SECTION VI--Abdominal Surgery

Bleeding Gastric and Duodenal Ulcers* By

D. PHILIP MAcGUIRE, A.B., M.D., F.A.C.S.t N E W YORK CITY, N E W YORK

A LONG with perforation, hemorrhage is an ex- tremely serious complication of gastr ic and duo-

denal ulcers. Clinically, ulcers may be classified as follows: (1)

exulcerat io s imp lex of Dieulafoy, the follicular eros- ions of Cruveilhier, and also the punctuate erosions of Brinton; (2) the acute round, simple or peptic ulcer whoae base is formed by the muscular i s mucosa; (3) the callous ulcer whose base is covered with granula- tions and whose margins show the results of long- standing reactive inflammation with the walls corres- pondingly thickened; frequently, the base ulcerates through the muscular is mucosa with a tendency to per- forate and adhere to the neighboring viscera; (4) the type tha t the Continental surgeons t e rm 'ulcer gas- t r i t is o r duodenitis ' which ~s, at times, almost phleg- monous in character. We invariably associate an in- vasion of bacteria, usually the streptococci, with both the third and four th yarieties.

The occurrence of hemorrhage varies f rom approxi- mately 25% to 30% in duodenal, and 20% in gastr ic ulcers (1). Von Bergman, whose view is shared by the highest English authorities, concluded tha t the mortality, under medical management, was 5% in an analysis of 2,000 cases of bleeding ulcers. Hurs t (2), of Guy's Hospital, London, reported a mortal i ty of 2 ~ % which is even less than tha t of yon Bergman. On the other hand, F ins te rer (3 and 4) gave a mortal- ity of 25% under medical management, with 50% hav- ing very massive hemorrhages. A mortal i ty of 25~/e was reported by Chiesman among the cases admitted to St. Thomas Hospital of London for gross hemate- mesis and melena.

In the wr i te r ' s opinion, these hemorrhages should be classified into four grades: (1) when there is a small hemorrhage or repeated small hemorrhages by bowel; (2) in which, the pat ient vomits blood repeat- edly in small quantities, in addition to small amounts of blood by bowel; (3) a ra ther continuous vomiting of small quantities of blood each time, possibly accom- panied by some bleeding into the bowel which is per- sistent and alarming to the patient, himself; and (4) the so-called massive hemorrhagic variety, in which, the pat ient suffers pr imari ly f rom serious epigastric distress before hemorrhage ensues. In those cases of duodenal and gastr ic ulcers tha t are being treated, and

*From the New York Post-Graduate Medical School and Hospital. tAss i s tan t Clinical Professor of Surgery, Columbia Universi ty . Submitted April 11, 1935.

cases of marginal ulcer that are suspected, there need be little conjecture as to the sources of the bleeding.

Hemorrhages may also be classified according to the blood and hemoglobin count. In the first and second grades, the red blood count is above two million and the hemoglobin 50 per cent. In the massive and serious forms, the red blood count is less than two million and the hemoglobin is less than 40 per cent. The systolic blood pressure is above 80 in the first and second, and less than 80 in the third and fourth grades. When in doubt, it should be remembered that bleeding occurs in the following liver conditions, viz. : portal cirrhosis, spirochaetosis icterohemorrhagica, obstructive hepatic jaundice, mal ignant tumors of the liver, hypertrophic biliary cirrhosis, hydatid disease, acute necrosis, portal cirrhosis, carcinoma of the common duct, haemochrma- tosis, p r imary carcinoma of the gall-bladder, calculi of the external biliary system, and cholecystitis. Special emphasis should be given to the congenital obliteration of the bile ducts and latent cirrhosis of Rolleston be- cause of the possibility of the same infection, causing the ulcer, might also bring about the cirrhotic change in the liver.

Hemorrhages may also occur f rom splenic diseases such as: Vaquez's disease, polycythemia, von Jaksch 's disease, Gaucher 's disease, and, most important of all, Banti 's disease (splenic anaemia) when the hemor- rhage is so profuse and alarming. Rolleston believed that the enormously distended vasa brevia ruptured into the stomach as a result of torsion of the splenic vein. This was due to the great bulk of the organ which resulted in massive hemorrhages. Hemorrhage may also be encountered in acute and chronic leuk- emias.

Hemorrhage may also occur in Meckel's diverticulum with aberrant gastr ic tissue in its wall, ulcerations of the small intestines, and, of most importance, in seri- ous pathological changes in the appendix.

According to Gray, in his Textbook of Anatomy, the gastro-duodenal a r te ry is a short but large branch of the hepatic which descends near the pylorus behind the first portion of the duodenum. At the lower border of the duodenum, it is divided into two branches, the gastro-epiploica-dextra and pancreatico duodenalis su- perior. This is in close relationship with the common duct, anter ior to the portal vein.

In the first, second, and third grades of ulcers of a single bleeding, the medical t rea tment of hemorrhage consists of the administrat ion of a hypodermic of mor-

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432 AMERICAN JOURNAL OF DIGESTIVE DISEASES AND NUTRITION

phine (gr. 1/6), and atropine (gr. one one-hundredth) which should be repeated in order that the pat ient may enjoy rest and quiet. Small quantities of ice water, about 200 to 300 c.c., each, of chilled ferr ic chloride (1-1,000) and also silver ni trate solutions (1-1,000), glucose solutions up to 50%, and adrenalin solutions may be introduced through a Levine or sire- i lar tube. I f the stomach is distended with blood, a suction should be applied with a syringe or an evacua- tor in order to permit the gastr ic walls to contract.

Dr. F rank Smithies (5), Chicago, advised the fol- lowing medical t rea tment for bleeding ulcers. Re- peated doses of morphine are to be administered which should be given intravenously in shocked patients. He prefers the Thomas Bogg method of clotting and esti- mat ing of blood clotting time. In cases of vomiting, bleeding, and gastr ic distension, he advocates a thor- ough lavage with normal saline solution at 110 ° F., as suggested by the late Dr. Rodman. After a prelimin- ary emptying by lavage, nothing should be given by mouth. For more than twenty years, Dr. Smithies has employed as a nutr ient enema the following: 8 ounces of normal salt solution, 50 c.c. of syrup of glucose, and 50 c.c. of 50% alcohol, administered by the Murphy drip at body tempera ture which is given four t imes within 24 hours. He also advises the administrat ion of fluids intravenously and per rectum to keep up the fluid reserve. In cases where bleeding continues up to 36 hours, he advocates operative procedure. Both Hur s t (2a) and Smithies (5) prescribe the immobili ty of the pat ient by keeping him quiet in bed, reassur ing him, and adminis ter ing sufficient morphine and atro- pine (one 1/100 gr.) or morphine alone, t o keep him drowsy. Whole blood t ransfusions of cross-grouped blood are advocated by Smithies for control of con- tinued seepage or "non-spurter" bleeding (5b). Some Internis ts have advised the use of foods and liquids by mouth but both Hurs t and Smithies disagree with this t reatment .

Dr. Lester Unger, the t ransfusionis t of our hospital who also advocates massive t ransfusions in these cases, has so thoroughly convinced the wri ter of the advis- abili ty of this method tha t he has consistently applied it in all such cases, in which, he routinely administered 1,000 c.c. of whole blood by t ransfusion with marked success. I f necessary, this amount is repeated three times in cases of massive hemorrhages. In the desper- ate ones, Dr. Unger believes that, a f t e r severe bleed- ing, a chemical change takes place at the site of the hemorrhage causing imperfect clotting to occur which has an unfavorable effect on checking the bleeding. Consequently, in these desperate cases, a r rangements should be made for three donors instead of the usual one. I f the hemorrhage continues a f t e r the adminis- t ra t ion of the usual medical t rea tment together with the series of massive blood t ransfusions advocated by Dr. Unger, it is generally conceded that all conserva- tive measures have been exhausted and operative pro- cedures must be considered.

Hurs t (2b) s tates: " I believe tha t the only indica- tion for operation, in the acute stage, is the persistence or recurrence of severe hemorrhage whilst the pat ient is still fasting, especially in individuals past middle life with a long his tory pointing to the presence of a chronic ulcer and with ar ter ies so degenerated that they are unlikely to contract sufficiently for satisfac- tory plugging by thrombosis ."

In operative cases of hemorrhage, particularly the third and fourth grades, the procedure usually consists of two stages. In the first stage, under local anesthesia supplanted by cylopropane, ethylene, or gas-oxygen, surgical intervention should be confined to the source of the bleeding. In the hemorrhagic ulcers of the duo- denum, the three vessels tha t we should bear in mind are the r ight branches of the coronary or gastric, and the pyloric branches of the hepatic a r t e ry in the bleed- ing gastr ic ulcers and the gastro-duodenalis, a branch of the hepatic.

A complete excision should be made through the healthy tissues, even to a t ransgas t r ic approach, in the gastr ic ulcers; i f necessary, l igating the "bleeders" with mat t ress sutures controlling the gastr ic or pyloric branches. I t may be necessary to cut through the gastro-hepatic omentum in order to mobilize the gas- tric area. Af te r mobilization of the gastr ic area, an incision is made 1 c.m. distal to the pyloric ring. I t is brought t ransversely across the duodenum, holding the superior and inferior angles tau t by stay sutures ac- cording to the von Haberer technique. The incision should be sufficiently extensive so tha t the ulcer may be excised by a cautery of low heat. The base of the ulcer should be scarified according to von Haberer ' s technique and the bleeding kept under control. Then, the resected edges of the ulcer should be sutured to- gether. The exclusion operations of von Eiselberg through the pyloric ring, or Devine of Melbourne, above the incisura, require too much t ime in patients whose lives virtually hang on a thread. In the before- mentioned operative procedure, the t ime factor in- volves the necessity for furnishing a jejunal anas- tomosis. Again, unfortunately, it leaves the acid producing pyloric an t rum intact.

In the Author 's opinion, there is no question but that the operating surgeon has been unable to find the offending lesion in many cases and has encountered a general oozing condition which might have been due to extrinsic causes and not ulcers. In such cases, the gastr ic or duodenal area mucous surfaces resemble the appearance of a wet blotter. Faul ty diagnosis was often due to an imperfect work-up.

In the third or fourth grouping tha t the wri ter has made, the condition to be dealt with is f a r more serious than the ulcer. This is a streptococcus invasion of the blood vessels, with all its a t tendant pathology, which reduces them to almost a gelatinous state obliging the surgeon to explore quite a distance to find an a r te ry sufficiently healthy to clamp-off.

Out of every seven cases of massive hemorrhages, three are fatal according to Aitken (6) and 10 to 11% of the moderately severe ones.

In those cases, not reacting favorably to medical t rea tment and massive whole blood t ransfusions (3 if necessary), operative intervention is indicated. I f the bleeding continues in a persistent hemorrhage f rom a posterior duodenal ulcer before a posterior duodenal approach has been made, it is advisable for the opera- t ing surgeon to pass his left index finger into the fora- men of Winslow and a t tempt to control the hemorrhage by applying pressure so tha t he may orient himself. The wr i te r has found that, by inser t ing his left index finger through this foramen and extending it under the gastro-hepatic omentum above the first portion of the duodenum, and making an incision in the omentum so tha t a rubber catheter may be passed through by

M A c G U I R E - - B L E E D I N G GASTRIC AND DUODENAL ULCERS 4 3 3

elevating the ends of the catheter caught by a Kelly clamp, the bleeding, in this area, may be controlled in most cases, except in those exceptional ones, in which, a collateral anastomosis exists with the gastro-epiplo- iea-dextra artery. There is little danger of injuring the common duct since the Author has found it to be a very resistant structure. In experiments on the cad- aver, his efforts to tear it after suturing in a rubber drainage tube were of no avail. Having controlled the hemorrhage, the next step is to make the posterior duodenal exposure and ligate the cause of the bleeding.

Some .authorities have cautioned against trans- fusions in amounts greater than 250 to 300 c.c.. They believed that it increased the systolic pressure to such an extent, even up to normal or above, that fur ther bleeding would be encouraged since ta r ry stools are sometimes seen even after a blood transfusion of 500 c.c. This is only a temporary condition and the blood added in large amounts is very beneficial to the patient. There has often been some question, in the Author 's mind, as to whether blood transfusions in small amounts are really beneficial in serious cases since the patient is usually disturbed by the preparations for the procedure as is evidenced by the perspiration and the look of anxiety that appears on his face. Small amounts of transfused blood hardly compensate for this nervous state. Dr. Unger disproved the before- mentioned theory and fur ther claims that the systolic pressure declines following repeated transfusions of whole blood, never coming up to normal, and is usually 10 ° to 20 ° below it.

Dealing with patients who are already mortally ill, it is not surprising that a mild, or even, severe alka- losis develops from a combination of alkalosis, due to the Sippy regime, a chloride formation of 2 gm. in- stead of 5 gm. according to Wildman, and a hemor- rhage with intense vomiting. When the acid gastric secretion occurs in normal function, chlorine ions are withdrawn from the blood bearing an excess base which, combining with CO~, increases the bicarbonate reserve of the blood. The base chlorine balance in the blood is re-established by the absorption of chlorides and water from the gastric juice in the ileum and colon. Alkalosis may result from any abnormality which prevents the absorption of the chlorides in the small intestine.

In the ulcer cases, particularly in the presence of an obstruction, there is a loss of gastric juice, which con- tains hydrochloric acid, due to the vomiting. This de- pletes the chlorine ion content of the blood.

The normal blood chloride level and blood volume may be maintained for a while by the withdrawal of tissue chloride and fluid which is actually responsible for dehydration. When this supply of tissue chloride has been exhausted, a hypochloremia develops which liberates the originally combined chloride base so that it unites with the CO 2 which increases the bicarbonate content. Then, the urine becomes alkaline because of the markedly diminished chloride excretion and the presence of an excess of base ions. The occurrence of alkalosis in ulcers is evidenced by a low chloride level, a high CO 2 combining power of the plasma, a marked increase in the non-protein and urea nitrogen, and an alkaline reaction of the urine.

The imperativeness for the recognition of this com- plication is evident. The benefit to the patient, derived from the transfusions, will be augmented when this

affection is cured by the intravenous injection of 5% glucose and saline solutions.

In these ulcer cases complicated by obstruction and vomiting, the Author firmly believes that many of the fatalities were mainly due to alkalosis and not to the hemorrhage.

A re-emphasis has been recently made by Dr. Wright ~ who states: "that preclinical and even severe scurvy is frequently present but unrecognized in adults. Vitamin C is omitted from the diet fo rvar ious reasons some of which include: poverty, individual dis- like for the foods containing Vitamin C, faddist diets, and last but of considerable importance, diets imposed by the medical profession in the therapy of gastric and duodenal ulcers, colitis, and certain other candi- tions."

Using a standard.capillary fragil i ty test, previpusly described by Dr. Wright (7), it has been ma0e pos- sible to demonstrate that the capillary fragili ty is definitely increased in a moderate percentage of pa- tients who have been on ulcer or colitis diets deficient in Vitamin C. At first, this is present without gross evidence of scurvy but is later accompanied by frank hemorrhage from the gums, intestines, and subcutane- ously. Thus, such diets have been shown to definitely increase the tendency to hemorrhage.

This syndrome can be quickly cured by the use of crystalline Vitamin C (cevitamic acid) either orally or intravenously. The oral dosage should be from 60 to 100 m.m. given daily in divided doses. The amount, given intravenously, is 100 m.m. dissolved in 5 c.c. of normal sterile saline solution or distilled water. In a series of acute ulcer and colitis cases, this substance has been well tolerated when taken by mouth. In several instances, severe intestinal hemorrhage, as- cribed to colitis, has been entirely cleared-up by simply adding this substance to the diet. Therefore, it is suggested that cevitamic acid should be included in all diets deficient in Vitamin G, particularly, in those con- ditions frequently associated with ' oozing or frank hemorrhage. I t is candidly admitted that the use of this substance will not effect hemorrhages which are dependent on the erosion of large blood vessels. How- ever, it may have a very definite influence on bleeding associated with changes in the smaller blood vessels.

Cases have been seen, in which, it is impossible to arrest the hemorrhages by the administration of re- peated blood transfusions and the application of glu- cose and saline solutions. In order to build-up these cases to the proper condition for exploratory opera- tion, the writer recommends repeated intravenous in- jections of liver extract from ampules (5 c.c.), the active and anti-anaemic principles, of which, are equi- valent to 100 grammes of fresh liver. He also recom- mends the intravenous injection of glucose solution up to 50 per cent. The liver extract raises the hemog- lobin and red blood cell count and both solutions are invaluable for the elimination of the hemorrhage. Fur- ther experiments with these injections will be reported at a later da~e.

Regarding the operation of choice for cases of ulcer in the vicinity of the pyloric ring, a modification of the Billroth No. 1 procedure, advocated and practiced by yon Haberer in nearly 2,000 cases, is becoming very popular at the present time. There should be no devia-

*Personal communication to the Author by Dr. Irving S. Wright of New York City, N. Y.

4 3 4 A M E R I C A N J O U R N A L OF D I G E S T I V E D I S E A S E S AND N U T R I T I O N

tion from this technique since he has perfected it to a high degree of efficiency.

The Hoffmeister-Finsterer type of operation is ad- vised to deal with ulcers higher up in the lesser, or in the greater curvature or body of the stomach. We are all well aware that the higher the resection is made, the greater is the corresponding increase in the mor- tality in these cases.

In cases of the non-resectable type of posterior hemorrhagic duodenal ulcers, in which, it is impossible to cover the base of the ulcers by suture, the only hope of alleviation is by neutralizing the gastric acidity by a gastrojejunostomy as advocated by Balfour (8 and 9), who reports such cases of his cured to as high as 85 per cent, or, preferably, a gastrectomy, in which, the percentage of cure is 10% higher or better. Dur- ing the period of operation, the mouth should be kept scrupulously clean in order to avoid the danger of parotitis. Hurs t (2c) recommends 15 ounces of nor- mal saline solution via rectum every 6 hours. Both Hurst and Smithies agree that it is necessary to wash out the stomach in cases of continuous hemorrhage.

Af ter the patient has recovered and is in good con- dition, the second stage of the operative procedure should be performed which should aim at preventing a recurrence of the ulcer.

CONCLUSIONS From the surgical standpoint, the most important

step in dealing with serious and persistent bleeding ulcers is to confine the operator 's efforts to the arrest of the hemorrhage since the second stage of the opera- tion eliminates the cause.

No surgeon should consider operating on cases of acute ulcer complicated with massive hemorrhages, which are often primary, when the patient is in actual shock since most of the patients die on the operating table as a result of the low systolic pressure, hemog- lobin and blood count.

Errors are seldom made in dealing with gastric bleeding ulcers, but this, unfortunately, is not the case in the duodenal variety. Small or already healed ulcers that appear on the anterior or superior surface of the duodenum are excised, following which, a gastro-en- terostomy is performed. When the patient starts to bleed again several days following the operation, which the operator may ascribe to a marginal or gastrojej- unal ulcer occurring post-operatively, he suddenly realizes his lack of foresight for not making a more thorough exploration of the area.

Von Haberer, whose technique is generally used o~ the Continent, incises the duodenum, transversely, clear across the anterior duodenal wall with a wire loop cautery. Exploration of the posterior duodenal wall can then be safely made with either a diagnostic lamp or the operator's finger since ulcers on the an- terior or superior surface of the duodenum have seldom been known to cause a severe hemorrhage. The Deaver- Judd exploratory longitudinal duodenal incision is often used in this country.

Extreme care should be exercised when handling a cautery so as not to injure the pancreatic capsules. I t should never be held at right angles, but flat to the surface being cauterized.

REFERENCES 1. Wilensky, A. O., and Crohn, B . B . : Studies in~ the physiology and

pathology of the stomach a f te r gastro-enterostomy. Am. J. M. Sc., 15~:808-809, June, 1917.

2. Hurst , A. F., and Stewart , M. $ . : Gastric and duodenal ulcer. London, Humphrey Milford, 1929.

2a. ibid.: p. 269. 2b. ibid.: p. 273. 2c. ibid.: p. 270. 3. Finsterer, Hans : Die Bedeutung der Resektion zur Ausscha]tung

fiir die Behandlung des n~cht resez~erbaren Ulcus duodeni. Wien. klin. Wchnschr, 46:545-549, May 5, 1933.

4. Finsterer, Hans, and Cunha, Felix: The surgical t r ea tment of duodenal ulcer. S., G. and 0., 52:1099-1114, June, 1931.

5. Smithies, F. : Notes on diagnosis and prognosis in gastric ulcer : A clinical study of five hundred consecutive, operatively demon- strated cases. Am. J. Digest. Dis. and Nutrlt . , 1:697-704, Dec., 1934.

5b. Smithies, F. : The t rea tment of massive gastro-duodenal hemor- rhage. Am. J. Digest. Dis. and Nutrit. , 1:803, Jan. , 1935.

6. Aitken, R. S. : The t rea tment of profuse bleeding from the stom- ach and duodenum. Lancet, 1:839-842, April 21, 1934.

7. Wright, I. S. : Trea tment of adult scurvy with crystalline Vitamin C (Ascorhic acid}. Proc. Soc. Exper . Biol. and Med., 32:475- 477, Dec., 1934.

8. Balfour, D. C. : Surgical t rea tment in the bleeding type of gastric and duodenal ulcer. J . A. M. A., 73:571-575, Aug. 23, 1919.

9. Balfour, D. C.: The surgical t rea tment of hemorrhagic duodenal ulcer. Ann. Surg., 96:581-587, Oct., 1932.

10. MacGuire, D. P. : Gastrojejuual or marg ina l ulcer. New York State J. Med., 35:161-164, Feb. 15, 1935.

11. Allen, A. W., and Benedict, E. B.: Acute massive hemorrhage from duodenal ulcer. Ann. Surg., 98:736-749, Oct., 1933.

12. Hinton, J . W. : Fatal hemorrhage in peptic ulcer treated con- servatively. Am. J. Surg., 22:315-317, Nov., 1933.

13. Crohn, B. B.: Affections of the stomach. Philadelphia, W. B. Saunders Co., 1927.

A B S T R A C T S

M c N E A L Y , R . W . AND L I C H T E N S T E I N , M . E .

Evolution and Present Technique of Gastro]ejunos- tomy. S., G. and 0., Vol. 60, No. 5, May, 1935, pp. 1003-1015.

In a complete review of the history of gastrojejunostomy the authors show how experimental work in the laboratory has contributed to our present knowledge in that branch of surgery, and how trial and error in actual clinical surgery have contributed far more. The stoma of the efferent limb of the first gastrojejunostomy performed by Billroth was found to be obstructed because of a mechani- cal defect. Shortly thereafter many modifications of the operation were suggested. Woelfler, who had performed the first gastrojejunostomy in 1881, suggested stenosing the stoma of the afferent loop by suture, or removing the

afferent limb entirely and suturing it to the afferent limb at a point beyond the anastomosis. That principle was later expounded by Roux in relation to posterior gastro- jejunostomy. In 1885 the feasibility of performing pos- terior gastrojejunostomy through an avascular area in the transverse mesocolon was proposed from Billroth's clinic.

The posterior operation grew in favor and attracted the attention of many surgeons. It received a further stimulus by Peterson, who showed that it was possible to anasto- mose the jejunum to the stomach close to the duodeno- jujunal flexure without much tension. That obviated the necessity of a proximal loop, and made it unnecessary to perform the Y operation of Woelfler or Roux.

Among the factors contributing to the failure of those early operations, infection and its sequellae were outstand-