The management of upper gastro-intestinal tract haemorrhage

Abstract

Abstract Two hundred successive patients with upper gastro-intestinal tract haemorrhage were admitted to a surgical unit for management. One hundred and thirty-five patients (67.5 per cent) had a chronic peptic ulcer, 33 patients (16.5 per cent) had acute lesions (either an erosive gastritis or an acute gastric ulcer), and 32 patients (16 per cent) were a mixture of other diagnoses, of which 13 (6.5 per cent) were simple conditions but 19 (9.5 per cent) were conditions with a bad prognosis, e.g., carcinoma of the stomach, oesophageal varices, aortic aneurysm. Surgery was undertaken for massive, continuing, or recurrent bleeding and was as ‘conservative’ as thought possible. In duodenal ulcer this consisted of suture of the ulcer with vagotomy and pyloroplasty, and suture of the ulcer with vagotomy where possible in cases of anastomotic ulcer. In gastric ulcer only those less than 2 cm. in diameter were treated by suture with vagotomy and pyloroplasty. Ulcers greater than 2 cm. in size requiring surgery were treated by gastrectomy. In the 181 patients whose underlying condition had a good prognosis there were 7 deaths (4 per cent). In this group 81 operations were carried out; 61 were ‘conservative’ operations for peptic ulcer, 2 were for repair of a hiatus hernia, and there were 18 gastrectomies, usually for a large gastric ulcer. There were 2 deaths among the operated patients; 1 after gastrectomy and 1 after a ‘conservative’ operation. There were 5 deaths among the 100 patients in the group which was treated non-operatively. There were 8 deaths among the 19 patients with underlying conditions of grave prognosis. The case for the admission of patients with upper gastro-intestinal tract bleeding to a surgical unit is fully discussed and it is advocated together with a selective policy for operation. Where operation is necessary this should be as conservative as possible for bleeding duodenal ulcer, chronic gastric ulcer less than 2 cm. in size (ulcers of larger size may well respond but the method was not assessed for such ulcers), solitary acute gastric ulcer, and anastomotic ulcer. Gastric resection should be retained for the few patients with diffuse erosive gastritis requiring surgery and possibly for patients with a very large chronic peptic ulcer.