THE BLEEDING MARGINAL ULCER*

Transcription

1 DECEMBER, 1975 THE BLEEDING MARGINAL ULCER* ABSTRACT: CATHETERIZATION DIAGNOSIS AND THERAPY By ALFRED ROSENBAUM, M.D.,t STANLEY S. SIEGELMAN, M.D.4 and SEYMOUR SPRAYREGEN, M.D. Superior mesenteric arteriography can often demonstrate actively bleeding marginal ulcers. Five cases diagnosed by angiography are reported. Pitressin infusions of the superior mesenteric artery stopped bleeding permanently in two cases, transiently in two cases, and was not attempted in one case. Pitressin infusions of the superior mesenteric artery should be attempted before surgery is performed for bleeding marginal ulcers. T HE diagnosis and therapy of gastrointestinal bleeding by catheterization techniques have made great advances since their introduction in the beginning of the last decade. However, no previous studies have specifically focused on the evaluation and treatment of bleeding marginal ulcers. We have had experience with five cases in which angiography was successfully employed in visualizing the bleeding site in the jejunum. Pitressin infusion of the superior mesenteric artery was utilized in four cases, with permanent cessation of bleeding in two cases and with transient control of bleeding in two cases. MATERIAL AND METHOD The patients were studied by the standard Seldinger technique. The bleeding site in the proximal jejunum was identified via selective superior mesenteric artery injection. The catheter was left in place for pitressin infusion in four of the five patients. The rate of infusion initially was 0.2 units per minute and was increased to 0.4 units on one occasion. REPORT OF CASES CASE I. A 92 year old man was admitted to BRONX, NEW YORK Montefiore Hospital and Medical Center (MHMC) with melena and epigastric pain. His hematocrit was 13 percent. A partial gastrectomy with gastrojejunostomy had been performed for duodenal ulcer disease ten years prior to admission. The patient also had a history of myocardial infarction two years previously. Emergency angiography with a selective superior mesenteric injection revealed a bleeding site in the upper abdomen considered to represent a marginal ulcer (Fig. i). A pitressin infusion was started and bleeding stopped abruptly. Follow-up for two months revealed no evidence of subsequent bleeding. CASE u. This 55 year old white male with widespread metastatic disease from bladder carcinoma was admitted to MHMC with black, tarry stools for two days. He had had a partial gastrectomy and gastrojejunostomy 20 years earlier for duodenal ulcer disease. The hematocrit on admission was 24 percent. Nasogastric aspiration revealed bright red blood and coffee ground like material. Endoscopy showed active bleeding which appeared to be originating from the efferent loop and refluxing into the stomach. No definite ulcer niche was identified. A superior mesenteric arteriogram (Fig. 2, A and B) demonstrated a bleeding site in the upper abdomen in the region of the gastrojejunostomy with contrast * Presented at the Seventy-fifth Annual Meeting of the American Roentgen Ray Society, San Francisco, California, September 24-27, From the Department of Diagnostic Radiology, Montefiore Hospital and Medical Center, and Albert Einstein College of Medicine, Bronx, New York. t Assistant Clinical Professor of Radiology, Albert Einstein College of Medicine, Bronx, New York. Professor of Radiology, Johns Hopkins Medical 5chool, Baltimore, Maryland. Associate Professor of Radiology, Albert Einstein College of Medicine, Bronx, New York. 812

2 VOL. :25, No. 4 The Bleeding Marginal Ulcer 813 material extravasating into the jejunum and from the jejunum into the stomach. A pitressin infusion of the superior mesenteric artery was instituted. For twelve hours pitressin was infused at a rate of 0.2 units per minute. No significant change in the bleeding occurred and the pitressin infusion was increased to 0.4 units per minute with the infusion continued at this rate for an additional six hours. The bleeding stopped and the infusion was maintained at a rate of 0.1 units per minute for an additional twelve hours, after which the catheter was withdrawn. Standard oral medical therapy for peptic ulcer disease was continued. No further gastiointestinal bleeding occurred. During the bleeding episode the patient had received four units of packed red blood cells and one unit of fresh frozen plasma. The patient died one month after admission from his bladder carcinoma. Autopsy showed no evidence of an active mucosal ulceration at the gastrojejunostomy. Slight telangiectasia was noted at the efferent loop. CASE in. A 40 year old woman was admitted to MHMC for severe epigastric pain. A subtotal gastrectomy with gastrojejunostomy for carcinoid tumor of the stomach had been performed one year prior to admission. One week following admission the patient developed rectal bleeding with a fall in hematocrit from 37 percent to 19 percent. Emergency superior mesenteric angiography revealed a bleeding site in the proximal jejunum at the level of the );5B #{149} I1 -.,. FIG. I. Case I. Late venous phase of superior mesenteric arteriogram demonstrates extravasation of contrast material (arrow) in the upper abdomen representing a bleeding marginal ulcer. gastrojejunostomy. A pitressin infusion was started and the bleeding subsided. Twenty-four hours later, when the pitressin infusion was stopped, the patient started to bleed abruptly. The pitressin infusion was started again and the bleeding stopped. At this time the patient was operated upon because of her stable condition and the considered likelihood of rebleeding. A FIG. 2. Case II. (A) Mid arterial phase of superior mesenteric arteriogram shows contrast material extravasation in the left upper quadrant from a jejunal artery (arrow). (B) Late venous phase of superior mesenteric arteriogram shows several distinct areas of pooled contrast material in the stomach and jejunum.

3 814 A. Rosenbaum, S. S. Siegelman and S. Sprayregen DECEMBER, 1975 FIG. 3. Case iv. Mid arterial (A) and (B) late venous phase of an emergency superior mesenteric arteriogram demonstrate massive extravasation of contrast material in the region of the proximal jejunum (arrows in B). The introduction of emergency angiogramarginal ulcer was found at operation. CASE IV. A 62 year old man was admitted to MHMC for massive rectal bleeding. The patient underwent partial gastrectomy and gastrojejunostomy 14 months previously for duodenal ulcer disease. On the day of admission the hematocrit dropped from 33 percent to i6 percent. Emergency superior mesen teric an giography revealed contrast material extravasation in the proximal jejunum (Fig. 3, A and B). A pitressin infusion was started and the bleeding stopped transiently. Several hours later hemorrhage increased while the pitressin infusion was running. The pitressin dose was not increased above 0.2 units per minute. Operation revealed a bleeding marginal ulcer. The hematocrit at the time of surgery was 29 percent. CASE V. A 6 year old woman was admitted to MHMC for hematemesis. The patient had undergone a gastrojejunostomy for carcinoma of the head of the pancreas seven months prior to admission. The patient s hematocrit on admission was 28 percent. Emergency angiography with selective superior mesenteric injection demonstrated a bleeding site in the proximal jejunum. No attempt to stop the bleeding via pitressin infusion was made. The patient underwent surgery and a marginal ulcer was resected. DISCUSSION j phy for the diagnosis of acute gastrointestinal bleeding was first described by Baum and Nusbaum in 1963 and Subsequent articles 13,5,6,9,11,12 attest to the value of angiography in the diagnosis of lesions causing upper gastrointestinal bleeding, many of which could not be detected by barium studies nor at operation.3 6 Few cases of marginal ulcers diagnosed by angiography are to be found in the litera- In 1968 Nusbaum et al.9 described pitressin infusion into the superior mesenteric artery as a successful means of stopping variceal bleeding in the majority of patients. Following this, the use of vasoconstricting drugs (epinephrine and pitressin) was attempted in the management of additional causes of upper gastrointestinal bleeding #{176} 2 Good results were obtained in treatment of bleeding due to certain superficial lesions such as are found in gastritis and Mallory- Weiss syndrome. #{176} The treatment of peptic ulcer disease was, however, disappointing. R#{246}schand associates #{176} failed to achieve complete control of bleeding in eleven of thirteen cases. In the clinical experience with catheter directed drug treatment of upper gastrointestinal bleeding, the marginal ulcer has received little comment. To date, no study has focused on the angiographic diagnosis and catheter directed therapy of marginal

4 Vo&. 125, No. The Bleeding Marginal Ulcer 8i ulcers, which are characteristically located on the jejunal side of the anastomosis. To emphasize the importance of this lesion, one has to consider that the most common operation for peptic ulcer disease is gastrojejunostomy. Up to eight percent of these patients develop marginal ulcers, 5 6 and almost 50 percent of these ulcers produce gastrointestinal hemorrhage. 4 As already emphasized by R#{246}schand associates, #{176} the selectivity of the infusion is of great importance in determining success or failure of the therapy by vasoconstrictors. Marginal ulcers are particularly suited for such a direct infusion because of the ease of catheterization of the superior mesenteric artery which directly feeds the bleeding site. The favorable response of bleeding marginal ulcers to pitressin infusion as demonstrated in our series is also most likely related to the tendency of the ulcers to be superficial and, as such, to be amenable to induction of coagulation. Alfred Rosenbaum, M.D. Fifth Avenue New York, New York REFERENCES I. BAUM, S., and NUSBAUM, M. Control of gastrointestinal hemorrhage by selective mesenteric arterial infusion of vasopressin. Radiology, 1971, 98, BAUM, S., NUSBAUM, M., BLAKEMORE, W. A., and FIN KELSTEIN, A. K. Preoperative radiographic demonstration of intra-abdominal bleeding from undetermined sites by percutaneous selective celiac and superior mesenteric arteriography. Surgery, 1965, 58, 797-8o5. 3. BAUM, S., NUSBAUM, M., and TURNER, H. J. Control of gastrointestinal hemorrhage by selective mesenteric arterial infusions of pi tressin. Gastroenterolog,y, 1970,58,926-93,3. 4. BAUM, S., ROY, R., FINKELSTEIN, A. K., and BLAKEMORE, W. S. Clinical application of selective celiac and superior mesenteric arteriography. Radiology, 1965, 84, FREY, C. F., RENTER, S. R., and BOOKSTEIN, J. J. Localization of gastrointestinal hemorrhage by selective angiography. Surgery, 1970, 67, KOEHLER, P. R., and SALMON, R. B. Angio.. graphic localization of unknown acute gastrointestinal bleeding sites. Radiology, 1967, 89, NUSBAUM, M., and BAUM, S. Radiographic demonstration of unknown sites of gastrointestinal bleeding. S. Forum, 1963, 14, NUSBAUM, M., BAUM, S., BLAKEMORE, W. S., and FINKELSTEIN, A. K. Demonstration of intra-abdominal bleeding by selective arteriography: visualization of celiac and superior mesenteric arteries. 7.A.M.A., 1965, 191, NUSBAUM, M., BAUM, S., KURODA, K., and BLAKEMORE, W. S. Control of portal hypertension by selective mesenteric arterial drug infusion. A.M.A. Arch. Surg., 1968, 97, R#{246}SCH, J., DOTTER, C. T., and ANTONOVIC, R. Selective vasoconstrictor infusion in management of arterio-capillary gastrointestinal hemorrhage. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1972, 116, II. R#{246}SCH, J., DOTTER, C. T., and ROSE, R. W. Selective arterial infusions of vasoconstrictors in acute gastrointestinal bleeding. Radiotogy, 1971, 99, R#{246}SCH,J., GRAY, R. K., and GROLLMAN, J. W., JR. Selective arterial drug infusions in treatment of acute gastrointestinal bleeding. Gastroenterologv, 1970,59, VARGHA, J. Funktionelle Roentgenuntersuchungen der Anastomose bei Anastomosenkarzinomen. Radio!. Diagn. (Berlin), 1962, 7, WALTERS, W. Six to ten-year follow-up of surgical treatment of duodenal gastric and gastrojejunal ulcers. Gastroenterologia (Basel), 1960, 93, WALTERS, W., PRIESTLEY, J. T., and BALDING, H. H. Vagotomy in treatment of gastro- 3ej unal ulcerations: postoperative clinical and laboratory study. 7.A.M.A., 1952, 148, 8c3-8ii. i6. WEIR, J. F., and BENNET, H. S. Peptic ulcer: follow-up study after partial gastrectomy. Proc. Staff Meet. Mayo Clin., 1956, 3!,

5 This article has been cited by: 1. Sven-Ola Hietala, Gary G. Ghahremani, Arthur R. Crampton, Marianne Wirell Arteriographic evaluation of postsurgical stomach. Gastrointestinal Radiology 10:1, [CrossRef]