Controlled trial of heater probe treatment in bleeding peptic ulcers

A prospective randomized controlled trial of endoscopic heater probe therapy in bleeding peptic ulcers was performed to determine whether probe therapy can reduce rebleeding rates. Of 630 patients endoscoped for suspected upper gastrointestinal haemorrhage over a 16-month period, 166 (26 per cent) were found to have a peptic ulcer. Either minor or no stigmata of recent haemorrhage were found in 115 patients at the time of endoscopy. A single peptic ulcer with either active haemorrhage or a visible vessel was found in 51 patients, 43 of whom were entered into the trial. There were eight exclusions: four were inaccessible, one was a torrential haemorrhage and three were excluded for non-technical reasons. Patients were randomized to receive either heater probe (n = 20) or sham (n = 23) therapy. In actively bleeding ulcers, immediate haemostasis was achieved following probe therapy in 14 of 18 patients (78 per cent) compared with none of 21 having sham treatment (P less than 0.002). No rebleeding occurred in the probe therapy group (n = 20) compared with rebleeding in five of 23 sham treated patients (P = 0.05). Urgent surgery for haemostasis was required in three of the five sham treated patients who rebled. It is concluded that heater probe therapy may be effective in reducing rebleeding rates in peptic ulcers accessible to the endoscope.     

Bleeding duodenal ulcer: reduction in mortality with a planned approach.

In a 6-year prospective study from 1972 to 1978 266 patients were admitted to a haematemesis and melaena unit with bleeding duodenal ulcer. There were 13 deaths, a mortality of 5 per cent. A comparison between the three consecutive 2-year periods of study showed an initial mortality of 6 per cent for the first 4 years falling to 2 per cent for the 93 admissions during the final 2 years of experience. Of the 120 patients treated surgically, 10 died in hospital, giving an operative mortality of 8 per cent. The trend in operative mortality was from 13 per cent for the initial 2-year period to 8 per cent for the second period and to 3 per cent for the final 2 years. The operative rate was consecutively 45, 50 and 34 per cent. There was 1 death in conservatively treated patients during each 2-year period of study. Three types of operation were performed: vagotomy, pyloroplasty and oversewing of the ulcer; Polya gastrectomy; and vagotomy and antrectomy. There was no difference in morbidity and mortality between these operations. At a mean follow-up of 3.1 years, 90 per cent of the patients had a good result from their operation. It is concluded that a prospective system of management with an active policy of early endoscopy, surgery and regular audit reduces the mortality from bleeding duodenal ulcer.     

A prospective evaluation of the management of bleeding peptic ulcer

Bleeding from a peptic ulcer is associated with significant morbidity and mortality, particularly in the elderly. The results of a management policy of early endoscopy and close monitoring of patients were prospectively evaluated to assess whether major stigmata of recent haemorrhage (SRH) helped to identify patients who were likely to rebleed. Early endoscopy allowed the diagnosis of the most likely site of haemorrhage in 94% of the 190 patients. The nature and site of SRH (visible vessel, fresh clot, red or black spot) was recorded. Ninety-three of 167 patients in whom the presence or absence of SRH were recorded, had major SRH (visible vessel, fresh clot) and 51% of these patients rebled while only 10 of 74 (14%) patients without major SRH rebled. Overall, 80% of those with further haemorrhage had major SRH. Operation was performed on 28% of patients and the main indication for operation was further haemorrhage. Major morbidity in the surgical patients was strongly correlated with vascular instability at the time of further haemorrhage. Significant morbidity occurred in 16 of 28 patients (57%) with vascular instability, compared with only 1 of 18 patients (6%) without vascular instability (P less than 0.001). The overall low mortality of 5.3% was attributed to an approach of joint medical and surgical management with early operation for further haemorrhage. Although major SRH identified a group of patients most likely to suffer further haemorrhage, the positive predictive value of major SRH was only 51%.     

Results of surgery of the hemorrhaging stomach and duodenal ulcer--a 10-year retrospective study

Operations were performed on 131 patients for haemorrhagic peptic ulcer at Wenckebach Hospital, between 1977 and 1986. Roughly two thirds of all patients had never had ulcer before. Persistent haemorrhage was recorded from about 20 per cent of these cases by emergency gastroscopy. Immediate surgical action had to be taken on 23.7 per cent. Interval interventions were possible for 28.2 per cent, while almost 50 per cent had to be laparotomised for early recurrent bleeding. Mortality in the wake of immediate emergency operations and surgery for recurrent bleeding was nearly twice as high as that in the context of interval interventions. Resection was performed on 70 per cent, haemostasis only on 26 per cent, and additional vagotomy on 14 per cent. Overall mortality amounted to 27.5 per cent including 36.6 per cent for women and 22.8 per cent for men. Ulcer localisation had no impact on mortality. The highest mortality rate, 38.2 per cent, was recorded from patients on whom only haemostasis had been performed, while 16.7 per cent were recorded from those to whom additional vagotomy had been applied. Lethality in the context of resection amounted to 25.6 per cent. Twenty-three patients had to be relaparotomised (17.6 per cent), which pushed up the mortality rate to 43.5 per cent.     

A controlled trial of bipolar electrocoagulation in patients with upper gastrointestinal bleeding

We have assessed the value of the BICAP electrocoagulation probe in reducing the incidence of further bleeding in patients with upper gastrointestinal haemorrhage. One hundred and twenty-nine patients were studied in a prospective randomized controlled trial. There were 85 male and 44 female patients, age range 16-92 years. Forty-five patients had stigmata of recent haemorrhage (visible vessel or spot) and were randomized during endoscopy to 24 control and 21 treatment patients. Seven control patients rebled compared with nine treated patients (Fisher's exact probability test P = 0.44). The transfusion requirements of control patients (3.9 +/- 3.2 units) was not different from that of treated patients (5.7 +/- 3.7 units): Mann Whitney U test, P = 0.06. In the treatment group there was no difference in the operation rate. Also, the number of probe applications between patients with further bleeding and those with no further bleeding was similar (11.6 +/- 5.5 and 11.0 +/- 5.75 respectively). Access with the probe was considered inadequate in 50 per cent of lesions, but this did not correlate with the incidence of rebleeding. Stigmata of recent haemorrhage were significant in predicting rebleeding (P = 0.0019 Fisher's exact probability test). Overall mortality rate of 3.2 per cent was low and was not influenced by electrocoagulation or presence of stigmata of recent haemorrhage. We have not shown that BICAP bipolar electrocoagulation reduces the incidence of rebleeding in upper gastrointestinal haemorrhage.     

Comparison of minimal and conventional surgery in patients with bleeding peptic ulcer: a multicentre trial.

A multicentre randomized prospective trial compared minimal surgery (under-running the vessel or ulcer excision and adjuvant ranitidine) with conventional ulcer surgery (vagotomy and pyloroplasty or partial gastrectomy) for the treatment of bleeding peptic ulcer. This report is based on 137 patients (eight withdrawn through misdiagnosis or lost data), of whom 62 received conservative surgery and 67 conventional operation. Twenty-nine patients died, 16 (26 per cent) after conservative surgery and 13 (19 per cent) after conventional operations. The only significant difference between the groups was the incidence of fatal rebleeding, which occurred in six patients after conservative surgery compared with none after conventional surgery (P less than 0.02, Fisher's exact test).     

MANAGEMENT OF ACUTE BLEEDING GASTRIC MALIGNANCY

Gastric malignancy was the cause of bleeding in 35 of a consecutive series of 2260 cases (1.5%) treated with upper gastrointestinal haemorrhage. Fifteen patients came to emergency surgery (43%). In 13 of 30 early endoscopies performed the lesion was thought to be benign (43%) and seven of these cases came to emergency surgery. Two patients died after 15 emergency operations (13%) compared with 15 deaths after 109 emergency operations (14%) for benign gastric ulcer during the same period of study. A total of four patients with malignant ulceration died after surgery in 33 cases (12%), two after 15 emergency operations and two after 18 elective procedures. The only significant predictors of urgent surgery for malignant ulcer were shock on admission and active bleeding or visible vessel on endoscopy. Resection of gastric malignancy was performed in 29 patients during initial admission and in four cases at a subsequent admission giving a final resection rate of 91%. Of the 28 patients with adenocarcinoma, 19 had localized disease (Stage 1 or 11) (68%). Nine patients were treated by total gastrectomy, five at an initial elective procedure and four at a second procedurc.     

Reduction of surgery and mortality rate of bleeding peptic ulcer by endoscopic haemostasis with alcohol

Eighty patients with peptic ulcers (45 duodenal ulcers, 30 gastric ulcers, and 5 stomal ulcers) presented at our emergency endoscopy unit with acute upper gastrointestinal haemorrhage (Forrest Ia, spurting bleeding; Forrest Ib, oozing bleeding) or stigmata of recent bleeding (Forrest II). They were divided into two groups, A and B, according to the day of the week on which emergency endoscopy was performed. Group A, consisting of 39 patients (24 duodenal ulcers, 13 gastric ulcers, and 2 stomal ulcers) was submitted to conventional treatment (blood transfusions, antacids, cimetidine, pirenzepine). Group B consisted of 41 patients (21 duodenal ulcers, 17 gastric ulcers and 3 stomal ulcers) on whom endoscopic haemostatic injection with absolute alcohol (Asaki's method) was performed. Patients of both groups underwent emergency surgery if the haemorrhage did not stop or if it recurred. In 10 cases (4 in group A and 6 in group B), elective surgery was performed, i.e. several days after the bleeding episode under conditions of haemodynamic safety. Endoscopic injection of absolute alcohol succeeded in arresting the haemorrhage in 17 of the 18 Forrest Ia and Ib cases and prevented recurrence in all Forrest II cases. Significant differences were recorded between the two groups as regards the number of patients undergoing surgery (18 to 7), emergency surgery (14 to 1) and the mortality (15% compared to 2.4%). The greatest difference was recorded between the postoperative mortality (27% in group A and 0% in group B).(ABSTRACT TRUNCATED AT 250 WORDS)     

Urgent fibre-optic panendoscopy in upper gastro-intestinal haemorrhage.

Urgent fibre-optic panendoscopy was performed in 400 patients within 24 hours of their admission to hospital for upper gastro-intestinal haemorrhage. The cause of bleeding was established by endoscopy in 87%. No cause was found in 10% and endoscopy failed in 3%. Twenty-five per cent of the patients had an additional lesion which was not the cause of bleeding. Complications owing to endoscopy occurred in 2% of the patients. Only 27% of the patients still had blood present in the stomach at the time of endoscopy. Chronic gastric ulcer was causative in 22%, and duodenal ulcer in 20% of the patients. Haemorrhagic gastritis accounted for 13%, Mallory-Weiss tear for 8%, acute ulceration for 5% and varices for 4% of the patients. Only 60% of the patients with dyspepsia were bleeding from peptic ulcers and only 64% of the patients bleeding from ulcers had a history of dyspepsia. Follow-up studies revealed that endoscopy, in experienced hands, is an accurate investigation which allows for an improved approach to management, and which probably also reduces the mortality rate.     

Early reoperations after surgery for duodenal ulcer

To assess the incidence of early, severe, and life-threatening complications demanding early reintervention following surgery for duodenal ulcer--initial or reoperative--2579 patients who underwent elective surgery, 2472 as an initial approach and 107 as a reintervention, are presented in this study. Twenty-three patients underwent early reoperation after initial surgery for duodenal ulcer and ten patients out of the 107 required reoperation for severe late postoperative complications. The overall incidence of early reoperation was 1 per cent (33 patients) and there was an incidence rate of .6 per cent after initial surgery versus 9.8 per cent after reoperative surgery (P less than 0.001). It is concluded that reoperative surgery for late complications following initial surgery for duodenal ulcer carries a high incidence rate for complications which warrant early reintervention. It is believed that reduction in the incidence of late complications following initial surgery for duodenal ulcer should simultaneously result in a reduction in the demand for early reoperation which is associated with a considerable mortality and morbidity rate.     

Prediction of wound sepsis following gastric operations.

Gastric aspirates were obtained from 12 healthy volunteers, 49 patients with duodenal ulcer, 14 with gastric ulcer and 35 with gastric carcinoma. The mean total viable bacterial counts in these groups were as follows: volunteers 0, duodenal ulcer 3.8 X 10(1), gastric ulcer 6.95 X 10(4), carcinoma 1.9 X 10(7) organisms/ml. The incidence of wound sepsis in patients without antibiotic cover was; duodenal ulcer 17 per cent, gastric ulcer 38 per cent, carcinoma 56 per cent. Regardless of the underlying pathology, patients with counts greater than 5 X 10(6) organisms/ml in the gastric aspirate had a 93 per cent incidence of wound sepsis, compared with 16 per cent in patients with counts of less than 5 X 10(6) organisms/ml (P less than 0.001). In the group with high counts all except one of the wound infections were caused by organisms present in the stomach at the time of operation. There was a good correlation in the bacteriology of apirates obtained during preoperative endoscopy compared with operative nasogastric samples (n = 31) both for viable counts (r = 0.93) and for the counts of individual organisms. Therefore, preoperative endoscopy can be used to identify patients who are at risk of developing wound sepsis after gastric surgery.     

Wounding,shock and stress lesions of the upper gastrointestinal tract

This retrospective study included 2532 wounded, of whom 354 (14 per cent) were treated in surgical intensive care units. In 32 patients, 1.3 per cent of all admissions, upper gastrointestinal bleeding was detected. It occurred on average 8.9 days (3–21 days) after the wounding or surgical procedure in severely injured patients and those treated in intensive care units, respectively (32 of 354 patients, 9.0 per cent). All patients received different analgesic drugs and 17 of a group that presented with bleeding were given psychotropic agents as well. The majority of patients (96.3 per cent) were administered H₂-receptor antagonists as prophylaxis against stress ulcer disease. There was a statistically significant difference between these patients treated with H₂-receptor antagonists and those on no prophylactic therapy. No statistically significant difference was found between cimetidine and ranitidine in terms of their efficacy. Endoscopic examination revealed multiple bleeding gastric and duodenal erosions. The lesions were most commonly located in the corpus of the stomach. In the majority of patients (56.25 per cent), the haemorrhage stopped spontaneously and rebleeding presented in four of 32 (12.5 per cent) patients. Of 354 patients treated in intensive care units, five (1.4 per cent) had to be operated on because of bleeding arrest. Despite all therapeutic and surgical procedures undertaken, five of 32 (15.6 per cent) patients died.     

Choice of emergency operative procedure for bleeding duodenal ulcer

In a consecutive series of 201 emergency operations in patients with bleeding duodenal ulcer the size of the ulcer was the only factor that showed a significant correlation with the procedure chosen. Vagotomy, pyloroplasty and underrunning of the bleeding point was performed in 101 cases with ten deaths (10 per cent), partial (Billroth II) gastrectomy in 81 cases with ten deaths (12 per cent), and vagotomy and antrectomy in 16 cases with one death (6 per cent). A patient was more likely to be treated by partial gastrectomy if a giant ulcer with an internal diameter of greater than or equal to 2 cm was found. The results suggest that while vagotomy and pyloroplasty, combined with a direct attack on the bleeding point or excision of an anterior ulcer is an acceptable standard emergency operation for bleeding duodenal ulcer, gastric resection proved to be a satisfactory alternative procedure and should be considered in the technically difficult case with a very large ulcer. A giant ulcer was present in 37 per cent of cases coming to surgery.     

Recurrent peptic ulceration after highly selective vagotomy: long-term outcome

A prospective assessment was made of the outcome 4 years after diagnosis of recurrence in a group of 27 patients with documented ulceration after highly selective vagotomy (16 symptomatic recurrence and 11 asymptomatic). In the 16 patients with a previous symptomatic recurrence, eight of the 11 patients with duodenal ulcer underwent a further endoscopy at 4 years and one active ulcer was found. Five patients with previous symptomatic gastric ulcer recurrence have all undergone further surgery. In the 11 patients who originally had an asymptomatic ulcer recurrence (five gastric, six duodenal) no patient has undergone further surgery, although two patients with a recurrent gastric ulcer and two with a recurrent duodenal ulcer subsequently developed symptoms from their ulcer and required H2 receptor blocker therapy. Eight of the 11 originally asymptomatic patients underwent further endoscopy at 4 years and two further duodenal ulcers were found. After highly selective vagotomy, asymptomatic ulcer recurrence occurs frequently and 40 per cent of these patients may develop symptoms.     

Hemorrhagic gastro-duodenal ulcers. In which cases should emergency surgery be performed?]

From January 1983 to December 1987, 127 patients with bleeding peptic ulcer were admitted to hospital. The mean age of the 85 males was 57 years and 72 years for 42 females. All but four of the patients were managed medically after emergency endoscopy. Twenty-seven patients required surgical operations (21.2%): seven for cataclysmic haemorrhage, eight for persistent haemorrhage, twelve for recurrent bleeding. An analysis of factors leading to the necessity of surgical haemostasis was undertaken by considering the clinical status, endoscopic findings and laboratory results. The size of the ulcer (greater than 2 cm) was the most significant parameter (less than 0.01). Five other criteria (rectal bleeding) shock, endoscopic signs of recent haemorrhage, gastric or duodenal posterior ulcer) were also significant (p less than 0.05). Considering the gravity of these patients (six deaths among twenty-seven), clinical trials in bleeding peptic ulcer disease should only include patients in the high risk group.     

Surgery for the complications of peptic ulceration in urban black patients

We report on a series of 63 urban black patients who required surgical treatment for duodenal or gastric ulcers. Intractable pain from duodenal ulceration was an uncommon indication for surgery, which was mostly required for the complications of perforation, haemorrhage and stenosis. Perforation was the most common indication for surgery in these patients, while in rural black patients pyloric stenosis is reported to be a common complication. It appears that the complications of duodenal ulcers in the urban black population now resemble those occurring in white patients. Giant duodenal ulcers were present in almost 25% of these patients and those presenting with haemorrhage required aggressive surgery to control the bleeding. Twenty-five per cent of cases of gastric ulceration proved to be malignant. These were mostly prepyloric ulcers, suggesting the need for vigorous investigation of such ulcers to exclude gastric carcinoma and early surgery if a conservative regimen fails to heal them. There was a 100% mortality rate among patients with perforated benign gastric ulcers, largely the result of late presentation.     

Bleeding ulcer: timing and technique in surgical management

The individual surgeon's training, experience and flexibility are decisive factors in the successful recovery of patients after surgery for acute bleeding peptic ulcer. With planned management, careful preparation for surgery should be considered as of equal importance to surgical skill. Early diagnosis and exact resuscitation are the two most important aspects of a plan of treatment which anticipates the need for early surgery. In the past, patients were often referred late for surgery after significant blood loss and transfusion. Surgeons have endeavoured to define the cases that are likely to rebleed and prepare them promptly for surgery. Probably the best indications for early surgery are severe haemorrhage, reflected by shock on admission, an age of over 50 and active bleeding from the ulcer seen at diagnostic endoscopy. Prospective studies have shown a reduction in mortality from bleeding ulcer where policy requires early endoscopic diagnosis, exact resuscitation in the intensive care unit and early surgery in high risk cases.     

Bleeding duodenal ulcer. A prospective evaluation of risk factors for rebleeding and death.

There were 12 hospital deaths in 433 patients (2.8%, 1.6% at 30 days) presenting with bleeding duodenal ulcer. Excluding patients who underwent immediate operation or early elective surgery, where ulcer size was measured at initial endoscopy rebleeding was evident in 40/288 patients (13.9%) and was associated with an increased mortality (0.4% v 12.5%) (p less than 0.0001). Rebleeding rates for ulcers less than or equal to 1 cm and greater than 1 cm were respectively 28/239 (11.7%) and 12/49 (24.5%) (p less than 0.02). Rebleeding occurred in 13/186 patients (7.0%) in whom endoscopic stigmata of recent haemorrhage were absent and in 27/102 (26.5%) with such stigmata (p less than 0.0001). The mortality rate for patients without stigmata was 3/186 (1.6%) whilst mortality figures for patients with ulcers less than or equal to 1 cm and greater than 1 cm in size were respectively 0/77 and 3/25 (12.0%) when stigmata were identified. Ulcers greater than 1 cm were more frequent in the greater than 60 year age group, more likely to have stigmata and carried an increased risk of rebleeding and mortality.     

Current practice of emergency vagotomy and Helicobacter pylori eradication for complicated peptic ulcer in the United Kingdom

BACKGROUND: The aim was to assess the current opinion of surgeons, by subspecialty, towards vagotomy and the practice of Helicobacter pylori testing, treatment and follow-up, in patients with bleeding or perforated duodenal ulcer. METHODS: A postal questionnaire was sent to 1073 Fellows of the Association of Surgeons of Great Britain and Ireland in 2001. RESULTS: Some 697 valid questionnaires were analysed (65.0 per cent). Most surgeons did not perform vagotomy for perforated or bleeding duodenal ulcer. There was no statistical difference between the responses of upper gastrointestinal surgeons and those of other specialists for perforated (P = 0.35) and bleeding (P = 0.45) ulcers. Respondents were more likely to perform a vagotomy for bleeding than for a perforated ulcer (P < 0.001). Although more than 80 per cent of surgeons prescribed H. pylori eradication treatment after operation, fewer than 60 per cent routinely tested patients for H. pylori eradication. Upper gastrointestinal surgeons were more likely to prescribe H. pylori treatment and test for eradication than other specialists (P < 0.01). CONCLUSION: Most surgeons in the UK no longer perform vagotomy for duodenal ulcer complications.     

Endoscopic approaches to upper gastrointestinal bleeding

Treatment for most patients with upper gastrointestinal bleeding has shifted from the operating room to the endoscopy suite. Endoscopic treatment has resulted in substantial benefit for patients with bleeding from peptic ulcer. Ulcers associated with high-risk stigmata of recent hemorrhage (SRH) not treated endoscopically have 40 per cent to 100 per cent risk of continued or recurrent bleeding and up to a 35 per cent chance of requiring surgical control of bleeding. Endoscopic therapy has reduced the risk of recurrent bleeding to 10 per cent to 20 per cent and the need for surgery to 5 per cent to 10 per cent. These improvements translate to shorter hospital stays, fewer transfusions, lower costs, and less morbidity. Similar progress has been made for patients bleeding from esophageal varices. Mortality for a first variceal bleed is now approximately 20 per cent as compared with 40 per cent to 60 per cent in past decades. Rebleeding after initially successful endoscopic hemostasis is often best treated by a second attempt at endoscopic control. The decision regarding management of recurrent bleeding should be made at the time initial endoscopic control is achieved. Local factors such as experience of the endoscopic team, availability of interventional radiologists, and individual patient characteristics should guide these decisions. Failures of endoscopic control and patients with massive hemorrhage still require operative intervention.