Benign Gastric Ulcer with Life-Threatening Hemorrhage

EDWARD S. STAFFORD, M.D., WALTER F. BALLINGER, II, M.D.,GEORGE D. ZUIDEMA, M.D., JOHN L. CAMERON, M.D.

From the Department of Surgery, The Johns Hopkins University School of Medicineand The Johns Hopkins Hospital, Baltimore, Maryland

As PART of a continuing study of specificproblems related to the surgical manage-ment of patients with peptic ulcer, we havepreviously analyzed and reported our ex-perience with 47 patients who had pyloricchannel ulcers, treated surgically in TheJohns Hopkins Hospital during the years1958-1963.2 During this same period, ex-cluding those with pyloric channel ulcer,there were 239 other patients who wereoperated upon for benign gastric ulcers.Nearly half of these patients (116) werebleeding. This report analyzes results of thesurgical treatment of 66 patients from thislatter group who were operated upon dur-ing the course of life-threatening hemor-rhage which could not be controlled bynon-surgical means. Thus, 49 per cent ofour patients with gastric ulcer were ad-mitted with bleeding and in 57 per cent ofthese, the hemorrhage was uncontrollablebefore operation.Review of the data indicates that surgical

treatment for gastric ulcer disease in ourhospital has seldom been undertaken forpatients under age 40. Operation becomesmore frequent as the age increases and,when the correction for survivors at anyage is applied, the relative number of pa-

Presented at the Annual Meeting of the South-ern Surgical Association, December 6-8, 1966,Boca Raton, Florida.

This study supported in part by NIH GrantAM-09174-03 and NIH Graduate Training GrantGM-1541-01.

tients undergoing operation for gastric ul-cer is greater in every decade up to age 80(Fig. 1). Although our entire series of pa-tients with gastric ulcer is about evenly di-vided between those bleeding (49%) andthose not bleeding (51%o), a remarkablebreaking point occurs at age 70. Of 203 pa-tients under 70, 92 (45%) bled; of these52 bled uncontrollably and 8 patients diedfollowing operation in the hospital (15%)(Table 1). There were 36 patients age 70and over, of whom 24 were bleeding(67%), among the latter 14 bled uncon-trollably and 6 patients died in the hospital(43% ).There were 49 patients (21%fo) in the se-

ries who bled on one or more occasionsprior to the hospitalization during whichoperation was performed. Of these, 21(43%), bled uncontrollably on this admis-sion. There was a history of previous bleed-

18 -

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1 30-39 40-49 50-59 60-69 70-79 80+

AGE IN YEARS

FIG. 1 A. Absolute numbers of patients withbenign gastric ulcer operated upon for uncon-trollable bleeding.

967

STAFFORD, BALLINGER, ZUIDEMA AND CAMERON Annals of SurgeryJune 1967

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FIG. 1 B. Prevalence of benign gastric ulcerswith uncontrollable bleeding requiring operationfor control in The Johns Hopkins Hospital, 19581963, using age distribution of the BaltimoreMetropolitan Area during these years.

ing in a somewhat higher fraction (33%7)of those bleeding on admission (Table 2).Of 190 patients who had never bled be-fore, 45 (24%) were admitted with uncon-

trollable bleeding on this occasion. Thischaracteristic, previous hemorrhage, had no

relationship, moreover, either to postopera-tive bleeding or to mortality. Six patientswho bled after operation had a previoushistory of bleeding but there was only one

death in this group; of eleven more who

bled postoperatively and of whom seven

died, there was no history of previousbleeding.

There were 151 men and 88 women; thisratio remained the same throughout thevarious groupings with one remarkable ex-

ception. Of 66 with uncontrollable bleed-ing, there was but one woman among 14patients who died in the hospital after op-

eration; this will be commented upon later.The use of alcohol or tobacco seemed notto exert any influence upon incidence, se-

verity or outcome of hemorrhage from a

gastric ulcer. Neither the duration of previ-ous symptoms nor any particular symptomsseemed to be significant. Five of the 66 pa-

tients who bled uncontrollably denied any

previous symptoms of ulcer disease; ofthese, however, two were psychotic, twohad been taking ulcerogenic drugs, and one

bled under stress while in the hospital fortreatment following a serious injury in an

automobile accident. With regard to ul-cerogenic drugs, 16 (14%o) of the patientswho were bleeding gave such a history,contrasting with 8 (7%o) patients who were

not bleeding and who admitted takingaspirin, steroid, or other such medications.The data were considered from the socio-

economic standpoint, using the differentia-tion between private and ward service pa-

tients (Table 3). The patients were dividedalmost evenly in the whole series. However,there were more who were bleeding among

ward patients, 75 among 126 ward patients

TABLE 1.

Patients

Under 70 70 and Over

Total No. Deaths No. Deaths

Total group 239 203 12 ( 6%) 36 7 (19%)Non bleeders 123 111 2 ( 2%) 12 1 ( 8%)Total bleeders 116 92 10 (11%) 24 6 (25%)Uncontrollable 66 52 8 (15%) 14 6 (43%)

bleeders

968

BENIGN GASTRIC ULCER WITH HEMORRHAGE

TABLE 2.

Non- Total UncontrollableTotal bleeders bleeders bleeders

Previous history 49 11 38 21of bleeding

None 190 112 78 45

Total 239 123 116 66

(60%o) and 41 among 113 private patients(36%o). Furthermore, there were 45 wardpatients (69%o) and only 21 private pa-

tients (32%o) among the 66 who were

bleeding uncontrollably. The same propor-

tionate split obtained in the 14 postopera-tive deaths, 10 service and 4 private.As to be expected in patients, most of

whom were over 40, and almost half over

60, there was a high incidence of co-

existing disease. Nearly half (28) of the66 patients with uncontrollable hemorrhagehad significant coexisting disease, includingesophageal hiatal hernia (7), urologic dis-ease (4), arthritis (4), cardiovascular dis-ease (3), cirrhosis of the liver (3), psycho-sis (3), pulmonary disease (3), diabetes(1), and severe trauma (1). However,these were more frequent among the sur-

vivors of surgical therapy of uncontrollablebleeding (24 of 52) than among the fatalcases (4 of 14).

All 66 patients with uncontrollable bleed-ing received large amounts of blood beforeoperation. Of 52 survivors, 20 receivedthree liters or more, but of 14 patients whodied, ten received three liters or more.

The location of the gastric ulcers fol-lowed the usual pattern, with the majorityin the prepyloric area or along the lessercurvature. There were seven patients, how-ever, among the 66 with uncontrollablebleeding, whose ulcers were located in theupper stomach, either cardia or fundus. Sixof these seven patients had postoperativecomplications and 4 (57%) died in thehospital.There were 29 operating surgeons who

employed a variety of procedures. Duringthe period reported (1958-1963) some type

TABLE 3. Socioeconomic Status

Ward Private

No. Deaths No. Deaths

Total group 126 13 (10%) 113 6 ( 5%)Non bleeders 51 2 ( 4%) 72 1 ( 1%)Total bleeders 75 11 (15%) 41 5 (12%)Uncontrollable 45 10 (22%) 21 4 (19%)

bleeders

of partial gastrectomy was favored, witheither a Billroth I or II restoration of conti-nuity. There were 44 partial gastrectomies(vagectomy was included in eight) per-

formed in 66 patients with uncontrolledhemorrhage. Among these 44 patients, therewere nine postoperative, in-hospital deaths.Excision of the ulcer was performed 13times, including five accompanied by py-

loroplasty and four accompanied by py-

loroplasty and vagotomy. In this groupthere were two deaths. One of two patientstreated by sleeve resection alone died; an-

other, in whom sleeve resection was ac-

companied by vagectomy recovered. Fourpatients underwent ligation of a bleedingvessel in the base of the gastric ulcer com-

bined with pyloroplasty and vagectomy;one of these died. Two patients were

treated by gastrojejunostomy and vagec-

tomy and one died.Of 66 patients operated upon for uncon-

trollable bleeding from a gastric ulcer, 14died in the hospital (Table 4). This mor-

tality rate of 21 per cent contrasts with a

mortality rate of 3 per cent in 173 patientswith gastric ulcer operated upon for allreasons other than uncontrollable hemor-rhage (Table 5). It is important that 36 ofthese 66 patients had one or more post-operative complications and that all deathsoccurred in the latter group. Furthermore,13 of 14 patients who died in the postop-erative period were men. Of 14 patients 70years of age or over with uncontrollablebleeding, eight were men and six were

women. There were no deaths among thesesix women. There were six deaths amongthe eight men (75%o).

Volume 165Number 6 969

STAFFORD, BALLINGER, ZUIDEMA AND CAMERON Annals of SurgeryJune 1967

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TABLE 5. Mortality

No. No.Patients Deaths

Total group 239 19 ( 8%)

Non bleeders 123 3 ( 2%)

Total bleeders 116 16 (14%)

Uncontrollable 66 14 (21%)bleeders

Total group minus 173 5 ( 3%)uncontrollablebleeders

The most frequent and most dangerouscomplication was postoperative bleeding.Sixteen patients bled in the immediatepostoperative period and of these, five re-

sponded to conservative therapy, requiringthree to four liters of blood; six patients,treated conservatively, died. Five patientswere reoperated upon for postoperativebleeding: two were bleeding from a sutureline, two were bleeding from an ulcer notseen at the first operation and in one, no

cause for bleeding was found. Two patientswho underwent second operations to con-

trol hemorrhage died. Thus, in this group,

postoperative hemorrhage resulted in onlya 50 per cent chance of survival. Therewere other serious complications amongthe eight who died, including aspiration(1) and E. coli septicemia (1).Careful consideration has been given to

all available information in each instanceof postoperative death (Table 4). Autopsyfindings were available in seven of the 14fatal cases. Six appear to have died as the

TABLE 6. 16 Postoperative Bleeders

Survival Died

Reoperated (5) 3 2Treated without 5 6

operation (11)

Total (16) 8 8

Annals of SurgeryJune 1967

TABLE 7. Follow up.

Total Patients 66Operative deaths 14Lost to follow up 6

Long-term follow up 46

Excellent 30Poor 16

Subsequently excellent 4Remain poor 12

Excellent (as of Nov. 1966) 34 (74%)

result of continued bleeding after opera-tion. Three, including the only woman, diedof massive pulmonary embolism. Threedied with leaking suture lines, peritonitis,and bacteremia. One had a serious infec-tion with multiple pyarthrosis before op-eration and succumbed to multiple lungabscesses. The final death was due tocardiac failure with massive pulmonaryedema, probably due to over transfusion.

Six of the 66 patients with uncontrollablebleeding are lost to follow up (Table 7).There were 14 postoperative deaths, leav-ing 46 patients available for long-termevaluation. Of these, 30 (65%) are con-sidered to have excellent results subsequentto operation. Our criteria for an excellentresult include good nutritional status, abil-ity to work or follow normal lives for age,and absence of unpleasant symptoms suchas dumping and diarrhea. Failure to meetany one of these criteria led to classifyingthe patient as a poor result. Sixteen (35%)were judged to have a poor result initially,although four of these have subsequentlybecome asymptomatic. Thus, at this writ-ing, 34 (74%) are asymptomatic and fol-lowing their usual activities. As expected inpatients of this age range, nine of the 66patients died of unrelated causes since op-eration. These patients are classified as tothe result of operation at the last visit be-fore death. One patient died of hemorrhagein another hospital a few days after dis-charge from this hospital.

BENIGN GASTRIC ULCER WITH HEMORRHAGE

Seven patients had proven or suspectedrecurrent or stomal ulcers. Four of thesehad subtotal or hemigastrectomy and gas-

troduodenostomy (two with vagectomy).The remaining three recurrences followedwedge resection (1), sleeve resection (1),and posterior gastrojejunostomy (1). Onepatient has persistent diarrhea after a

sleeve resection with gastrojejunostomy andvagectomy. Another patient complains ofdumping and has difficulty maintainingnutrition after subtotal gastrectomy, gas-

troduodenostomy and vagectomy and thethird has nutritional difficulty followingsubtotal gastrectomy, gastrojejunostomyand vagectomy. There have been three epi-sodes of late bleeding in the 46 patientsavailable for follow up (7%). The first pa-

tient, a heavy drinker, had esophagealvarices demonstrated by x-ray on four dif-ferent examinations. The second patientbled from a marginal ulcer six months afterthe original operation. Vagectomy was usedto control the recurrence. The third patienthad a single, recent hematemesis, but upon

arrival in our emergency room, her stoolswere negative for occult bleeding, her

hematocrit was normal and no source ofbleeding was found.

Discussion

The worst result of surgical treatmentof a bleeding gastric ulcer is the postopera-tive death of the patient. The mortality ratefor 116 patients bleeding from benign gas-tric ulcers was 14 per cent. For those pa-

tients with uncontrollable bleeding, it was21 per cent. This mortality rate compareswith other reports, although exact compari-son of various series is difficult due to dif-fering criteria for "massive" or "uncontrol-lable" hemorrhage and to the inclusion ofboth gastric and duodenal ulcers. That themortality can be reduced further is indi-cated by a recent report 1 from this hospitalof the practice of deferring induction ofanesthesia in hypovolemic patients until

central venous pressure could be restoredto normal by transfusions.There is no certain way to detect bad

risks before operation, although in thisseries there was far less risk in operatingupon women with uncontrollable bleedingfrom gastric ulcer than upon men. Menover 70 were exposed to three times therisk of uncontrollable bleeding as were

men under 70. It was predicted that thisanalysis would reveal significant differencesin risk over age 60; the increased mortalitywith age did not appear until age 70. Curi-ously, when the data were analyzed, co-

existing disease did not increase mortality.Frequently it is proposed that patients

who are bleeding from peptic ulcers shouldbe operated upon early. The question arisesas to how it can be determined which pa-

tient will stop bleeding and which will not.The records of 42 patients bleeding froma gastric ulcer during the first three years

of our study, but admitted to the medicalservice in The Johns Hopkins Hospital andtreated without operation were reviewed.Obviously, none were uncontrollably bleed-ing and less blood was required for stabi-lization. Only one patient died duringmedical therapy. During a relatively shortfollow up, half of these patients remainedasymptomatic. Eight came to operation on

a subsequent admission, and at least 14 re-

quired subsequent hospitalization for ulcertherapy. It cannot be argued, then, that im-mediate operation is a necessity for all pa-

tients who bleed from gastric ulcers, al-though the need for further medical ther-apy in the hospital confirms that gastriculcers tend to recur after medical treatment.The number of patients requiring surgi-

cal intervention for gastric ulceration was

evenly divided between ward and privateservices, but there were twice as many

patients with serious hemorrhage on theward service, illustrating again the higherrisk patient often seen in ward services.Nevertheless, operative mortality followed

Volume 165Number 6 973

974the same ratio, indicating the comparablecare afforded patients on either service.Some deaths in this series were prevent-

able and were due to technical errors.

There were three deaths attributable togram-negative septicemia, each occurringfollowing disruption of a gastroentericanastomosis. One death was due to pulmo-nary edema probably following over-

transfusion, and one was due to aspirationof gastric contents. The majority of deaths,however, occurred in patients who con-

tinued to bleed after operation as thoughthe procedure had changed nothing. Therewere 16 patients who continued to bleedafter operation and eight recovered. Ofthese, five stopped bleeding spontaneouslyand three were controlled by reoperation.Of the other eight who died, two were re-

operated upon but continued to bleed, andthe remaining six continued bleeding untildeath. Continued hypovolemia and massivereplacement with stored blood may createor perpetuate decreased coagulability ofthe blood. The role of coagulation defectswas suggestive in some patients who con-

tinued to bleed, but this could not be deter-mined with certainty. There was, as ex-

pected, a higher mortality among patientswho received more than three liters ofblood than among those who received lessthan that amount. Possibly reoperationwould have saved some of these but thisis a difficult judgment for the surgeon tomake in individual cases. No doubt suchfactors as experience and, as has been re-

cently pointed out,3 the state of well-beingor fatigue of the surgeon are importantsince these emergencies occur so often atthe end of a busy day or at night. It isrecommended that patients who continueto bleed after an operation intended to con-

trol hemorrhage be reoperated upon withinfour to six hours if the hemorrhage has notspontaneously ceased. Severe rebleedinghas been uncommon in our experience as

a late complication of the surgical treat-ment of uncontrollable hemorrhage from

Annals of SurgeryJune 1967

gastric ulcer, in marked contrast to earlypostoperative hemorrhage.The high risk entailed in surgical therapy

of ulcers located in the upper part of thestomach is well known but the cause or

causes are still mysterious. Because theseare relatively infrequent, it may be thatinexperience in dealing with this area is a

chief factor. However, fundal ulcers are

difficult to demonstrate radiologically, maybe missed at operation and are often asso-

ciated with hiatal hernia and reflux esopha-gitis. In this series, uncontrollable bleedingfrom a fundal ulcer carried an excessivelyhigh mortality.The rather high incidence of fatal pulmo-

nary embolism (3 of 14 deaths) suggeststhat more careful attention to the venous

system is indicated. Two of three patientsin this group had evidence of pulmonarydisease before the massive embolism oc-

curred.A review of the results of operation in

survivors indicates that nearly three-fourthsof the patients can be rendered symptom-free. It is apparent that none of the varioussurgical procedures is always followed bya good result. Also apparent, however, isthe lack of success following simple exci-sion or sleeve resection for bleeding gastriculcers; in six of these procedures there weretwo deaths and four bad results.

SummaryThe clinical characteristics, operative

procedures, early and late results andcauses of death have been analyzed in a

series of 66 patients who were bleedinguncontrollably from gastric ulcer. Thereseemed to be no way to pre-select thegravest risks, although the highest mor-

tality was in patients over 70 years of age.More than half of 14 deaths occurred inpatients who continued to bleed after op-

eration. Among 14 patients who died were

13 men and only one woman, a significantdifference from the ratio of three men totwo women in the entire series. Simple

STAFFORD, BALLINGER, ZUIDEMA AND CAMERON

Volume 165 BENIGN GASTRIC ULCER WITH HEMORRHAGE 975Number 697excision or sleeve resection failed to curepermanently any patient, although thisgroup was small. Over 90 per cent of sur-vivors could be followed and, except forthose dying from unrelated causes, approxi-mately 75 per cent attained an excellentresult, although several required reopera-tion. In early postoperative bleeding, it isrecommended that reoperation be per-

formed without delay. Late postoperativebleeding was uncommon in this series.

References1. Fisher, R. D., Ebert, P. A. and Zuidema, G. D.:

Peptic Ulcer Disease. Arch Surg., 92: 909,1966.

2. Murray, G. F., Ballinger, W. F., II and Staf-ford, E. S.: Pyloric Channel Ulcers. Amer.J. Surg., 113:199, 1967.

3. Schenk, Worthington G., Jr.: The Tired Sur-geon. Ann. Surg., 161: 627, 1965.

DISCUSSIONDR. RALEIGH R. WHITE (Temple, Texas):

Thank you, Dr. Mahomer. The authors are cer-tainly to be congratulated for a very realistic studyof a dangerous disease, bleeding gastric ulcer.

After excluding patients with acute gastriculcers and those whose ulcers are steroid- anddrug-induced, I am sure most of us here wouldfeel that the remainder of patients with gastriculcers should be considered candidates for earlysurgery. We can all recall the giants of this As-sociation such as Drs. Lahey, Ravdin and Ochsnerspeaking to this point many times in the past. De-spite this sound surgical advice, our medical col-leagues do not wholly subscribe to this policy.

If you would review the records of many medi-cal centers, you will find that only about half ofthe patients with gastric ulcer receive early sur-gery as the primary method of treatment. If sur-gery is, in fact, the preferable method of manage-ment then it is imperative that internists also ac-cept this doctrine, as they see the patients first,and usually decide as to whether or not surgicalconsultation is even obtained.

In an attempt to find an answer to this prob-lem in our practice at Scott and White Clinic, Ihave reviewed the records of 363 patients whohad a preliminary diagnosis of benign gastric ulcerand were followed for at least five years. Of these363 patients, 12 or 3.3% were eventually found tohave cancer of the stomach. Five malignant ulcerswere resected within three weeks; but in the re-maining seven patients definite surgical treatmentwas not done until 7 weeks or longer had elapsedafter admission, which in my view is not goodsurgical practice. These seven patients, or 2% ofthe original 363 patients, represent failures in themanagement of gastric cancer. However, our medi-cal colleagues quickly point out that this failurerate of 2% corresponds closely to the mortalitywhich might be anticipated if all patients withgastric ulcer should be operated upon. Therefore,the small error of overlooking an ulcerating carci-noma is not sufficient reason to operate upon allpatients with gastric ulcer.

But the study reveals another important point.

It is well documented that surgery for gastric ulceris eminently satisfactory in about 90% of patients.However, when followed for five years, only 69%of our patients treated medically had satisfactoryresults. In other words, 31% of medically treatedpatients had poor results with medical treatmentor required surgery eventually anyway.

This fact is, I believe, the important point. Pa-tients with gastric ulcer should be advised to haveearly surgery, not only because of the danger ofcarcinoma, but because of the poor results ofmedical treatment over the five-year interval.Thank you.

DR. WALTER F. BALLINGER, II (Closing): Weare extremely grateful to Dr. White for his dis-cussion of our paper.

I think perhaps we are very fortunate at TheJohns Hopkins Hospital in having a group of in-temists who are quite interested in the problemsassociated with massive hemorrhage from gastriculcer. As we reviewed our series, we found that49% of our patients with gastric ulcer were op-erated upon because of bleeding, indicating theinterest in referring these patients to us, and inmost instances early.

We also collected and reviewed the records ofthose patients admitted to the medical service withhemorrhage from a gastric ulcer during the firstthree years of our study, that is, 1958 through1960. There were 52 of these patients, all bleedingand all managed medically. There was only onedeath. Furthermore, most of the deaths on thesurgical service were in patients admitted directlyto the surgical service with massive hemorrhageor those who were admitted to the medical serv-ice but with early collaborative management byboth internist and surgeon. This indicates that ourmedical colleagues are quite aware of the neces-sity for surgical intervention in the presence ofmassive hemorrhage. In this series, it appearedthat a critical point in approaching a state of mas-sive hemorrhage is when two liters or more ofblood must be transfused in approximately 24hours in order to maintain circulatory equilibrium.Dr. Zuidema emphasized that many of our pa-