George B. Eusterman

Gastro-Intestinal hemorrhage from otherwise symptomless lesions, with special reference to duodenal ulcer

H EMATENIESIS or melena, or both, are reliable evidence of gross hemorrhage from the upper portion of the gastro-intestinal tract, which may be due to a variety of causes. When such hemorrhage is associated with a history of upper abdominal pain or discomfort related to the digestive cycle and with other digestive disturbances, one logically assumes the presence of some type of intrinsic lesion of the stomach or duodenum until proved otherwise. Every now and then one sees patients whose sole complaint is the vomiting of blood and the passing of t a r ry stools, singly or repeatedly, and of varying degrees of severity. Such patients have never experienced pain, discomfort or indigestion. What are the circumstances that give rise to such a state of affairs, and to what extent do gastro-duodenal lesions, so-called silent, concealed or asymptomatic lesions, play a role?

Traumatic peptic ulcer

T HE factor of trauma in the genesis of acute and chronic peptic ulcer has been of interest for many years. In spite of extensive German and French writings, which embody numerous reports of cases, contributions to the subject in EngIish are strikingly few. However, some of the ear-her Continenta reports were written before roentgenoscopy came into use, and before duodena1 uIcer was a frequentIy observed entity, and many times the diagnosis of uIcer was based on symptoms alone, without confirmation by operation or necropsy. But contemporary authors of texts on diseases of the stomach writing in EngIish, such as Crohn, Hurst and Stewart, Rehfuss and others, have given consideration to the cIinica1 significance of traumatic peptic uIcer. A compIete review and appraisa1 of a11 materia1 printed up to five or six years ago has been made by von Redwitz and Fuss. The 1930 edition of Stern’s textbook aIso contains a comprehensive review of the German Iiterature. Von Redwitz and Fuss concIuded that undoubtedIy in rare instances, trauma may Iead to the origin and deveIopment of a chronic ulcer of the upper part of the digestive tract. By virtue of the exceIIent tendency to hea demonstrated after a freshIy sustained injury to the gastric mucosa, onIy under circumstances entireIy favorabIe to formation of uIcer can acute trauma resuIt in a chronic ulcer. Therefore, it must be assumed that other uIcer-forming factors are present; acute trauma reaIIy is probabIy more a precipitating than an unaided causative factor. It would be diffrcuIt to determine whether death of a circumscribed area of mucous membrane had resuIted from direct injury to the mucous membrane itself, or whether the necrosis had been caused indirectIy, by injury to bIood vesseIs and nerves. It appears more probabIe that chronic trauma has a definite inffuence on the chronicity of an uIcer, but it does not aIways suffice of itseIf to produce the picture of chronic peptic uIcer. From a cIinica1 standpoint it is obvious that trauma is not a factor in the origin of the majority of acute and chronic gastric and duodena1 uIcers, unIess the incidence and significance of miId degrees of trauma to patients predisposed to uIcer has been disregarded. Because there is no indubitabIe proof that an uIcer forms as the direct result of trauma, there are physicians who, without due deIiberation of a11 the ascertainabIe facts, deny the existence of a traumatic uIcer under any circumstance. Trauma, when it is said to be causative of uIcer, usuaIIy impIies externa1 bIunt force directed to the epigastrium, without direct penetration of the abdomina1 or viscera1 parietes, resuIting in variabIe degrees of injury to the gastric waI1. It is chiefIy in this sense that the subject wiI1 be considered; a case aIso wiI1 be reported. However, mechanical trauma to the stomach and duodenum may occur not onIy from without, in an acute or chronic fashion, but aIso from within in the same way. Aside from uIcers resuIting from external trauma, the other types of traumatic ulcer chiefly observed cIinicaIIy are those secondary to foreign bodies, and diaphragmatic hernia.