Clinical Diagnosis in Gastrointestinal Hemorrhage

A Planned Investigation Including Arteriographic Studies of the Human Stomach
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      A personal study of 250 cases of hematemesis or melena, planned to assess the value of symptoms and signs for determining the causal lesion, is reported. A comparison of gastric and duodenal ulcer shows that the following features were significantly more common (P < 0.05) with either one or the other.
      Gastric ulcer. (1) Pain or discomfort occuring within 1/2 hour of eating; (2) anorexia; (3) empty feeling between meals; (4) vomitus containing blood clots; and (5) chronic bronchitis.
      Duodenal ulcer. (1) Nocturnal pain or discomfort; (2) periodic pain or discomfort; (3) pain or discomfort confined to the right upper abdominal quadrant; (4) copious vomitus; (5) vomitus resembling coffee grounds; and (6) tenderness confined to the right upper abdominal quadrant.
      These findings were employed in an attempt to diagnose the cause of the hemorrhage in a further 100 cases at the time of their admission. The majority of the patients with duodenal ulcer gave a typical history whereby this lesion could be diagnosed with considerable assurance.
      The findings of the present series are compared with those of other studies.
      In contrast to series of gastric ulcer that include other modes of presentation besides hemorrhage, few of my ulcers were found in the antrum and a relatively high proportion lay in the upper third of the stomach. Arteriographic studies of the normal stomach made in this connection showed that in both the seromuscular and the submucosal layers the arteries that are large enough to cause really severe hemorrhage are mostly confined to the upper two-thirds of the stomach. Those of the submucosa are further limited to a band on either side of the lesser curvature and the greater curvature with its adjoining walls. These circumscribed areas are therefore the only likely source of severe hemorrhage from a shallow ulcer, and, what is more, all the acute lesions of the present series that caused such hemorrhage lay within a few centimeters of the upper two-thirds of the lesser curvature—most of them being on the adjoining part of the posterior wall.
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