Rupture of the stomach complicating bleeding peptic ulcer. Case report.

Three cases of overdistension and rupture of the stomach complicating bleeding ulcer are reported. Despite early surgery two of the patients died of multiorgan failure and rebleeding. The pathogenesis, clinical picture and treatment of this rare condition are discussed. The literature is reviewed.

Penetrating wounds of the neck. Experience from a Swedish hospital.

Stab wounds of the neck were retrospectively studied in 28 patients. Neck stabbings constituted 9% of all stab wounds recorded during the same period. Vascular injuries were most frequent, and the mortality rate was 14%. The management of neck stab wounds is discussed and three cases are presented to illustrate the difficulties and pitfalls. It is proposed that all wounds penetrating the platysma should be explored in general anaesthesia.

Acute gastric hemorrhage secondary to wandering spleen.

A patient presenting with acute life-threatening upper gastrointestinal hemorrhage caused by a wandering spleen is reported. Emergency laparotomy revealed profuse gastric bleeding, large engorged varicose veins in the gastric wall, and a normal liver parenchyma. Gastroscopy after arrest of the hemorrhage showed varicose veins in the fundus without esophageal varices. Angiography revealed an ectopic spleen, occlusion of the splenic vein, and large venous collaterals in the gastric fundus. Elective splenectomy was performed. Wandering spleen as a cause of left-sided portal hypertension, also referred to as segmental splenic hypertension, is discussed.

Effects of hypovolemia on local metabolic changes in skeletal muscle following high velocity missile injury.

The effect of blood loss and reinfusion after 6 h on the tissue damage around a high-velocity missile tract in skeletal muscle has been studied in pigs (n = 13). Hemodynamic variables and blood chemistry were monitored and the levels of ATP, creatine phosphate (CP), glucose, glucose-6-phosphate ( G6 -P), and lactate were repeatedly analyzed in muscle samples from the wound area and from control tissue. In vitro amino acid incorporation into proteins by isolated ribosomes was also studied. The missile injury induced pronounced local metabolic disturbances in the muscle tissue surrounding the missile tract. After 6 h these disturbances were more pronounced and extended further out from the wound channel in bled than in unbled animals. One hour after reinfusion of the shed blood, no remaining difference in the size of the metabolically disturbed tissue area between the two groups of animals could be demonstrated. It is thus concluded that a moderate hypovolemia markedly increases the metabolic deterioration around a high-velocity missile tract in skeletal muscle but that volume restitution, even if given as late as 6 h after the missile injury and the blood loss, will almost completely within 1 h reverse the effects caused by the hypovolemia.

Effects of penicillin G on local metabolic changes in skeletal muscle following high velocity missile injury.

The effect of systemic penicillin G treatment on the local tissue damage 12 h after a high velocity missile injury in skeletal muscle has been studied in pigs (n = 13). Blood pressure, rectal temperature, hemoglobin concentrations, hematocrits, blood gases and acid base balances were followed and the tissue levels of ATP, creatine phosphate, glucose-6-phosphate, glucose and lactate were determined in control skeletal muscle as well as in muscle samples taken from the wound area. After 12 h all devitalized tissue was debrided and weighed. Penicillin G treatment slightly diminished the local tissue metabolic deterioration and significantly reduced the amount of debrided tissue as compared to untreated animals. It may be concluded that early treatment with penicillin G will considerably diminish the local tissue damage during the first 12-hour period following a high velocity missile injury.

Treatment of acute massive gastroduodenal haemorrhage with cimetidine in elderly patients.

Ninety-two patients over the age of 60 with acute upper GI-haemorrhage were included in a prospective randomized doubleblind three-centre study of the effect of a five day treatment with cimetidine. Twenty patients had to be excluded because of different reasons. The remaining 72 patients bled from either erosive gastritis, gastric ulcer or duodenal ulcer. Thirty-two patients received cimetidine and 39 placebo. There was no difference in the number of transfusions, rebleedings or operative interventions. Mortality was 1/33 (3%) in the cimetidine group compared to 5/39 (13%) in the placebo group (NS). In the gastric ulcer group there was no mortality among 10 cimetidine patients compared to a mortality of 4 of 12 (33%) patients receiving placebo (p less than 0.05). It is concluded with caution that cimetidine might be effective in haemorrhage from gastric ulcer in patients 60 years and older. For convincing conclusions a larger study of patients with bleeding ulcers is desirable.

Ranitidine in the treatment of gastric, prepyloric and duodenal ulcer--a controlled prospective double-blind trial.

Fifty adult outpatients with endoscopically proven gastric, prepyloric or duodenal ulcers were included in a prospective, randomised double-blind trial of ranitidine (40 mg X 3 daily and 80 mg at bedtime) versus placebo. After 4 weeks the ulcers had healed in 21 of 25 patients receiving ranitidine compared with 7 of 23 in patients receiving placebo (p less than 0.001). The ranitidine treated patients had fewer days of pain (p less than 0.001) and lower consumption of antacids (p less than 0.01) than placebo patients. Patients whose ulcers were not healed after 4 weeks went into an open 4 weeks trial with ranitidine. After the second 4 week period there were still 5 unhealed ulcers, all located in the prepyloric region. No serious side effects or haematological or biochemical abnormalities were observed. It is concluded that ranitidine is a very potent and safe ulcer healing substance. Patients with prepyloric ulcers may need a higher dose or a longer period of treatment.

Transcatheter occlusion of an intrarenal arteriovenous fistula.

A patient with a large intrarenal arteriovenous fistula in the left kidney is presented. Successful transcatheter occlusion of the fistula was performed and the patient followed angiographically. The diagnostic value of angiography and its therapeutic potential is discussed.

Local metabolic changes in skeletal muscle following high-energy missile injury.

The extent of cellular deterioration around a high-velocity missile injury was studied in canine skeletal muscle biopsies. The tissue levels of high-energy phosphates and glycolytic metabolites were analyzed in four zones surrounding the bullet tract and in an uninjured extremity. Incorporation of leucine into skeletal muscle proteins in vitro in the different zones was determined. In the tissue adjacent to the bullet tract ATP and phosphocreatine (CP) decreased significantly and remained low. No significant changes of ATP and/or CP occurred in the other zones or in the control muscle. Lactate and glucose levels increased in all zones but G6-P levels decreased in the three zones close to the wound indicating anaerobiosis and disturbed utilization of glucose. Incorporation of leucine decreased in the innermost zone and no restoration took place, but more peripherally a certain reversible decrease was seen. The present results indicate that irreversible cell damage will occur in the tissue adjacent to a high-velocity bullet tract. Reversible cellular dysfunction may occur in tissues without gross changes.

LOcal effects of antibacterial therapy (benzyl-penicillin) on missile wound infection rate and tissue devitalization when debridement is delayed for twelve hours.

Spherical steel bullets (0.88 g, 6.00 mm in diameter, impact velocity around 1000 m/s, smooth-bore rifle) were used for infliction of trauma to the thigh of pigs. The aim was to find out the effect of early antibiotic therapy (benzyl-penicillin) on wound infection rate and on the local progressive tissue devitalization when debridement was delayed until 12 hours after infliction of trauma. The main study on infection and tissue devitalization contained 20 missile wounds; the pilot study on cell metabolism 13 wounds. In the first group 11 pigs, and in the second group 7 pigs were treated with penicillin. Debridement was performed 12 hours after the infliction of trauma. Bacteriological analyses were done on tissue samples from the wound after pc treatment. The contents of adenosine triphosphate, creatine phosphate, glucose, glucose 6-phosphate and lactate were analysed in tissue samples from the wound with and without pc-treatment 12 h after trauma. The usual growth of bacteria when debridement was delayed for 12 h was totally inhibited by the early provision of penicillin. The amount of devitalized tissue-removed in relation to transferred energy was significantly reduced after the treatment as compared to the non-pc-group. The results of the studies on cell metabolism point to a graded tissue damage and possibly reversible injuries in the periphery of the wound, and to less metabolic disturbances after pc-treatment. The results indicated that early general supply of antibiotics may confine the local tissue injury when delayed debridement is anticipated.

Leucine incorporation into skeletal muscle proteins in vitro and protein synthesis by isolated ribosomes from skeletal muscle around a high velocity missile injury.

Protein synthesis in skeletal muscle around a high velocity missile injury was investigated in two series of experiments. In the first series a shot wound was induced in the hindleg of dogs. Muscle biopsies were taken at various distances from the wound channel and bundles of muscle fibre were incubated in a medium containing 14C-leucine under protein synthetizing conditions. A significant reduction in the rate of leucine incorporation into muscle protein was seen in the adjacent to the wound channel. At a distance of 3 cm from the bullet track no reduction in leucine incorporation into protein occurred. In the second series of experiments a high velocity missile injury was induced in the hindleg of pigs. The capacity of ribosomes to incorporate 14C-phenylalanine into protein was analyzed. Ribosomes were isolated from skeletal muscle around the shot wound. The effect of missile injury alone and that of the combined effect of missile injury and hemorrhage were studied. A marked reduction in ribosomal activity was found in tissue adjacent to and up to 2.4 cm from the wound channel. At a distance of 3 cm from the wound ribosomal activity remained unaffected. Ribosomal activity was significantly more reduced in tissue close to the wound channel after missile injury and hemorrhage than after missile injury alone. The reduced capacity for protein synthesis in muscle around the missile injury found in this study probably reflects a lowered cellular energy level. The local metabolic changes were aggrevated in animals where hemorrhage was also induced indicating that in the clinical situation prevention of hemorrhage and hypovolemia might reduce the amount of tissue that has to be excised following a short wound.

Early local and systemic fibrinolytic response to high energy missile trauma.

In dogs, tissue and blood fibrinolysis was studied after a high velocity missile injury to one hind leg. Plasminogen activator activity in skeletal muscle at different distances from the wound was estimated with a histochemical method. Samples from venous blood draining both the injured and the not injured leg were regularly analysed for fibrinogen, plasminogen, alpha 2-antiplasmin, alpha 2-macroglobulin, fibrinolysis on fibrin plates and fibrin(ogen) degradation products. Tissue close to the bullet track judged as devitalized displayed a significant and persistent reduction of plasminogen activator activity. The same pattern of reaction was observed in muscle without apparent lesions 3 cm from the wound but no uniform pattern could be discerned at a distance of 10 cm. In the blood a very early activation of fibrinolysis took place. There was no difference between the two sides, thus the trauma induced a general activation of fibrinolysis in the organism. Towards the end of the experiments a continuous decrease of fibrinolysis in the euglobulin fraction of plasma on fibrin plates was noted. Concomitantly an increase of plasmin inhibitors took place. It was concluded that a high velocity missile injury to skeletal muscle induced a reduction of plasminogen activator activity in the tissue surrounding the wound. A very early and general activation of systemic fibrinolysis was followed by a decreased fibrinolysis within a few hours.