Experiences with angiography in diagnosis and treatment of acute gastrointestinal bleeding of various etiologies: preliminary report

Emergency abdominal colectomy with primary anastomosis

From 1968 to 1979, 18 patients underwent emergency abdominal colectomy with ileorectal anastomosis. Indications for operation included massive colonic bleeding (11), obstructing carcinoma (5), toxic megacolon (1), and enterocolitis (1). Five patients died postoperatively (27.8 per cent). Causes of death included sepsis, upper gastrointestinal bleeding, and respiratory failure. All had peritonitis, and five had documented anastomotic leaks. Seven of the surviving patients had significant morbidity from the procedure which included anastomotic leak, small bowel obstruction, wound infection, sepsis, and pulmonary emboli. Only six patients survived without complications. Although others have written about the safety of emergency subtotal colectomy with ileorectal anastomosis, our experience suggests this procedure is associated with excessive morbidity and mortality.

Transcatheter therapy of gastrointestinal arterial bleeding

Transcatheter therapy for arteriocapillary gastrointestinal bleeding is often an effective form of treatment. The choice of transcatheter therapy (ie, vasoconstrictor or occlusive) often is dependent on the etiology and location of bleeding. Vasopressin is a generally safe form of treatment which is often successful in treating bleeding secondary to gastritis, Mallory-Weiss mucosal tears, and diverticular disease. It is less effective in treating bleeding peptic ulcers, neoplastic bleeding, or bleeding when clotting abnormalities exist. Occlusive therapy is an effective alternate form of therapy in selected circumstances. Ischemic complications from vasoconstrictor and embolic therapy may occur and require appropriate caution and discretion with their use.

Survival following infusion of Pitressin into the superior mesenteric artery to control bleeding esophageal varices in cirrhotic patients

Morbidity and mortality data from patients with bleeding esophagogastric varices treated with portosystemic shunts relate to the clinical status of the patient and to control of hemorrhage both in the immediate postoperative period as well as later. To obtain comparable data following selective infusion of pitressin into the superior mesenteric artery (SMA), records of 23 consecutive patients with cirrhosis, diagnosed by endoscopy as bleeding from varices and treated with SMA pitressin infusions, were reviewed. Twenty-four infusions were performed and hemorrhage was controlled in 12. Fourteen of the 23 patients subsequently underwent portosystemic shunts. Pitressin infusion controlled hemorrhage preoperatively in seven of these, and five survived one year or longer. The remaining seven, in whom bleeding was not controlled by pitressin, died postoperatively. One of the nine patients not undergoing a portosystemic shunt survived more than eight weeks after pitressin infusion. Vascular complications occurred in seven of 17 who died. These complications and the delay between institution of pitressin and operative therapy to control variceal hemorrhage appears to be a factor in the high mortality rate. Portosystemic shunt remains the best therapy for uncontrolled hemorrhage and to prevent recurrent bleeding from esophageal varices.

Peroperative endoscopic diagnosis of small intestinal bleeding

Two patients with recurrent bleeding from vascular anomalies in the small intestine are described. In both patients intestinal angiography had shown either pathological vessels or extravasation of blood into the proximal part of jejunum, but during explorative laparotomy the source of bleeding had not been found. The diagnosis was made by performing peroperative endoscopy. After resection of the involved small bowel segment one patient with cavernous hemangioma has remained asymptomatic. In the other patient, who suffered from a combination of multiple arteriovenous malformations and a congenital platelet defect, limited surgical resection did not influence the need of blood transfusions. This investigational approach should become the method of choice in patients suspected of bleeding from the small intestine.

Selective intraarterial infusion of vasopressin for control of gastrointestinal bleeding: experience with 35 cases

Selective intraarterial infusion of vasopressin was performed in 32 patients for 35 episodes of gastrointestinal bleeding. Active bleeding was from esophageal varices in 11 cases and from an arterial site in 22 (stomach 11, duodenum 1, jejunum 2, colon 7, liver 1), including a jejunal diverticulum and a colonic ulcer in Behcet's disease. Two patients, not actively bleeding, were infused for portal decompression before an elective mesocaval shunt. Active bleeding was controlled in 64% of patients with variceal hemorrhage and in 59% of those with arterial sources. Infusion periods ranged from 15 minutes to 70 hours. There were no significant complications directly attributable to this therapy.

Nonsurgical control of massive acute gastric mucosal hemorrhage with antacid neutralization of gastric content

A simple and safe method of medical treatment for control of massive acute gastric mucosal hemorrhage is described. The procedure was developed from the observation that gastric HCl played a central role in peretuating the syndrome. The treatment consists in neutralization of the gastric acid with antacid to pH of 7.0. In preliminary observations of consecutive admissions, 19 of 20 (95 per cent) patients treated with this techinique stopped bleeding. The one remaining patient required surgery. There were no deaths. In contrast, 10 of 15 (66 per cent) patients stopped bleeding with conventional medical therapy. Four of the remaining patients required surgery to control the bleeding. One patient did not stop on medical management. All five (33 per cent) patients died.

Use of levarterenol bitartrate in massive hemorrhage after retropubic prostatectomy

A case of massive hemorrhage following retropubic prostatectomy is presented. There was a dramatic decrease in bleeding with the use of levarterenol bitartrate in the irrigation solution. The implications of this finding are discussed.

Emergency subtotal colectomy: preferred approach to management of massively bleeding diverticular disease

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