[Symptomless and complicated peptic ulcer as an extreme clinical form of ulcer disease: consequences for choice between conservative and surgical therapy]

Asymptomatic recurrent ulcers following drugs and surgical therapy are true failures of treatment (Visick IV). Several types of bias at present do not allow any conclusion whether medical treatment and maintenance increase the rate of ulcer complications. The mechanisms of action for medical treatment with cimetidine and operative treatment with SPV are similar, but not identical. Bad compliance and incomplete vagotomies mainly account for success of mutual exchange between the two types of therapy. Using a decision tree with mortality as outcome recommendations are developed for a step-wise therapeutic concept in peptic ulcer patients.

Controlled trial of liquid monopolar electrocoagulation in bleeding peptic ulcers

The aim of this study was to evaluate the efficacy and the safety of liquid monopolar electrocoagulation in the endoscopic control of major haemorrhage from peptic ulcers. During the 24-month period of the trial, emergency endoscopy was performed on 480 patients consecutively admitted with acute upper gastrointestinal tract hemorrhage. Ulcers were seen in 168 cases (35%). Seventy-eight of these were included in the trial. Active bleeding was present in 21 cases and stigmata of recent bleeding were observed in 57. Immediate hemostasis was achieved in nine of 11 patients with active bleeding ulcers. However, active bleeding can stop spontaneously (as in four of 10 control patients), which reemphasizes the importance of randomized studies. There was a trend toward hemostatic benefit for the electrocoagulation-treated patients with actively bleeding ulcers. In the group of 31 patients with visible vessels, the electrocoagulation treatment reduced significantly both the rate of rebleeding and the emergency surgery. In the group of 26 patients with other stigmata of recent bleeding (fresh or altered clot, or black spots), only in two cases allocated to placebo treatment occurred rebleeding. These patients are at minimal risk of further bleeding. The results offer support to the contention that liquid monopolar electrocoagulation is a safe and effective method of reducing the incidence of further bleeding and emergency surgery. This new technique has the advantages of low cost, easy maintenance, durability, and portability.

Changes in the surgical treatment of acid peptic disease

The surgical treatment of acid peptic disease at Hennpin County Medical Center (Minneapolis, MN) during two time periods separated by a 12-year interval was reviewed. In comparing the more recent period with the earlier, the following was observed: 1) total number of operations decreased by one-third, but the number of emergency operations was the same; 2) overall operative mortality did not change even though more patients in the recent period had associated systemic disease; 3) the location of ulcers did not change; 4) hemorrhage, as an indication for emergency surgery, increased both relatively and absolutely; and 5) the preferred surgical procedure during both periods was vagotomy and antrectomy, but vagotomy and drainage was done with increased frequency in the more recent period. During both time periods, emergency surgery was associated with almost a tenfold increase in operative mortality.

Laser treatment of upper gastrointestinal hemorrhage

The goal of laser treatment of the visible vessel or bleeding ulcer is to stop the bleeding to allow healing of the ulcer base. Adjuvant techniques including the use of vasoconstrictive agents, tissue adhesives, and tissue injection hold future promise in complementing laser therapy. Laser photocoagulation appears to be an effective method of treatment. At this time, however, the therapy of this serious clinical problem is evolving. As experience increases and as new technology and techniques are applied, the development of an effective treatment for the bleeding peptic ulcer or visible vessel is even more promising.

Surgical management of acute hemorrhagic postbulbar duodenal ulcer after a previous major surgical procedure

The choice of operation for acute hemorrhagic postbulbar duodenal ulcer after an operation is discussed. Distal partial gastrectomy was performed in six patients. The ulcer was treated by resection, suture, or removal by mucoclasis. Hemostasis was attained in five patients. In another, multiple ulcers were observed in the descending portion of the duodenum and gastrectomy failed to control hemorrhage, resulting in death. Rebleeding was observed in two, one from a newly formed ulcer in the upper part of the papilla of Vater after gastrectomy with truncal vagotomy and which was halted by suture of the ulcer and another was from a newly formed ulcer in the remnant stomach after gastrectomy and which was halted by selective vagotomy and ligation of the left gastric artery. It is recommendable to perform a subtotal gastrectomy and vagotomy combined with removal of the ulcer by mucoclasis or ulcer suture. In some cases, pancreatoduodenectomy may have to be done.

Prophylaxis for acute stress ulcers. Antacids or cimetidine

Two hundred and forty-nine patients are divided into four homogenous groups to compare the efficacy of Cimetidine versus antacids, as well as the mode of delivery--bolus versus continuous drip--in the prophylaxis of acute hemorrhagic gastritis in critically ill patients. Antacids were favored over Cimetidine, and the continuous drip was the superior method with both drugs.

[Emergency surgery of complicated gastroduodenal ulcers: risk factors and results]

Between 1972 and 1981, 290 patients underwent emergency surgery in this Department for hemorrhagic (n = 104) or perforated (n = 186) gastric or duodenal ulcer. The introduction of cimetidine in 1977 did not influence the annual number of operations for complicated ulcer. Operative mortality was 15% for haemorrhage and 11% for perforation. Age, associated diseases, total bleeding, and delay between perforation and surgery were the most significant risk factors. In the case of inaugural complication or of brief peptic disease, simple closure, with a recurrence rate of 21%, remains the procedure of choice.

Endoscopic control of upper gastrointestinal bleeding

One important objective in managing patients with upper gastrointestinal hemorrhage is to control the bleeding until the patient's condition is stable and definitive therapy can be carried out. Endoscopic techniques are now available to attain this goal. Endoscopic sclerosis has become an accepted treatment for bleeding esophageal varices, especially in patients with Child's class B or C cirrhosis. Control of nonvariceal bleeding by endoscopic techniques is now feasible and involves laser photocoagulation and electrocoagulation. Clinical experience with endoscopic laser photocoagulation has demonstrated that it can successfully arrest bleeding in gastric and duodenal ulcers. Endoscopic electrocoagulation has been successful in stopping bleeding from Mallory-Weiss tears, acute gastric erosions, and gastric, duodenal and stomal ulcers. Use of an endoscopic heater probe, now in the development stage, to control bleeding gastric and duodenal ulcers will be an important addition.

Duodenal ulcer disease in the elderly: a retrospective study

A retrospective study was performed of 163 patients aged 65 years and over with a diagnosis of duodenal ulceration admitted to one Health District over a period of six years. Eighty per cent of the patients were admitted with acute complications, 50% bled and 30% were perforated. A large proportion of these patients were currently taking anti-inflammatory agents. Patients managed surgically for their complications had a high mortality rate but this was even higher for those managed conservatively. Giant ulcers were found to occur frequently in this age group which had a tendency to severe bleeding. It is concluded that early diagnosis and prompt surgical intervention is essential in the management of complications associated with duodenal ulceration in the elderly.

[Hemorrhage in angioterebrant duodenal ulcers]

Over half the 42 patients seen with severe hemorrhage from antioterebrant posterior duodenal ulcers were 60 years or more. Mortality is still high but has been lowered by the use of routine emergency fibroscopy and subsequent earlier operation. The preferred surgical solution is by weinberg's technique (hemostasis, vagotomy, pyloroplasty).

Comparison of heater probe and YAG laser in endoscopic treatment of major bleeding from peptic ulcers

In our experience using the YAG laser and the heater probe in endoscopic treatment of major hemorrhage from peptic ulcers, ultimate hemostatic success was achieved in 19 of 20 (95%) ulcers treated with the heater probe, versus 24 of 35 (69%) YAG laser-treated ulcers (p less than 0.05). The heater probe was considerably faster, more convenient to use, and safer than YAG laser. We presently consider the heater probe to be the preferred endoscopic hemostatic device.

Electrohydrothermoprobe--a simple alternative to laser therapy in the management of acute gastrointestinal haemorrhage

One hundred and twenty six consecutive patients presenting with upper alimentary bleeding were endoscoped. Seventeen gastric and 11 duodenal lesions with visible blood vessels were identified and cauterised with the electrohydrothermoprobe. One gastric and four duodenal vessels rebled, necessitating surgery. For the gastric vessels this represents about one tenth of the expected rebleeding rate, and is a significant reduction. The technique appears to have no effect on the rebleeding rate in duodenal vessels.

Endoscopic prediction of major rebleeding--a prospective study of stigmata of hemorrhage in bleeding ulcer

Two hundred fifty patients with stigmata of active or recent hemorrhage from peptic ulcer were studied. Stigmata, subgrouped according to bleeding status and the presence or absence of a visible vessel, were related to the subsequent clinical course of hemorrhage. Sixty patients (24%) rebled massively and required emergency hemostasis. At the initial endoscopy a visible vessel was a relatively rare finding (21%). Less than one-third of the visible vessels rebled massively. None of the stigmata or subgroups of stigmata emerged as reliable predictors of major rebleeding. Bleeding status and ulcer site, however, were observed to influence the relative importance of a visible vessel. When a visible vessel was identified in patients with oozing, overlying clot, or gastric or duodenal ulcer, the probability of major rebleeding increased, but not significantly. However, when a visible vessel was identified in patients without other stigmata or in patients with prepyloric ulcer or older stigmata, there was a decreased probability of major rebleeding. Older stigmata was a superior predictor of self-limited hemorrhage.

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.

[Means of improving the surgical treatment of gastric and duodenal peptic ulcer]

Based upon the experience with the treatment of 2312 patients with ulcer disease of the stomach and duodenum the authors analysed the major tasks which must be solved for obtaining better immediate and long-term results of the surgical treatment. In 1880 (81,3%) of the patients with a gastric ulcer and a complicated ulcer of the duodenum the stomach resection gave favorable outcomes in 98,6%. In 432 patients (18,7%) organ-preserving operations were made, in 185 of them it was vagotomy. The vagotomy was followed by recovery of 99,5% of the patients. Longterm results were studied in 1486 patients. Bad outcomes were noted in 34 patients (2,4%) after stomach resections and in 16 patients (11%) after vagotomy.