Upper gastrointestinal bleeding: a review

Despite recent diagnostic and therapeutic ad- vances, the mortality rate for upper gastrointestinal bleeding has remained at 10% for the past three Thomas A. Broughan, M.D decades.1 Two factors are probably responsible for David P. Vogt, M.D. this persistently high mortality rate. First, this pop- ulation is composed of a larger than average pro- Department of portion of elderly patients who have marked asso- ciated medical diseases. Second, advanced tech- niques in intensive care allow patients who are critically ill or have had multiple traumas to be supported for long periods of time; many of these patients subsequently develop upper gastrointes- tinal bleeding that may be fatal. Recent developments in the management of the patient with gastrointestinal bleeding include fiber- optic , cimetidine therapy, gastric pH monitoring, and radiographic arterial emboliza- tion. Their clinical application is being investi- gated. Although bleeding episodes are controlled in most cases with medical management, approxi- mately 15% to 20% of patients require surgery.1

Etiology The most frequently encountered causes of upper gastrointestinal bleeding are , acute gastric mucosal lesions, , and the Mallory-Weiss syndrome. Depending on

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Table 1. Comparison of causes of sure in the fourth ventriclc stimulates upper gastrointestinal bleeding in two the vagal nuclei with a resultant gastric series hypersecretion.5 The erosions resulting

Detroit Toronto from stress, burns (Curling's ulcer), and (Sugawa)2 (Halmagyi)"' ulcerogenic agents are in part caused by Etiology (%) (%) the destruction of the gastric mucosal Duodenal ulcer ii 41 barrier. Loss of this barrier allows back 2 Acute erosive 42 diffusion of hydrogen ions into the mu- Gastric ulcer 18 11 cosal cells, which in turn releases vaso- Mallorv-Weiss 15 6 active amines. The injuries caused by tear the hydrogen ions and vasoactive Esophageal 5 7 amines include mucosal congestion, varices hemorrhagic infarction, mucosal slough, Other 10 33 and finally bleeding. Although a patient may have docu- the patient population considered, pre- mented esophageal varices, in about cise order of frequency varies (Table 50% of patients, the bleeding episode /).2'3 Peptic ulcer disease is responsible may be from another lesion such as an for approximately 50% of the cases of ulcer or hemorrhagic gastritis. There- upper gastrointestinal bleeding in most fore, early investigation is mandatory series. Bleeding is directly responsible since treatment of these various lesions for 40% of all deaths encountered in the differs dramatically. The prognosis for 20% of patients who bleed as a result of patients with a variceal hemorrhage is peptic ulcer disease.4 Although duo- considerably worse than for patients denal ulcers are encountered more fre- with other lesions that may cause upper quently, gastric ulcers are more virulent gastrointestinal bleeding and may ap- because of their greater associated blood proach 50% mortality. The exact mech- loss and greater tendency for bleeding anism that precipitates variceal rupture to recur. and hemorrhage is not clear. No definite The term acute gastric mucosal lesions correlation has been found between the encompasses a wide range of disorders. degree of and the These include stress ulcers, Cushing's risk of subsequent bleeding. ulcer, Curling's ulcer, and erosive gas- The Mallory-Weiss syndrome has tritis. Although the exact pathophysiol- been recognized more frequently with ogy may vary among these disorders, the routine use of fiberoptic endoscopy the lesion that results is the same, mu- in studying patients with upper gas- cosal ulceration that does not penetrate trointestinal hemorrhage. Atkinson et the muscularis mucosa. The gross ap- al7 have described an increased trans- pearance of these lesions may vary from mural pressure gradient in the a single bleeding point to a diffuse hem- and that may occur with pro- orrhagic gastritis that involves the entire tracted vomiting or any other condition mucosal surface of the stomach. that markedly increases intra-abdomi- The pathophysiology is at least par- nal pressure. This increased pressure tially understood in some of these dis- gradient seems to focus on the area of orders. In Cushing's ulcer, associated the gastroesophageal junction and may with patients who have had neurologi- result in mucosal laceration in this re- cal trauma or surgery, increased pres- gion. Risk factors include alcohol or

Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. Summer 1982 Gastrointestinal bleeding 99 aspirin abuse, and the presence of a Table 3. Associated diseases in patients hiatal . An endoscopic study re- with upper gastrointestinal bleeding3 8 ported by Knauer observed that most Percent tears involved either the gastroesopha- Cardiovascular 31.5 geal junction or the proximal stomach. Liver 13.2 Skeletal 8.9 Clinical presentation Chest 8.0 Although a good history and physical Central nervous system 8.0 Renal 6.3 examination are mandatory in studying Psychiatric 6.0 the patient with upper gastrointestinal Multiple system failure 6.0 bleeding, they are of limited value in Malignancy 5.3 identifying the source of bleeding. Allan Hormonal 3.9 and Dykes found the history to be di- Pancreas 1.2 Septicemia 1.0 agnostically helpful in only 57% of cases. Blood dyscrasia 0.7 Twenty-five percent of patients with chronic dyspepsia do not have a bleed- ing peptic ulcer, and conversely, up to tients with critical associated medical one third of patients with a bleeding diseases are at higher risk and therefore peptic ulcer deny any previous symp- should be identified. Table 3 shows a toms.10 Although esophageal varices are series reported by Halmagyi in which the most likely source in a patient with 65% of patients had at least one associ- classic signs of chronic , ated disease and 50% had more than other lesions must be considered. A one. thorough oropharyngeal examination should be conducted to eliminate this Diagnosis area as a possible source of the bleeding. Fiberoptic endoscopy is the procedure Most patients present either with of choice in identifying the source of or ; several associ- bleeding in a patient with upper gas- ated symptoms and signs are shown in trointestinal hemorrhage. Sugawa et al2 Table 2. Another important reason to reported a 97% accuracy rate with emer- obtain a thorough history is that pa- gency endoscopy, compared to a 33% accuracy rate with emergency upper Table 2. Signs and symptoms of upper gastrointestinal fluoroscopy. It is impor- gastrointestinal bleeding tant to perform endoscopy early because its accuracy decreases from 90% to 33% Percent after 48 hours.9 Melena 87.0 Four early studies in the 1970s cast Hematemesis 61.6 Pain 57.2 doubt on the efficacy of emergency en- Dizziness 46.8 doscopy in decreasing morbidity and Tachycardia 28.2 mortality associated with upper gas- I Ieartburn 24.0 trointestinal bleeding.9,11-13 Although Vomiting 22.6 these studies had several errors in exper- Shock 17.9 imental design, no subsequent prospec- Anorexia 17.7 Fainting 13.5 tive, randomized study has yet clearly Weight loss 12.4 shown that emergency endoscopy as the Bloating 4.7 single variable decreases the morbidity Pyloric obstruction 3.0 and mortality of upper gastrointestinal

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bleeding. However, Griffiths et al14 iden- line, a central venous pressure line, a tified a subset of patients who did bene- Foley catheter, and perhaps a Swan- fit from early endoscopy. These patients Ganz catheter. A patient who has suf- all had a visible vessel in the base of the fered a major bleeding episode should ulcer associated with an 86% incidence be admitted to an intensive care area of bleeding recurrence, and a 14% inci- and initially resuscitated with crystal- dence of uncontrolled hemorrhage. All loid solutions. If indicated, whole blood of these patients required surgery. De- should be given after proper blood typ- spite the unproved benefit from early ing and crossmatching has been per- endoscopy, this aggressive attitude re- formed. In addition, fresh frozen plasma mains. An emergency upper gastrointes- should also be available for patients tinal barium study has many shortcom- with liver disease or for those who will ings. The barium may obstruct the view require several units of blood. Once in- of the endoscopist, and this study fails itial evaluation and resuscitation are un- to identify most of the superficial mu- derway, arrangements should be made cosal lesions. More importantly, barium for urgent endoscopy to delineate the in the may obscure source of bleeding. any subsequent attempts at emergency Passing either a large nasogastric tube diagnostic angiography. or an Ewald tube is helpful for many When a rapidly bleeding lesion makes reasons. Return of a bloody gastric as- accurate endoscopy impossible, angiog- pirate suggests that the bleeding point raphy is the procedure of choice. Exper- is proximal to the ligament of Treitz. imentally, a bleeding rate of at least More importantly, evacuation of clots 0.5-1.0 ml/min is necessary to demon- from the stomach facilitates endoscopy. strate a bleeding site radiographically. Thorough gastric lavage controls the In practice, however, a bleeding rate of hemorrhage in approximately two 3-4 ml/min is probably necessary. Un- thirds of cases. Although iced saline is der these circumstances, the bleeding the most frequently used irrigating so- vessel may be identified in 50% to 70% lution, Ponsky et al advocate the use of cases.15 In addition to its diagnostic of room-temperature solutions. If saline capabilities, angiography has useful lavage alone fails to control the hemor- therapeutic modalities. These include rhage, small amounts of norepinephrine the intra-arterial infusion of vasopressin may be added to the irrigating solution. and embolization of the bleeding vessel. Kiselow and Wagner17 reported a 54% success rate with this technique. Medical management The best prophylaxis for stress-in- A patient who presents with melena duced upper gastrointestinal hemor- or hematemesis must undergo immedi- rhage is yet to be determined. ate simultaneous evaluation and resus- and cimetidine, either alone or in com- citation. While the history is being ob- bination are the two most frequently tained and the physical examination used agents. The work of Priebe et al18 performed, appropriate blood samples and Hastings et al19 demonstrated the must be drawn, intravenous lines efficacy of therapy if the gastric started, and a nasogastric tube passed. pH was monitored hourly and main- Other monitoring modalities that may tained at 3.5 or above. Only one clinical be warranted include a mean arterial trial has generated data to suggest that

Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. Summer 1982 Gastrointestinal bleeding 101 antacids alone are more effective than esophageal varices. In 1973, Johnston cimetidine alone for bleeding prophy- and Rodgers 3 reported a 15-year expe- laxis.20 A further implication of this rience with this technique in which study was that their combined use was hemorrhage was controlled in 93% of additive. Therefore, in a patient who is 117 patients with a 12% mortality. More at risk for stress, upper gastrointestinal recently, the fiberoptic endoscope has bleeding should be treated with either been used for this same problem with of these agents alone or more preferably similar results. Endoscopic electrocoag- in combination. ulation and laser photocoagulation are The management of an acute variceal new techniques that seem to be prom- hemorrhage continues to be challeng- ising. In Gaisford's experience, electro- ing. After the stomach has been thor- coagulation was successful in controlling oughly lavaged and the diagnosis of hemorrhage in 92% of 71 patients.24 Of bleeding esophageal varices has been the six patients in whom bleeding re- confirmed by endoscopy, a Pitressin in- curred, only two did not respond to a travenous drip is usually begun. If this second application of this technique. does not control the hemorrhage, either Laser photocoagulation is currently a Sengstaken-Blakemore tube or a Min- being studied at this institution. nesota tube is passed into the stomach In recent years, new angiographic in an attempt to effect tamponade at techniques have been added to our ther- the bleeding site. Aspiration is less of a apeutic regimen for the treatment of problem with the latter tube because a upper gastrointestinal bleeding. These fourth lumen has been added to aspirate include intra-arterial infusion of vaso- any blood that may accumulate in the pressin and therapeutic embolization. esophagus. If inflation of the gastric bal- The former modality has been shown to loon does not control the bleeding, the be effective in controlling the bleeding esophageal balloon is inflated to a pres- from Mallory-Weiss tears and acute gas- sure of 35-40 mm Hg. If this controls tric mucosal lesions approximately 80% the bleeding, the esophageal component of the time. However, the intra-arterial is deflated after 24 hours, and if the infusion of vasopressin has been success- bleeding remains controlled, the gastric ful in controlling duodenal ulcer bleed- balloon is deflated after a subsequent 24 ing in only 40% of patients.25 The much hours. If the patient remains stable after lower success rate in this latter group this, the tube is removed. In Pitcher's reflects the difficulty in controlling;the series, in 92% of patients, bleeding bleeding from the gastroduodenal ar- stopped with the first tamponade, and tery. Intra-arterial embolization has a in 62% of those in whom bleeding re- reported success rate of 65% to 70% in sumed, it stopped with a second tam- the distribution of the gastroduodenal ponade.21 Balloon tamponade is no artery. Autologous blood clot, Gelfoa^n, longer indicated in the treatment of a polyvinyl alcohol, and the Gianturco Mallory-Weiss tear for fear of convert- coil are but a few of the agents used for ing a partial-thickness tear into a full- embolization. Athanasqylis25 recom- thickness perforation.22 mends infusing vasopressin into the left The endoscope is no longer simply a gastric^, artery to control acute gastric diagnostic tool. The rigid endoscope has mucosal lesions, and emb

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ing from a duodenal ulcer. Few compli- mortality rate for gastric resection was cations have been associated with these 20%, twice that for vagotomy and py- techniques. loroplasty. Also, rates of bleeding recur- rence for these two operations were not Surgical management dissimilar, ranging from 8% to 33% for Several authors, including Palmer,26 vagotomy and pyloroplasty, and 5% to and Himal et al,27 advocate aggressive 26% after gastric resection. Some au- management of upper gastrointestinal thors30' 31 have favored the removal of bleeding. This includes urgent endos- giant posterior, penetrating duodenal copy, and deciding early which patients ulcers because of a 30% bleeding re- are likely to continue bleeding or are at sumption rate after vagotomy and py- higher risk, and therefore should be con- loroplasty. sidered for prompt operative interven- It is more difficult to determine the tion. Factors favoring early surgery in- best operation for a bleeding gastric ul- clude hemodynamic instability after cer than for a bleeding duodenal ulcer. three units of blood, the loss of five to In the good-risk patient who has not six units of blood, a transfusion require- suffered a marked blood loss and is hem- ment of three units of blood per day, odynamically stable, removal of the ul- gastric ulcer, or bleeding after initial cer by a hemigastrectomy and vagot- stabilization.28 A further indication for omy is probably the best operation.10 aggressive management includes signifi- However, patients who are poor risks, or cant associated medical diseases. Using hemodynamically unstable, or have an this approach, Himal et al reported a ulcer high on the lesser curvature, are reduction in mortality rate from 12.5% not amenable to gastric resection with- to 6%. In contrast to bleeding ulcers, out a marked increase in operative mor- acute gastric mucosal lesions are gener- bidity and mortality. Therefore, wedge- ally treated conservatively. Relatively excision or oversewing of the bleeding few of these patients require an opera- point in the ulcer in addition to a va- tion to control bleeding. Unfortunately, gotomy and pyloroplasty is recom- in most series, the mortality rate for mended in this group of patients. In a emergency surgery still varies from 10% review by Sapala and Ponka, the re- to 50%, depending on the lesion treated, current ulcer rate after a gastric resec- age of the patient, and coexisting med- tion varied from 0% to 17%, and was 1% ical problems.2? to 15% after vagotomy and pyloro- 33 Truncal vagotomy, pyloroplasty, and plasty. Schiller's series confirms the oversewing the bleeding ulcer constitute higher mortality associated with resec- the most frequently performed opera- tion. He reported no mortality after a tion for a bleeding duodenal ulcer. An vagotomy and pyloroplasty, 10% after a alternative procedure is a truncal vagot- Billroth I resection, and almost 20% omy and antrectomy. However, in a after a more extensive resection. bleeding and unstable patient, the for- Acute gastric mucosal lesions vary mer procedure is much faster and asso- from a single bleeding ulcer to diffuse ciated with less morbidity and mortal- hemorrhagic gastritis, and the proper ity. These two procedures were com- operation must be tailored to each case. pared in terms of operative mortality, For instance, performing a vagotomy, morbidity, and the incidence of bleed- pyloroplasty, and oversewing the bleed- ing recurrence. The average operative ing point is appropriate for an isolated

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Table 4. Choices of operation for acute gastric mucosal lesions

Bleeding Mortality (%) Recurrence ('/Í)

Vagotomy and pyloroplasty''5 27 29 Hemigastrectomy with vagotomy35 35 45 Gastric devascularization'"' 38 9.5 Near-total gastrectomy34 100 0 erosion, whereas a nearly total gastrec- an emergency operation for bleeding tomy may be necessary to control the esophageal varices is performed only if hemorrhage from a diffusely eroded the patient continues to bleed despite stomach. Because of the high incidence maximal nonsurgical measures. of postoperative bleeding in these criti- In most instances, bleeding from a cally ill patients, some authors favor Mallory-Weiss tear can be controlled by more aggressive resections, despite the medical management. However, surgi- higher mortality rate.34 These workers cal intervention is occasionally neces- maintain that the higher operative mor- sary. In these instances, a large gas- tality is more acceptable than the risk trotomy is necessary to expose the distal of a second or third operation for bleed- esophagus and the gastroesophageal ing. A comparison of bleeding recur- junction. The bleeding point is suture rence and mortality rates for the various ligated and additional tears are sought. procedures is shown in Table 4. Also, the stomach is inspected for any Although intravenous vasopressin additional mucosal lesions, since they and balloon tamponade, either alone or have been reported in 80% of patients in combination, initially control acutely requiring an operation for a Mallory- bleeding esophageal varices in 85% of Weiss tear.8 patients, the remainder fail to be con- trolled with these modalities and require Summary emergency operation. Either a portosys- A review of the current management temic shunt or ligation procedure may of acute upper gastrointestinal hemor- be performed. A standard portacaval rhage raises many questions. For in- shunt or a mesocaval shunt are the two stance, prospective studies have not sup- most frequently performed diversion ported the hypothesis that early endos- procedures in the acute setting. A liga- copy lowers the mortality and morbidity tion procedure consists of oversewing associated with upper gastrointestinal the bleeding varices, interrupting the bleeding. Whether antacids or cimeti- column of varices in the distal esopha- dine should be used alone or in combi- gus either by hand suture or by the nation is under investigation. Finally, stapling device, devascularization of because acute gastric mucosal lesions both the greater and lesser curvatures of are so diversified, a' single operation of the stomach, and occasionally a splenec- choice cannot be proposed. Until these tomy. Although most patients survive issues are resolved, an aggressive atti- the operation, at least 50% die in 2-4 tude must be maintained. weeks, predominantly of . A patient with an acute' upper gas- This high operative mortality reflects trointestinal hemorrhage must have a the limited hepatic reserve of the cir- rapid and thorough simultaneous eval- rhotic liver in thèse patients. Moreover, uation and resuscitation. This includes

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assessing hemodynamic stability, re- 5. Norton L, Greer J, Eiseman B. Gastric secre- placing volume with crystalloid solution tory response to head injury. Arch Surg 1970; and blood, thoroughly lavaging the 101: 200-4. 6. Drapanas T, Woolverton WC, Reeder JW, stomach, and arranging early endos- Reed RL, Weichert RF. Experiences with copy. In many instances, the patient surgical management of acute gastric mucosal may require monitoring available only hemorrhage; a unified concept in the patho- in an intensive care unit. The gastric physiology. Ann Surg 1971; 173: 628-40. pH should be kept at ^4.0 with ant- 7. Atkinson M, Bottrill MB, Edwards AT, Mitchell WM, Peet BG, Williams RE. Mu- acids, and cimetidine may be given in- cosal tears of the oesophagogastric junction travenously. Variceal hemorrhage that (the Mallory-Weiss syndrome). Gut 1961; .2: does not cease spontaneously is first 1-11. treated by intravenous vasopressin. If 8. Knauer CM. Mallory-Weiss syndrome; char- the bleeding continues, a Sengstaken- acterization of 75 Mallory-Weiss lacerations in 528 patients with upper gastrointestinal Blakemore tube is inserted and the bal- hemorrhage. 1976; 71: 5-8. loons are inflated. An emergency oper- 9. Allan R, Dykes P. A comparison of routine ation, either a portosystemic shunt or and selective endoscopy in the management ligation procedure, is attempted only if of acute gastrointestinal hemorrhage. Gas- these measures fail. When endoscopy is trointest Endose 1974; 20: 154-5. 10. Cotton PB, Russell RC. Diseases of the ali- not diagnostic because of the rate of mentary system; haematemesis and melaena. bleeding or some other technical prob- Br Med J 1977; 1: 37-9. lem, angiography is helpful both from 11. Keller RT, Logan GM Jr. Comparison of a diagnostic and therapeutic stand- emergent endoscopy and upper gastrointes- point. Intra-arterial vasopressin and em- tinal series radiography in acute upper gas- bolization are valuable therapeutic mo- trointestinal hemorrhage. Gut 1976;17r 180- .- 4. dalities, especially in poor-risk patients. 12. Morris DW, Levine GM, Soloway RD, Miller . Early surgery should be advocated for WT, Marin GA. Prospective, randomized patients with lesions that are not likely study of diagnosis and outcome in acute up- to stop bleeding with medical manage- per-gastrointestinal bleeding; endoscopy ver- ment or who have significant associated sus conventional radiography. Am J Dig Dis 1975; 20: 1103-9. medical diseases. Finally, acute gastric 13. Sandlow LJ, Becker GH, Spellberg MA, et-al. mucosal lesions and Mallory-Weiss tears A prospective randomized study of the. man- should be treated conservatively. agement of upper gastrointestinal hemor- - rhage. Am J Gastroenterol 1974; 61: 282-9. 14. Griffiths WJ, Neumann DA, Welsh JD. The References visible vessel as an indicator of uncontrolled 1. Protell RL, Silverstein FE, Gilbert DA, Feld or recurrent gastrointestinal hemorrhage. N AD. Severe upper gastrointestinal bleeding. Engl J Med 1979; 300: 1411-3. Part I. Causes, pathogenesis and methods of 15. Butler ML, Johnson LF, Clark R. Diagnostic diagnosis. Clin Gastroenterol 1981; 10: 17-26. accuracy of fiberoptic panendoscopy and vis- 2. Sugawa C, Werner MH, Hayes DF, Lucas ceral angiography in acute upper gastrointes- CE, Walt AJ. Early endoscopy; a guide to tinal bleeding. Am J Gastroenterol 1976; 65: therapy for acute hemorrhage in the upper 501-11. gastrointestinal tract. Arch Surg 1973; 107: 16. Ponsky JL, Hoffman M, Swayngim DS. Sa- 133-7. line irrigation in gastric hemorrhage; the ef- 3. Halmagyi AF. A critical review of 425 patients fect of temperature. J Surg Res 1980; 28: 204- with upper gastrointestinal hemorrhage. Surg 5. Gynecol Obstet 1970; 130:419-30. 17. Kiselow MC, Wagner M. Intragastric instil- 4. Way LW. Stomach and . In: Dun- lation of levarterenol; a method for control of phy JE, Way LW, eds. Current Surgical Di- upper gastrointestinal tract hemorrhage. agnosis and Treatment. 5th ed. Los Altos: Arch Surg 1973; 107: 387-9. Lange Medical Publications, 1981: 409-44. 18. Priebe HJ, Skillman JJ, Bushnell LS, Long

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PC, Silen W. Antacid versus cimetidine in orrhage; a 23-year prospective study of 1400 preventing acute gastrointestinal bleeding; a patients. JAMA 1969; 207: 1477-80. randomized trial in 75 critically ill patients. 27. Himal HS, Perrault C, Mzabi R. Upper gas- N Engl J Med 1980; 302: 426-30. trointestinal hemorrhage; aggressive manage- 19. Hastings PR, Skillman JJ, Bushnell LS, Silen ment decreases mortality. Surgery 1978; 84: W. Antacid titration in the prevention of 448-54. acute gastrointestinal bleeding; a controlled, 28. Crook JN, Gray LW Jr, Nance FC, Cohn I randomized trial in 100 critically ill patients. Jr. Upper gastrointestinal bleeding. Ann Surg N Engl J Med 1978; 298: 1041-5. 1972; 175: 771-82. 20. Zinner MJ, Zuidema GD, Smith PL, Mignosa 29. Hines JR, Wilkholm L. The bleeding duo- M. The prevention of upper gastrointestinal denal ulcer. IMJ 1974; 146: 180-4. tract bleeding in patients in an intensive care 30. Silen W, Moore FD. Surgical treatment of unit. Surg Gynecol Obstet 1981; 153: 214-20. bleeding duodenal ulcer; a plea for caution. 21. Pitcher JL. Safety and effectiveness of the Ann Surg 1964; 160: 778-9. modified Sengstaken-Blakemore tube; a pro- 31. Snyder EN Jr, Stellar CA. Results from emer- spective study. Gastroenterology 1971; 61: gency surgery for massively bleeding duo- 291-8. denal ulcer. Am J Surg 1968; 116: 170-6. 22. Bubrick MP, Lundeen JW, Onstad GR, 32. Sapala JA, Ponka JL. Operative treatment of Hitchcock CR. Mallory-Weiss syndrome; benign gastric ulcers. Am J Surg 1974; 125: analysis of fifty-nine cases. Surgery 1980; 88: 19-28. 400-5. 33. Schiller KF, Truelove SC, Williams DG. Hae- 23. Johnston GW, Rodgers HW. A review of 15 matemesis and melaena, with special refer- year's experience in the use of sclerotherapy ence to factors influencing the outcome. Br in the control of acute haemorrhage from Med J 1970; 2: 7-14. oesophageal varices. Br J Surg 1973; 60: 797- 34. Hubert JP Jr, Kiernan PD, Welch JS, Re- 800. Mine WH, Beahrs OH. The surgical manage- 24. Gaisford WD. Endoscopic electrohemostasis ment of bleeding stress ulcers. Ann Surg 1980; of active upper gastrointestinal bleeding. Am 191: 672-9. J Surg 1979; 137: 47-53. 35. Bernuau J, Nouel O, Belghiti J, et al. Severe 25. Athanasoulis CA. Upper gastrointestinal upper gastrointestinal bleeding. Part III. bleeding of arteriocapillary origin. In: Athan- Guidelines for treatment. Clin Gastroenterol asoulis CA, Pfiester RC, Greene RE, et al, 1981; 10: 38-59. eds. Interventional Radiology. Philadelphia: 36. Richardson JD, Aust JB. Gastric devascular- WB Saunders, 1982, 55-89. ization; a useful salvage procedure for massive 26. Palmer ED. The vigorous diagnostic ap- hemorrhagic gastritis. Ann Surg 1977; 185: proach to upper-gastrointestinal tract hem- 649-55.

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