Timothy Noel Mills

NATURE OF THE BLEEDING VESSEL IN RECURRENTLY BLEEDING GASTRIC-ULCERS

An unselected consecutive series of 826 patients admitted for acute upper gastrointestinal bleeding underwent urgent endoscopy. Peptic ulcers were found in 402 (49%). Of the 329 ulcer craters that could be fully examined, visible vessels were identified in 156 (47%), other stigmata of recent hemorrhage in 66, and no stigmata of recent hemorrhage in 107. One hundred twenty-nine patients with stigmata of recent hemorrhage (93 of whom had visible vessels) randomly allocated to no endoscopic treatment were observed for evidence of further bleeding. Fifty-four of the 93 patients (58%) with visible vessels rebled, compared with 2 of 36 (6%) with other stigmata of recent hemorrhage. No patient without stigmata of recent hemorrhage rebled. Twenty-seven patients in whom a visible vessel in a gastric ulcer was identified at endoscopy underwent urgent partial gastrectomy because of recurrent bleeding. The vessel identified at endoscopy was found in 26 of 27 resection specimens (96%). The arterial vessel wall protruded above the surface of the ulcer crater in 10 specimens, and clot in continuity with a breach in the vessel wall protruded in a further 10 specimens. Postoperative angiography, when technically possible, showed that the breached artery ran across the base of the ulcer in all of these specimens. Pathological changes were common in the bleeding artery and included arteritis in 24 of 29 (83%) eroded arteries found in these specimens, with aneurysmal dilatation in 14 of 27 (52%) bleeding points that could be fully examined. The ulcer had penetrated to serosa in 13 specimens (45%). The bleeding artery had a mean external diameter of 0.7 mm with a range of 0.1-1.8 mm. This study provides new information about the nature of the bleeding vessel in gastric ulcers, and some of this information is relevant in planning studies of endoscopic therapy for bleeding peptic ulcers. It validates the endoscopic identification of a visible vessel, and confirms that such identification has a high predictive value for the development of recurrent hemorrhage.

An endoscopic stapling device: the development of a new flexible endoscopically controlled device for placing multiple transmural staples in gastrointestinal tissue.

Figure 2. The mechanism of the endoscopic stapling device. A, A fold of tissue is sucked into the cavity of the stapler. B, The tissue is compressed to an optimal thickness prior to stapling. C, The staple rammers force the staples through the tissue onto shaped anvils that bend the staples into a B configuration. 0, A spring opens the cavity to allow the stapled tissue to slide out of the stapling device. Note: This diagram has been simplified to show the closure of only two staples. In the device, the staples were arranged in an overlapping double layer forming a semicircle 1 mm from the outer circumference of the stapler. Received October 14, 1988. Accepted December 24, 1988. From the Departments of Medical Physics and Bioengineering, University College Hospital, and Gastroenterology, The London Hospital, London, England. Reprint requests: C. Paul Swain, MD, Department of Medical Physics and Bioengineering, University College Hospital, Shropshire House, 11-20 Capper Street, London WC1E 6JA, England. DESCRIPTION OF THE STAPLER AND ITS MECHANISM