Summary
Four problems are discussed: — (1) The clinical diagnosis of the site of upper gastrointestinal
bleeding. Difficulties of differential diagnosis are pointed out. Radiological examination
without compression is considered justified, but its value is limited. Gastroscopy
is less helpful. — (2) Indications for conservative vs. surgical treatment. Large
statistics and own results comparing the two methods are presented and critically
analysed. The following conclusions are drawn: The first haemorrhage, even if massive,
should be treated conservatively, if bleeding stops after a short time; if the first
bleeding continues, the rate of blood loss (rapid loss — more than 500 cc blood replacement
required in 8 hours — argues for surgical intervention), the patient's age (over 50
is an indication for surgery), and the duration and severity of shock are the factors
determining the choice of treatment. — (3) Localisation of the bleeding spot at the
time of operation. This is often very difficult. If a gastric bleeding site is indicated,
gastrotomy of the distal part of the body of the stomach should be undertaken; wide
exposure may be necessary. The ulcer crater must be exposed. A two-thirds resection
by a Billroth II resection is the authors' procedure of choice. A special type of
gastric haemorrhage is the one of gastritic causation, for which — following Konjetzny's
original suggestion and practice — ⅔ resection is now widely employed. — A difficult
problem concerns the renewal or continuation of bleeding in the resection stump. In
2 of the authors' own cases bilateral vagotomy successfully stopped the previously
intractable bleeding. In the rare cases of severe bleeding from an hiatus hernia the
authors now perform a gastropexy. Three case reports are briefly given to describe
special situations (gastric haemorrhage after radical oesophagectomy for carcinoma;
bleeding from acute ulceration following extensive burns; haemorrhage from a benign
tumour). — For bleeding after gastric operations re-laparotomy is recommended, in
which a gastrotomy is made parallel to the previous anastomosis. The bleeding edges,
having been evaginated through the gastrotomy, are the re-sutured.
Resumen
La gran gastrorragia
A pesar de los grandes progresos realizados en la organización de la restitución sanguínea
y en la técnica quirúrgica de las operaciones gástricas y sus cuidados posteriores,
todavía no son en modo alguno satisfactorios los resultados obtenidos en el tratamiento
de las gastrorragias graves y peligrosas. La causa principal de ésto parece ser el
aumento considerable del número de pacientes ancianos con hemorragias, por motivo
del continuo ascenso del nivel de vida actual de la población. En ellos ha sido enjuiciada,
con gran reserva y sin justificación alguna, la cuestión de la hemostasia quirúrgica.
Determinar a su debido tiempo en esta clase de pacientes cuando debe intervenirse,
contribuiría esencialmente a mejorar los resultados estadísticos. Aparte se describen
y razonan las posibilidades para asegurar la exacta fuente de hemorragia y la técnica
quirúrgica más adecuada para su tratamiento.
