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Progress in the treatment of acute gastroduodenal mucosal lesions (AGML)

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Abstract

This article presents an analysis of acute gastroduodenal mucosal lesions (AGML) based on a review of current literature and the personal experience of the authors. The pathology of AGML involves two distinct types of lesions, namely, superficial erosions confined to the acid-secreting gastric mucosa and presenting as erosive hemorrhagic gastritis, and acute ulcers that occur in the alkaline gastric mucosa and duodenum. The etiology of these two lesions is very likely different. Acute gastroduodenal ulcers, best known as stress ulcers, are probably “peptic” lesions, whereas erosive hemorrhagic gastritis appears to be due to pathologic back diffusion of hydrogen ions caused by a breakdown of the gastric mucosal barrier as a result of endogenous factors, such as gastric mucosal ischemia, and sometimes exogenous factors, such as alcohol, urea, and acetylsalicylic acid. Catecholamine hypersecretion resulting from severe stress, such as occurs in hypovolemia, sepsis, and hypercapnea, contributes to ischemia of the gastric mucosa by producing splanchnic vasoconstriction. The key to the diagnosis of AGML is early endoscopy in all cases of upper gastrointestinal bleeding. Therapy for AGML should begin with a trial of medical measures directed at restoring effective perfusion of tissues and removing hydrogen ions from the stomach by gastric washing. Medical therapy is effective in 80% of patients with erosive hemorrhagic gastritis, but surgical treatment is usually required in acute gastroduodenal ulcer. When surgery is necessary for either type of lesion, vagotomy with hemigastrectomy appears to be the most effective operation. The personal experience of the authors has involved 36 patients with AGML who were treated in three periods between 1968 and 1976. The mortality rate of patients with AGML has been reduced from 50% in the first 2 years to zero in the last 2 years by the use of emergency endoscopy for diagnosis, appropriate medical therapy, properly timed and executed surgery, and, most recently, selective angiography.

Résumé

Cet article présente une étude sur les lésions aigus de la muqueuse gastro-duodédenale (AGML), étude basée sur une revue de la littérature récente et sur l'expérience personnelle de l'auteur. Les lésions pathologiques de l'AGML sont de deux types: 1) des érosions superficielles limitées à cette portion de la muqueuse gastrique qui sécrète l'HCL, et qui se pre'sentent comme une gastrite érosive hémorragique; 2) les ulcères aigüs qui surviennent sur la portion alkaline de la muqueuse gastrique et dans le duodénum. L'étiologie de ces lésions est probablement différente. Les ulcères gastro-duodénaux aigüs, mieux connus sous le mon d'ulcère de stress, sont vraisemblablement des lésions “peptiques”, tandis que la gastrite érosive hémorrhagique semble reliée à la diffusion rétrograde anormale des ions hydrogènes; cette diffusion rétrograde est causée par la perte de la fonction protectrice de la muqueuse gastrique reliée soit à des facteurs endogènes, telle l'ischémie de la muqueuse gastrique, soit à des facteurs exogénes, tels l'alcool, l'urée et l'acide acetyl-salicylique. L'hypersécrétion des catécholamines associée aux états de stress grave, tels l'hypovolémie, les états infectieux et l'hypercapnée, contribue a l'ischémie de la muqueuse gastrique en produisant une vasoconstriction des vaisseaux splanchniques. La clé du diagnostic des AGML repose sur l'endoscopie précoce dans tous les cas d'hémorragie du tube digestif haut. Le traitement initial est conservateur et a pour but de rétablir la perfusion tissulaire et de soustraire l'estomac a l'action des ions hydrogénes par lavage gastrique. Le traitement médical est efficace dans 80% des cas de gastrite érosive hémorrhagique mais la chirurgie est habituellement nécessaire pour les ulcères gastroduodénaux aigüs. Lorsque la chirurgie devient nécessaire le traitment de choix semble Être la vaguotomie avec hémigastrectomie. L'auteur a personnellement traité trente-six (36) patients porteurs d'AGML entre 1968 et 1976. De 50% qu'il était durant les deux premières années, le taux de mortalité a été réduit a zéro par l'emploi de l'endoscopie diagnostique d'urgence, du traitement médical adéquat, de la chirurgie bien faite au moment opportun, et plus récemment de l'angiographie sélective.

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  1. Istituto di 3a Patologia Chirurgica, University of Rome, School of Medicine, Rome, Italy

    Vincenzo Speranza M.D. & Nicola Basso M.D.

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  1. Vincenzo Speranza M.D.
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Speranza, V., Basso, N. Progress in the treatment of acute gastroduodenal mucosal lesions (AGML). World J. Surg. 1, 35–44 (1977). https://doi.org/10.1007/BF01654729

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