Upper gastrointestinal bleeding among Saudis: Etiology and prevalence the Riyadh Central Hospital experience

Fiberoptic esophagastroduodenoscopic examination of 747 Saudi patients who presented with acute upper gastrointestinal (UGI) bleeding between January 184G to December 1986G showed that ruptured esophageal varices, erosive gastritis, duodenitis and peptic ulcer disease were the most common findings. There were 515 males and 232 females (M:F 2.2:1). Multiple lesions were detected in 83% of patients, emphasizing the need to anticipate more than one lesion at endoscopy in a patient with UGI bleeding. Sixty-seven patients (8.9%) gave a history of drug ingestion prior to the episode of bleeding; gastric and duodenal erosions were the most common lesions in these patients. No source of bleeding was apparent in 26 (3.5%) patients at the time of endoscopy. Endoscopy rather than barium studies has become established as the standard investigation in our patients with upper gastrointestinal bleeding.

Selective visceral angiography for unexplained acute gastrointestinal bleeding in a district general hospital

Eleven patients are reported with unexplained gastrointestinal haemorrhage (GIH) presenting over a 2 year period in whom selective visceral angiography (SV A) was carried out after a negative endoscopy. SV A revealed the anatomical source of bleeding in all eleven patients and the aetiology in six of them. The latter comprised two tumours of the small bowel, an A-V malformation of the jejunum, enlarged pancreaticoduodenal vessels, angiodysplasia of the caecum and carcinoma of the rectum. Of the remaining five patients, four were seen to have active bleeding into the large bowel and one into the duodenum. Local surgical resection was carried out in nine patients, only one of whom rebled. There was one preoperative and one postoperative death. Experience with this technique has altered our management such that SV A is carried out sooner, saving the patient repeated admissions, investigations and transfusions. SV A is recommended as a pre-operative investigation for the surgeon managing acute unexplained GIH.

Factors identifying the probability of further haemorrhage after acute upper gastrointestinal haemorrhage

Ninety-five (24 per cent) of 389 admissions with acute upper gastrointestinal haemorrhage had further haemorrhage. An analysis of factors leading to further haemorrhage was undertaken by considering patients' clinical history, physical state on admission and endoscopic findings. The risk of further haemorrhage was significantly greater in patients bleeding from oesophageal varices or peptic ulcer and in those patients who were sober, shocked or anaemic on admission. Overall, those over 60 years of age were more likely to rebleed, but this difference was not apparent in relation to endoscopic source of blood loss.

Surgical treatment in asymptomatic patients with duodenal ulcers as a prophylaxis against haemorrhage

In a group of 17 patients who underwent surgery for chronic duodenal ulceration because of past bleeding but without current symptoms, one patient re-bled with a follow-up of 81 patient years, as compared to one bleed over 6.8 patient years before surgery. This suggests that surgery is protecting these patients against recurrent episodes of haemorrhage.

Randomised trial of endoscopic argon laser photocoagulation in bleeding peptic ulcers

Emergency endoscopy on 332 patients with acute upper gastrointestinal bleeding showed that 178 had peptic ulcers; 28 of these were actively bleeding (spurting) and 108 showed stigmata of recent haemorrhage (vessels or spots in the ulcer base) suggesting a risk of rebleeding. These 136 patients were randomly allocated to Argon laser photocoagulation or to no additional therapy (controls) at the time of initial endoscopy. All patients received conventional management, and the controlling clinicians did not know whether or not the laser had been used in any individual patients. The laser system proved both simple and safe in use. Initial haemostasis was achieved by the laser in 10 of 15 'spurting vessels', but four of 13 'control' spurting vessels also stopped bleeding spontaneously. Overall, there were no statistically significant differences between the laser treated and control groups in terms of rebleeding, the need for surgical intervention, or death. These results require amplification in larger trials, and comparison with other studies using different protocols and other haemostatic methods.