continued to bIeed and were operated upon, as far as we couId determine, whiIe stiI1 bIeeding. Of these twelve patients, three died, giving for that particuIar group a 25 per cent mortality rate. We teII the medical people, of course, that there is a 75 per cent salvage rate, but it only points out the seriousness of the disease.
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