136 POSTGRADUATE MEDICAL JOURNAL March I954

It will be seen that three of the cases wereunder forty and two under forty-five. Except forone case, the length of history was measured inyears. Seven of the eight ulcer-cancers occurred inthe pyloric antrum, thus confirming that it is thechronic ulcer in this situation which is particularlyliable to undergo malignant change. Five of thepatients are dead, one was dying when last seenand two are still alive and well, but these wereoperated on within the last i8 months.From the present series, therefore, it may be

concluded that it is rare for a chronic gastriculcer to undergo malignant change, but that it does

occur there can be no doubt. The prognosis isextremely bad.

BIBLIOGRAPHYASKANAZY M. (1920), Rev. mdd. de la Suisse Romande, 40, 477.ASKANAZY, M. (1924), Virch. Arch., 250, 370.BOCKUS, H. L. (1946), 'Gastro-enterology,' Vol. I, p. 364.

Saunders.DIBLE, J. H. (i925), Brit. J. Surg., 12, 666.HURST, A. F., and STEWART, M. J. (I929), 'Gastric and

Duodenal Ulcer,' Oxford University Press.NEWCOMB, W. D. (1932-33), Brit. J. Surg., 20, 279.SWYNNERTON, B. F., and TANNER, N. C. (I953), Brit. med. J.,

ii, 841.WILSON, L. B., and McCARTHY, W. C. (I9I0), Amer. J. Med.

Sci., 138, 846.

THE ACUTE COMPLICATIONS OFPEPTIC ULCER AND THEIRSURGICAL TREATMENT

By A. G. R. LOWDON, O.B.E., F.R.C.S.E.From the Department of Surgery, University of Edinburgh

Perforation and haemorrhage, the acute com-plications of peptic ulcer, are of importance mainlybecause they may be the cause of death in a diseasewhich otherwise does not usually threaten the lifeof the patient; these complications are also ofspecial interest at the present time because theviews of physicians and surgeons about their treat-ment have recently changed and are, indeed, stillundetermined.

PerforationThe term ' perforation' is used to describe the

free perforation of a peptic ulcer into the peritonealcavity in distinction to the 'penetration' whichoccurs when an ulcer invades a neighbouring organsuch as the pancreas.

Perforation occurs most commonly in ulcers onthe anterior surfaces of duodenum or stomach, butoccasionally a posterior ulcer perforates freely intothe lesser sac. Perforation may also occur in agastrojejunal ulcer or in an ulcer related to Meckel'sdiverticulum, and an oesophageal peptic ulcer mayperforate into the pleural cavity. The simultaneousperforation of two ulcers has been reported.Most perforated ulcers are of a chronic type,

but the complication may occur in relatively acuteulcers which have been present for at most one ortwo weeks (Fig. I).

IncidenceBecause perforation of a peptic ulcer almost

invariably leads to admission to hospital and toaccurate diagnosis, studies of the frequency of thecomplication are comparatively reliable. In theIgth century perforation was an uncommon eventand the majority of cases occurred in young women(Brinton, I857), but a remarkable change of theincidence has occurred since the first decade ofthis century (Stewart and Winser, I942; Tidy,1945). Perforation is now relatively common andoccurs much more frequently in men--about 15men to one woman. It may occur at any age, butis rare before adolescence; it is most frequentbetween 30 and 45 years, but it is now not un-common in the aged. The perforation of an ulcerdoes not appear to be related in time to the eatingof food or to physical exertion. There is moredanger of the complication when the patient isphysically or mentally tired; the incidence ofperforation rises in the winter months, at the endof the working week and at the end of the workingday (Illingworth et al., I944; Jamieson, 1947).The Clinical Features of PerforationThe typical clinical picture of an acute perfora-

tion in a patient who gives a history of pepticulcer symptoms is easily recognized from the

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March 1954 LOWDON: Acute Complications of Peptic Ulcer and their Surgical Treatment 3

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FIG. i.-Photomicrographs of sections of two per-forated ulcers. (a) A chronic ulcer as shown byextensive subserous fibrosis and obliterative end-arteritis; there is in addition evidence of recentactivity in zones of necrosis and granulation.

(b) A relatively acute ulcer with absence of sub-serous fibrosis and obliterative endarteritis; underthe necrotic zone is a minimal granulation tissuereaction. (X 6)

history of sudden onset of agonizing pain and thefinding of a rigid and acutely tender abdomen.Sometimes, however, the escape of bowel contentis limited, as may occur when the stomach is nearlyempty, when the opening is small, or when thereis early spontaneous sealing of the opening byadhesions or even blocking of the hole by a largeparticle of food. The symptoms and signs maythen be less severe and there may be difficulty inestablishing the diagnosis. When minimal escapehas occurred the signs may be quite localized; thedescription of ' leaking ulcer' is often applied tothis type of case. If physical signs are relativelylocalized to the right upper quadrant of theabdomen there may be confusion with acute chole-cystitis. The soiling from a perforation in thepyloric region tends to track downwards over thetransverse colon and the omentum into the rightlower quadrant of the abdomen (Mitchell,.-I940),and the pain and tenderness may appear to bemaximal in the right iliac fossa, leading to con-fusion with appendicitis. Acute pancreatitis andcoronary thrombosis are other important sourcesof confusion.

In doubtful cases a detailed history is of greathelp, but the clinician must remember that be-tween io and 15 per cent. of perforations occur inpatients who have not had previous dyspepsia ofthe ulcer type. The patient usually lies supine andimmobile, afraid of movement, but there are ex-ceptions even to this traditionally characteristicfeature, because an occasional patient will throwhimself about in his agony or sit upright and refuseto lie down. One of the most helpful findings onexamination is the detection of free gas in theperitoneal cavity. The quantity of gas may be

small and the clinical sign of loss of liver dullnessis only rarely helpful, but even a small quantity ofgas can be demonstrated under the diaphragm byX-ray examination with the patient in the sittingposture, or in the right flank with the patient lyingon his left side. Radiological examination shouldbe made in any doubtful case; the finding of gasis almost conclusive, but the sign is absent in about20 per cent. (Olson and Norgore, 1946).Serum and urinary amylase estimations may

help in the diagnosis of acute pancreatitis, but itshould be remembered that in perforation someescape and absorption of pancreatic secretions mayoccur and lead to a moderate rise of these con-centrations. If coronary thrombosis is seriouslyconsidered, a delay of a few hours, after sedation,to observe progress and get an electrocardiogramcarries less risk than an ill-advised operation.The Treatment of Perforated UlcerFor more than 50 years it has been the estab-

lished practice to treat perforated peptic ulcer byoperative closure of the perforation. In this timethe only. important change of technique has beenthe abandonment of suprapubic drainage of thepelvis, which was formerly routinely employed inall but early cases.The immediate mortality of perforation when

treated by simple closure has fallen rapidly in thelast 10 years. Before 1940 an average mortality was20 per cent., but more recent reports have shownthat it is now possible to keep the death rate downto about 5 per cent. This improvement must beascribed to advances in anaesthesia, resuscitation,fluid and electrolyte control and chemotherapy.

In more recent years two alternative methods oftreatment have been advocated: conservative

El

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management based on measures designed to en-courage natural sealing of the opening, and moreradical operative treatment by partial gastrectomy.The technique of operative closure is well enoughknown to require no further description here andconsideration will be limited to presentation of theadvantages and disadvantages of these alternativemethods of treatment.

The conservative method was first advocated as aroutine measure by Bedford-Turner (I945). It isbased on the prevention of further peritoneal soil-ing by continuous aspiration of gastric contents fortwo or three days, initial sedation of the patientwith morphine, the administration of fluids paren-terally and chemotherapy. It is claimed by thosewho employ this method of treatment that theresulting mortality rate is at least no higher thanthat which follows routine operation. The ad-vantages are that the patient is not subjected tolaparotomy and can return to work, on the average,in less than half the time required for convalescenceafter operation (Heslop et al., I952). Perhaps themost obvious theoretical objection to this methodof management is the notorious difficulty of keep-ing the stomach empty by aspiration. It has beengiven a trial by many surgeons, but is recom-mended by few; even those who have supportedit emphasize the difficulties involved. It is notsuitable for any case of gastric perforation or whenperitoneal soiling is massive. It should not beemployed when there is doubt about the diagnosisor when the perforation is complicated by haemor-rhage. When it has been adopted at the outset inthe treatment of a case it should be abandoned infavour of operation if pain is not rapidly relievedor if gastric aspiration is ineffective as judged bythe quantities removed, by X-ray control of theposition of the tube in the stomach and by X-raycontrol of the extent of pneumoperitoneum. Itrequires the constant vigilant supervision of anexperienced clinician.On the whole, there can be little doubt that the

disadvantages of the conservative procedure heavilyoutweigh the advantages. The lesson to be learnedfrom its use is that gastric aspiration can discouragefurther peritoneal soiling and can promote spon-taneous sealing. Gastric suction may be life-savingin circumstances which make operative treatmentimpracticable, as in a snow-bound cottage or onboard a ship. It is to be hoped, too, that we shallsoon see the day when every general practitionerwill carry a small gastric tube and will use it toempty the stomach of any patient who perforatessoon after a meal or who will, because of distanceor other factors, take several hours to reach ahospital. In hospital conservative measures are tobe preferred only when it is confidently judged

that any small perforation has already sealed offspontaneously.

Partialgastrectomy in the treatment of perforatedulcer was first advocated by Yudin (I937) and isnow a routine procedure in many parts of thecontinent of Europe (Samain, i950; Nuboer,195I). Experience shows that it can be employedwith surprising safety provided the selection ofcases excludes the aged and patients with seriousconcomitant disease (Lowdon, 1952). Whetherits employment is justified is another questionwhich must be answered by consideration of thelate results after treatment by simple closure. It isknown that about 50 per cent. of patients will suffera severe recurrence of peptic ulcer symptomswithin five years of a perforation treated by closure(Illingworth et al., 1946; Gilmour, I953), and itmay be concluded that most, if not all, of thesepatients would benefit from the more radicaltreatment. The problem is to select the cases withbad prognosis.

Partial gastrectomy as a primary procedure inthe treatment of perforation has as yet had only alimited trial in this country, but it will probably beemployed more frequently when the indicationsare more clearly defined. At present it may beconcluded that it should be considered, if contra-indications are absent, in the following circum-stances: When the perforation is in a gastric ulcer(other than an evidently acute prepyloric ulcer);when the perforation is complicated by haemor-rhage; when there has been a previous perforation;when there is evidence of pyloric stenosis; orwhen the perforation culminates a long period ofulcer dyspepsia. It should not be consideredunless the surgeon and his team are experienced inthe operation of gastrectomy.

HaemorrhageIn considering haemorrhage from a peptic ulcer,

distinction must be made between occult bleedingand manifest bleeding in the form of haematemesisor frank melaena. Manifest bleedings, with whichwe are here concerned, have a wide range ofseverity. The loss of less than Ioo ml. of bloodfrom the ulcer may give rise to obvious blood inthe vomitus or to a black stool (Daniel and Egan,I939); in such a case there may be no apparentsystemic upset. At the other extreme are cases inwhich two o: three litres of blood are rapidly lostfrom a large vessel and the patient is profoundlyshocked and exsanguinated. Attempts have beenmade to classify the degrees of manifest haemor-rhage as slight, moderate and massive, but thecriteria are necessarily arbitrary and have led tomore confusion than clarification in the com-parison of results of treatment.

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March- I954 LOWDON: Acute Complications of Peptic Ulcer and-tieir Surgical Treatment39

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FIG. 2.-Photomicrograph of a section of a gastric ulcer removed at emergency partial gastrectomyfor massive haemorrhage. A large vessel opens on to the ulcer base where its natural closure isprevented by the surrounding chronic inflammatory tissue. (x 6)

Incidence and MortalityPublished reports of the incidence and mortality

of the complications are very variable, but Ivy et al.(195I) have levelled out some of these discrep-ancies by making a review of more than 23,000collected cases. They conclude that manifestbleeding occurs, sooner or later, in about 25 percent. of patients with peptic ulcer, and that about7.5 per cent. of bleeding ulcers have proved fatal.Men and women patients are equally liable to havea haemorrhage, but the risk of bleeding increaseswith age. Gastrojejunal ulcers are most liable tobleed, and gastric ulcers bleed more readily thanduodenal ulcers.

The Selection of Cases for Surgical TreatmentSince the pioneer work of Gordon-Taylor (I934,

1935) in this field it has been generally acceptedthat some patients with bleeding peptic ulcersshould be treated by emergency operation. Thecriteria by which these cases are to be selected arestill, however, ill-defined.The selection should be made by physician and

surgeon together, preferably under circumstanceswhich allow both to be in touch with the problem

from the time of the admission of the patient tohospital. Having excluded, as far as possible, allcases of gastroduodenal bleeding due to causesother than peptic ulcer, they must attempt toselect the patients in whom the risk to life undercontinued medical treatment is greater than therisk of immediate surgery. The factors involvedare so numerous and so difficult to assess that it isnot possible to define categorically the type of casethat should be treated by emergency operation.It will be profitable, however, to mention the mainfactors which must be considered.The prognosis under continued medical treat-

ment is affected adversely by the followingfeatures:Age over 50 years. This is an arbitrary dividing

line, but it is clear that the mortality rises withage, and bleeding is more likely to continue orrecur in older persons.

Continued or recurrent bleeding under treatment.This clinical feature is generally agreed to beassociated with poor prognosis if medical treatmentis continued and to be the most pressing indicationfor emergency surgery.

Gastric ulcer. The mortality from bleeding

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gastric ulcer is approximately double that ofbleeding duodenal ulcer. The site of the bleedingiAcer is not always known, but if there should beevidence that it is in the stomach the decision totreat by operation-should be the more readily made.

Massive bleeding or severe haemorrhagic shock.If the clinical evidence, more particularly thegeneral condition of the patient, shows that theblood loss is both large and rapid, it is probablethat the bleeding is from a relatively large vessel.Under these circumstances, emergency surgeryshould be the more readily and the more promptlyundertaken. It must be appreciated that some ofthe more massive haemorrhages occur from ter-minal or lateral openings in large arteries which areunlikely to stop bleeding by natural means (Fig. 2).

It is to be noted that a second or subsequenthaemorrhage is not any more dangerous than afirst episode of bleeding, provided that the patienthas recovered from the previous blood loss. Itis sometimes said that the persistence of pain afterbleeding heralds a bad prognosis, but the writerhas been unable to confirm this in a survey of 355cases.The risks of operation which have to be put

against these considerations are equally difficult toassess. Severe haemorrhagic shock will never byitself be a contraindication to operation, becauseit can be combated by rapid and adequate bloodtransfusion-if need be, after arrest of the activebleeding on the operating table. On the otherhand, if the state of anaemia, dehydration andunder-nutrition which commonly follows a severehaemorrhage is allowed to persist for more than24 to 48 hours, the patient becomes a poor surgicalrisk. This is a fundamental observation, supportedby experience as well as theory, and leads us topractical conclusions:

In any case of continued bleeding, if surgicalintervention is to carry a reasonable hope ofsuccess, it should be decided on early and carriedout promptly. If the patient has been' too low fortoo long,' operation may seal his fate rather thanimprove his chances of recovery. If a recurrence ofbleeding after an interval is to be accepted as anindication for emergency surgical measures, it ismost desirable that the patient should not havespent the intervening days in a depleted state. Ifsurgical intervention is to remain a practical possi-bility, the conservative treatment should includeprompt and liberal transfusion of blood.The patient's age and general physical condition,

including any associated but unrelated disease,must also be considered. It cannot be too stronglyemphasized, however, that the object is not toselect for surgery a series of good risk patients.The results of surgical treatment cannot be judgedby operative mortality: 15 deaths in 20 operations

may represent five lives saved if all 20 would havedied without surgery.On the basis of such considerations, each case

may be judged on its own merits, some acceptedfor emergency surgery at the time of admission,others treated conservatively at first, and broughtto operation only if bleeding continues or recurs.It is, however, desirable for any hospital to have a-'policy' even if only to guide the junior medicaland nursing staff, so that developments which maycall for immediate surgical intervention are notoverlooked until the next ward round. The policyadopted must depend on local circumstances andindividual views, but examples may be quoted.Tanner and Desmond (1950) have published a

valuable report of the results of different methodsof dealing with the problem. They found that theiroverall mortality was lowest (7 per cent.) when thedictates of Finsterer (I947) were followed, i.e.immediate operation for all patients with massivehaemorrhage and a known chronic ulcer, and lateroperation on the others if bleeding recurs or per-sists. In this period, however, they found that 60per cent. of all patients admitted with manifestbleeding were treated by operation; this repre-sents a surgical undertaking which will not befound practicable in many hospitals. The policyadopted by Ogilvie et al. (I952) is more generallyapplicable; they report a series of 358 cases ofbleeding in which the decision to operate was madeif at the end of 24 hours of hospital treatmentbleeding was continuing, or if bleeding, havingonce stopped, started again. On these indicationsoperation was carried out in io per cent. of theircases and the overall mortality was 5 per cent.

It is worthy of note that both these series arereported with quotation of the overall mortalityonly: the results of the groups treated by surgeryare not given. Both papers give the proportion ofpatients over 60 years of age in the series, becausethis is a measurable factor which is bound toinfluence the results. In Tanner's series 42 percent. and in the Newcastle series 30 per cent. wereover 60 years of age.The Surgical Management of Bleeding UlcerWhen a decision to treat the patient by emer-

gency operation has been made there should be aslittle delay as possible. Immediately before opera-tion, and preferably in the anteroom of the theatre,blood transfusion is speeded up so that the patientcomes to operation in the best possible condition.Rarely the failure to respond even to rapid trans-fusion shows that bleeding is continuing so activelythat laparotomy to arrest the haemorrhage isneeded before resuscitation can be effective.

Anaesthesia may be local or general; in eithercase a small stomach tube should be passed and all

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precautions taken against the risk of furthervomiting.The laparotomy incision must give good ex-

posure. Examination of the organs will usuallygive ready confirmation of the presence of a chronicpeptic ulcer and the absence of other causes ofgastroduodenal bleeding, but in a disturbinglylarge minority of cases the source of the bleedingmay be difficult to find. If there is no obviouslesion in stomach or first part of duodenum, thegastrocolic ligament should be opened to permitcareful examination of the posterior aspects. Ifthe lesion is still not apparent, the surgeon mustconsider two probable sources of difficulty: arelatively acute gastric ulcer or multiple gastricerosions may elude the most careful examinationof the outside of the stomach, or a duodenal ulcermay be located unusually far from the pylorus,even in the pre-ampullary region. If exhaustivesearch reveals no evidence of the causative lesion,and if the patient's condition is reasonably good,it is best to proceed with the operation of partialgastrectomy and to ensure by palpation of theinside of the duodenum after its division, and pal-pation and inspection of the inside of the gastricremnant, that no obvious source of bleedingremains.Some surgeons advise that when the lesion is

not apparent a gastroduodenotomy should be madeto allow palpation and inspection of the mucosalsurfaces; this procedure is sometimes successful,but on the whole its value is open to doubt.

If the ulcer is identified, it is desirable, ifpossible, to perform a partial gastrectomy, in-cluding resection of the ulcer. When the generalcondition of the patient and the absence of bloodin the duodenum and upper jejunum give reasonto believe that there is no active bleeding, thesurgeon may follow his usual technique in per-forming the resection. Occasionally, when there isevidence that bleeding is active, a direct attack onthe ulcer first by digital pressure and then byappropriate suture ligatures is required. If theulcer has penetrated into the pancreas, the basemust be left; if the bleeding point is not apparentin the edge which has been removed, the ulcerbed must then be underrun with silk sutures. Thefeeding vessels also should, as far as possible, be

ligated and the ulcer bed left outside the recon-stituted bowel.

In the case of a bleeding gastric ulcer the surgeonmay adopt some less radical procedure, such aslocal resection of the ulcer or gastrotomy and theplacing of silk sutures through the ulcer bed.Duodenotomy and suture ligature of a duodenalulcer is less satisfactory; it may be just as difficultto close a duodenum in continuity as to close aduodenal stump and a gastro-enterostomy isusually required. It must be appreciated that thereis considerable risk of recurrence of bleeding whenan ulcer has been left in situ; the silk suturesthrough the ulcer bed cut out readily and may evenbe the cause of later bleeding from another vessel.The less radical procedures may, however, bejustified when the patient is old and feeble orwhen the operator is not experienced in gastricsurgery.Few problems in emergency surgery are more

challenging than that of the operative treatmentof bleeding ulcer. The good management of thesecases calls for judgment, courage and skill fromsurgeon, anaesthetist, assistants and nurses alike.

BIBLIOGRAPHYBEDFORD-TURNER, E. W. (I945), Brit. med. J., i, 457.BRINTON, W. (I857), ' Ulcer of the Stomach,' Churchill, London.DANIEL, W. A. (JUN.), and EGAN, S. (I939), J. Amer. med. Ass.,

113, 2232.FINSTERER, H, (I947), Wien. med. Wschr., i, 3.GILMOUR, J. (I953), Lancet, i, 870.GORDON-TAYLOR, G. (I934), Proc. R. Soc. Med., 27, 1524.GORDON-TAYLOR, G. (I935), Lancet, ii (CCXXIX), 8II.HESLOP, T. S., BULLOUGH, A. S., and BRUN, C. (1952),

Brit. J. Surg., 40, 52.ILLINGWORTH, C. F. W., SCOTT, L. D. W., and JAMIESON,

R. A. (I944), Brit. med. J., ii, 617, 655.ILLINGWORTH C. F. W., SCOTT, L. D. W., and JAMIESON,

R.A. (1946), Ibid., i, 787.IVY, A. C., GROSSMAN, M. I., and BACHRACH, W. H. (i95i),

'Peptic Ulcer,' Churchill, London.JAMIESON, R. A. (1947), Brit. med. J., ii, 289.LOWDON, A. G. R. (1952), Lancet, i, 1270.MITCHELL, G. A. G. (1940), Brit. J. Surg., 28, 291.NUBOER, J. F. (I95I), Lancet, ii, 952.OGILVIE, A. G., CARDOE, N., and BENTLEY, F. H. (1952),

Brit. med. J., ii, 304.OLSON, H. B., and NORGORE, M. (I946), Ann. Surg., 124, 479.SAMAIN, A. (I950), Acta gastro-ent. belg., 13, o00.STEWART, D. N., and WINSER, D. M. (I942), Lancet, i, 259.TANNER, N. C., and DESMOND, A. M. (I950), POSTGRADUATE

MEDICAL JOURNAL, 26, 253.TIDY, H. (x945), Brit. -med. J., i, 319.YUDIN, S. (1937), Surg. Gynec. Obstet., 64, 63.

Copies of Title Page and Index for Vol. 29 of The Postgraduate MedicalJournal are now available on request. See page 173 for binding particulars.

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