Symptoms and signs in the prognosis of massively bleeding gastroduodenal ulcer

Abstract

Approximately 50 per cent of all patients with massive gastroduodenal ulcer hemorrhage bled from one to seven days before admission to the hospital. The others had bled repeatedly for periods of weeks or years. Those with a duodenal ulcer sought admission sooner than those with a gastric ulcer. There seemed to be no critical period in the duration of hemorrhage in our patients affecting mortality rates. Pain occurred at some period in the history of over 80 per cent of the patients bleeding massively, slightly more often in patients with gastric ulcers than in those with duodenal ulcers. The pain localized most often in the epigastrium. Radiation to the back was more frequent with gastric ulcers. Over one-third of the patients described a time sequence to the pain, and had a lower mortality rate than those who did not. The pain was improved in over 45 per cent of the patients; most effectively by alkalies, then by food in general, and then by milk. Relief of pain was experienced more often in patients with gastric bleeding; the mortality rates were significantly lower than in those with bleeding whose pain was unrelieved by such measures. Hematemesis occurred in over two-thirds of the patients. Repeated emesis was seen in three-fourths of those patients and was associated with increased mortality rate as compared to a single emesis. The vomitus most often was described as “coffee grounds,” then as “red blood,” then as “tarry blood,” and least often as “blood clots.” There was no substantial difference as to the color or character of the blood from a gastric or duodenal ulcer. Melena occurred in approximately 83 per cent ot the patients, just as frequently with gastric as with duodenal ulcer. The prognosis was the same with melena as with hematemesis. An antecedent ulcer history or complication was established in 58.0 per cent of patients with gastric ulcers, and 70.7 per cent ot those with bleeding duodenal ulcers; more than 50 per cent of these patients had these complaints over a period of one or more years, the actual length of time ran longer in patients with duodenal ulcer, but had little effect upon the mortality rate of either group. The mortality rate for patients with a positive ulcer history was significantly less than the 42.0 per cent of gastric and 29.3 per cent of those with bleeding duodenal ulcers who did not have a past history of ulcer. Intractable pain was the most frequent specific ulcer complication, followed by previous hemorrhage, previous ulcer operation, previous perforation, and previous obstruction; all of these complications occurred more frequently in patients with duodenal ulcers. Clinical symptoms of shock were noted in two-thirds of patients with bleeding gastric ulcers and in three-fourths of those with bleeding duodenal ulcers. Weakness was the most frequently noted of these symptoms, followed by fainting, collapse, sweating, chills and pallor. Shock alone did not adversely affect the mortality rate. Approximately one-third of the patients with hemorrhage from gastric ulcer had systolic blood pressures below 80 mm. Hg, as did approximately one-fourth of patients with hemorrhage from duodenal ulcer. Patients with gastric ulcers with systolic shock levels always had higher mortality rates than patients with duodenal ulcers at the same systolic pressures. The incidence of hypertensive systolic pressures was the same in those with gastric and duodenal ulcers, 6.9 per cent. This is considerably below the hospital incidence of hypertension and the anatomic evidence of cardiac hypertrophy in necropsies of patients with peptic ulcer hemorrhage. In this series, the mortality rate of patients with bleeding gastric ulcers with hypertension was 45.3 per cent and in those with bleeding duodenal ulcers with hypertension it was 22.3 per cent. The admitting temperature was a sensitive index of prognosis. Patients with subnormal temperatures and those with a fever in excess of 100 °F. had significantly higher mortality rates. A pulse rate in excess of 100 beats per minute was often noted and the effect upon the mortality rate varied directly as the degree of rise in pulse. Tachypnea indicated a grave prognosis in patients with gastroduodenal hemorrhage. The nutritional status of the patient was also a reliable prognostic sign. Patients who were well nourished, but not obese, had a better than average prognosis; this was seen more often in patients with duodenal ulcers than in those with gastric ulcers. Thinness, emaciation, and dehydration was seen more often in patients with gastric ulcers; in this group, the mortality rate was higher. Physical signs portending a grave prognosis were: distended abdomen, poor oral hygiene, rales, emphysema, cardiac enlargement and hepatomegaly. Abdominal tenderness, most often epigastric, was present in approximately 50 per cent of the series of patients and was without discernible influence upon the mortality rate.