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Management of stress ulcers Sheet Music
Authors: David W Mercer, MD Matthew R Goede, MD Section Editor: David I Soybel, MD Deputy Editor: Wenliang Chen, MD, PhD Contributor Disclosures
All topics are updated updated as new evidence becomes becomes available available and our peer our peer review process complete. Literature review current through: Mar through: Mar 2017. | This topic last updated: Sep updated: Sep 01, 2015
INTRODUCTION — Stress ulcers were once a major cause of morbidity and mortality in critically ill patients. However, with the advent of ulcer prophylaxis and improved critical ca surgical intervention is only necessary for a small number of patients with life threatening hemorrhage or perforation from stress ulcers [1].
The nonsurgical management, indications for surgery, and surgical management of patie with stress ulcers are reviewed here. The epidemiology, pathogenesis, clinical manifestations, and prophylaxis prophylaxis of stress ulcers, as well as the nonsurgical nonsurgical treatments of upper gastrointestinal bleeding are discussed elsewhere. (See "Stress ulcer prophylaxis the intensive care unit" and "Approach to acute upper gastrointestinal bleeding in adults" The surgical treatment of peptic ulcer disease (not stress ulcer disease) is presented separately. (See "Surgical management of peptic ulcer disease". disease" .)
CLASSIFICATION — Stress gastritis may be referred to as diffuse mucosal injury, stress related mucosal disease stress ulceration, hemorrhagic gastritis, erosive gastritis, Curlin ulcer, and Cushing’s ulcer. Stress-related Stress -related erosive syndrome was first described in 1971 commonality to all is the presence of multiple superficial erosions of the gastric mucosa, beginning in the proximal acid-secreting portion of the stomach and progressing distally. Cushin Cushing’s ulcers develop following central nervous system injury. Morphologically, Sign up to vote on this title ulcers tend to be single and deep and may involve the esophagus, stomach, or duodenum Useful Not useful [3]. Curling’s ulcers occur following burns involving greater than 30 percent total body sur area. Curling’s ulcers can occur in the stomach or duodenum [4]. Stress gastritis erosion ,
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INITIAL MANAGEMENT — Despite almost universal use of ulcer prophylaxis, some criti ill patients still develop stress ulcers, and a small number of them may develop clinically significant bleeding. The clinical manifestations and diagnosis of stress ulcers are discuss elsewhere. (See "Stress ulcer prophylaxis in the intensive care unit" .)
When patients are diagnosed with bleeding stress ulcers, they should be promptly resuscitated with intravenous fluid or blood products. Any coagulopathy is corrected. A nasogastric tube should be inserted to remove gastric blood and irritants such as acid, bi or pancreatic secretions, which may cause further injury to the gastric mucosa. An intravenous proton pump inhibitor should be administered, and broad-spectrum antibiotic should be given to septic patients. Underlying sepsis is an important cause of stress ulce Thus, in patients with sepsis, appropriate antibiotic coverage and source control are requ for adequate ulcer healing. (See "Evaluation and management of suspected sepsis and septic shock in adults".)
Endoscopy is usually the first-line therapy for patients with bleeding stress ulcer disease, both for diagnosis and treatment. Depending upon local expertise, angiographic intervent can also stop bleeding from stress ulcers.
Resuscitation — Fluid resuscitation usually begins with crystalloid infusion. Maintenance normothermia through utilization of fluid warmers is mandatory, as administration of large volumes of room temperature crystalloid may cause dilutional and hypothermic You're Reading a Preview coagulopathy. Once the patient is typed and crossed, blood products including packed re Unlock and full access with a free trial. be used (in a 1:1:1 ratio) as blood cells, fresh frozen plasma (FFP), platelets should early as possible in place of intravenous fluid. (See "Maintenance and replacement fluid Download With Free Trial therapy in adults".)
Correction of coagulopathy — Coagulopathy is an independent risk factor for developi clinically significant bleeding from stress gastritis [6]. Patients with overt gastrointestinal bleeding and prolonged prothrombin time with INR greater than 1.5 or platelet count less than 50,000 per microliter should be given FFP or platelet transfusion, respectively. Plate transfusions should also be given to patients with normal platelet count but who received antiplatelet agents such as aspirin or clopidogrel [7]. Sign up to vote on this title
Data from mixed trauma patients with massive transfusion requirements indicate that Useful Not useful patients with acute traumatic coagulopathy appear to benefit from receiving transfusions packed red blood cells, FFP or similar products (eg, PF24), and platelets in ratios
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stomach to prevent gastric distension (which increases gastrin production) and removes luminal irritants [10]. Historically, gastric cooling with iced saline was also done through a nasogastric tube as a physical means of hemostasis. (See "Nasogastric and nasoenteric tubes".)
Antisecretory agents — The administration of intravenous antisecretory agents, prefera proton pump inhibitors, is of paramount importance. Either a proton pump inhibitor or an H receptor antagonist can satisfactorily inhibit acid secretion, which promotes healing of erosions and ulcerations. However, proton pump inhibitors have been shown to be more efficacious than H2-receptor antagonists in the resolution of gastric bleeding [11]; althoug these data come from patients with peptic ulcer disease, the findings are likely t o be applicable to patients with stress ulcers [12-15].
Endoscopy — Endoscopic therapy is usually the first-line intervention for upper gastrointestinal hemorrhage, including that from stress ulcers. Endoscopy aids in both diagnosis and potential treatment of the bleeding source. Unfortunately, in stress ulcers bleeding is frequently diffuse throughout the stomach without a dominant bleeding source that would be amenable to intervention. Despite this, initial endoscopic control of bleedin often successful with either injection or coagulation therapy. However, the rebleed rates c be high. (See "Overview of the treatment of bleeding peptic ulcers", section on 'Endoscop therapy'.)
You're Reading a Preview Angiography — In facilities with the requisite expertise, angiographic intervention may b Unlock full access a free trial. used to treat bleeding stress ulcers as well. (Seewith "Angiographic control of nonvariceal gastrointestinal bleeding in adults".) Download With Free Trial When a discrete bleeding vessel is identified on angiography, it can be subsequently embolized to stop bleeding. When no discrete bleeding source is found on angiography, a attempt at vasopressin infusion can be made into the left gastric artery, which typically supplies the bleeding site. Although catheter directed vasopressin infusion can successfu halt bleeding initially, some patients rebleed after discontinuation of vasopressin. Thus, if vasopressin infusion is initially successful in bleeding control, the left gastric artery should then be embolized to prevent rebleed. In patients with diffuse bleeding, complete gastric to vote on this title devascularization can be accomplished angiographicallySign by up embolizing both the left and r Notextensive useful Useful the gastric arteries and the left and right gastroepiploic arteries. Due to collater circulation of the stomach, in patients without a history of previous foregut surgery, the stomach usually survives such a procedure without ischemia. (See 'Blood supply' below.
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Refractory bleeding — Surgical intervention may be indicated in two different clinical scenarios involving bleeding from stress ulcers.
Bleeding causing hemodynamic instability — Surgical control of bleeding is a life sav intervention in hemodynamically unstable patients with stress ulcers. These patients frequently present with blood loss in excess of 8 units of packed red cells, and hemostas unlikely to occur without surgery.
Stable patients with persistent blood loss complicating comorbid conditions — Surgical control of bleeding is sometimes warranted in patients with persistent, refractory bleeding from stress ulcers who are showing signs of clinical deterioration [16]. These patients are hemodynamically stable, but have ongoing transfus requirements. Continuation of blood product replacement therapy could lead to immunolo and inflammatory complications, and also depletes resources.
Gastrointestinal perforation — Compared with patients who have superficial ulcers from trauma, shock, or sepsis, patients with Cushing’s and Curling’s ulcers are more suscepti to gastrointestinal perforations, as these two types of stress ulcers tend to be deep and cause extensive necrosis [3,17].
Patients who develop free gastrointestinal perforation require immediate surgical intervention. Closure of the perforation is necessary to achieve source control in order to You're Reading a Preview manage associated sepsis. Mortality without surgical intervention approaches 100 percen these patients. (See "Overview of Unlock gastrointestinal tract section on 'Stomach full access with a freeperforation", trial. duodenum'.)
Download With Free Trial Because Cushing’s or Curling’s ulcers can cause extensive necrosis of the gastric wall before perforation occurs, more extensive gastric resection (like a subtotal gastrectomy, w a delayed anastomosis until the patient has stabilized) may be required to treat a gastric perforation caused by stress ulcers than a g astric perforation caused by type 1 gastric pe ulcers. (See 'Gastric resection procedures' below and "Surgical management of peptic ul disease", section on 'Type I gastric ulcer'.) PREOPERATIVE PREPARATION — Patients who are referred for surgery because of Sign up to vote on this title complicated stress ulcer disease (refractory bleeding or gastric perforation) are typically Useful Not useful gravely ill. Thus, thorough preoperative preparations are important to ensure the best surgical outcomes. Many of these procedures are also performed emergently in the
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●Heat the operating room to an appropriate temperature (usually 85 degrees Fahrenheit); cold operating room air temperatures can exacerbate hypothermia and therefore coagulopathy.
●Ensure that blood products (typed and cross-matched packed red blood cells, fres frozen plasma, and platelets) are readily available. ●Have adequate numbers of fluid warmers and rapid infusers readily available. ●Use pneumatic compression devices for prophylaxis against venous thromboembolism. (See "Prevention of venous thromboembolic disease in surgical patients".)
●Give antibiotic prophylaxis prior to incision in patients who are not already receiving antibiotics. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
SURGICAL ANATOMY — The stomach resides in the left upper quadrant of the abdome Anteriorly, it is contained by the chest and abdominal walls, and usually a large portion is covered by the left lateral segment of the liver. Superiorly and posteriorly, it is confined by diaphragm. The spleen occupies its position superiorly and laterally to the greater curvatu The pancreas resides in the lesser sac, posterior to the stomach. Inferiorly, the stomach bordered by the transverse colon. The stomach is fixed at the gastroesophageal junction the pylorus (figure 1). However, between these two points the stomach is mobile, which assists in its ability to distend. You're Reading a Preview
The most proximal portion of the stomach the intraabdominal esophagus Unlock full that accessattaches with a free to trial. the cardia. Between the esophagus and the cardia is the lower esophageal sphincter. Th highly distensible fundus is distal toDownload the cardiaWith andFree is bordered by the angle of His, which Trial forms between the left edge of the esophagus and the fundus, the diaphragm superiorly, the spleen laterally. Continuing distally is the body of the stomach. This is the largest port of the stomach and contains the majority of the parietal cells. The body is defined from th antrum by the angularis incisura, at which point the lesser curvature of the stomach acute angles towards the right. The pylorus then lies between the antrum of t he stomach and th first portion of the duodenum.
Blood supply — Most of the blood supply to the stomach from the title celiac artery Signarises up to vote on this (figure 2). Four vessels supply the majority of the stomach. The left right gastric arte Not useful Useful and supply the lesser curvature. The left and right gastroepiploic arteries supply the greater curvature. The largest artery to the stomach is the left gastric artery. In 15 to 20 percent o
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The venous drainage from the lesser curvature is through the left gastric vein (also know the coronary vein) and the right gastric vein, which both drain into the portal vein. The left gastroepiploic vein drains into the splenic vein and the right gastroepiploic vein drains into the superior mesenteric vein.
Vagal innervation — The sympathetic innervation of the stomach is from the celiac plex The parasympathetic innervation of the stomach is from the vagus nerve (figure 3). The vagus nerve arises in the vagal nucleus in the brain, travels through the carotid sheath in neck, and then enters the mediastinum where it divides into numerous branches around esophagus. At the level of the diaphragmatic hiatus, those vagal branches then coalesce the left (anterior) and right (posterior) vagus nerves. T he left vagus nerve branches to the hepatic branch and the anterior nerve of Latarjet, which courses down the lesser curvature of the stomach. The first branch off of the r ight vagus nerve is the criminal nerv Grassi. The criminal nerve of Grassi is of particular interest because if it is not divided, recurrent ulcers can develop. The right vagus nerve continues to travel down the lesser curvature of the stomach, giving off branches to the celiac plexus along the way.
In order to perform a truncal vagotomy, both left and right vagus nerves are divided above the hepatic and celiac branches. A selective vagotomy divides below these branches, wh preserves the hepatic and pyloric branches.
SURGICAL APPROACH — Surgery for stress ulcer disease can be challenging because You're Reading a Preview patients are often ill from both their underlying disease processes (eg, sepsis), as well as Unlock patients full access with acute hemorrhagic shock. For bleeding whoa free aretrial. acidotic, hypothermic, or coagulopathic, a staged surgical approach appears safer [18]. Download With Free Trial The initial stage of the operation is usually done with the primary goal of bleeding control [19,20]. Once that is achieved, the second stage of the operation needs to be tailored to each individual patient based on their hemodynamic stability. Stable patients go on to hav vagotomy and pyloroplasty before abdominal closure, while unstable patients are sent ba to the intensive care unit for further resuscitation with an open abdomen. More elaborate procedures such as gastrectomy or gastric devascularization are now rarely used becaus the high morbidity and mortality associated with them. Sign up to vote on this title
Abdominal incision and exploration — A long midline for its Useful is Not useful incision recommended versatility and expediency. The entire abdomen is then quickly but systematically explore exclude any pathology including bleeding, perforation, infection, obstruction, or tumor.
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can be made across the pylorus after a Kocher maneuver to mobilize the duodenum. Th would allow for inspection of the distal stomach, pyloric channel, and proximal duodenum Subsequent approach based upon hemodynamic stability
Stable patients — In patients who are hemodynamically stable after incision, exploration and oversewing of bleeders, a vagotomy and pyloroplasty can be added, followed by clos of the abdomen.
Vagotomy and drainage procedure — Some forms of vagotomy, usually in combinatio with a drainage procedure, have a long-standing history in the treatment of peptic ulcer disease (see "Vagotomy"). Not surprisingly, vagotomy has been used in conjunction with other procedures in the treatment of stress gastritis. Vagotomy reduces luminal acid production and has some efficacy in the treatment of stress gastritis in those patients requiring surgery [23,24]. Vagotomy and pyloroplasty (or other drainage procedure) can b performed in this setting, although ligation of actively bleeding ulcers must be accomplish first. Closure — The anterior gastrotomy is closed in two layers. If a gastroduodenostomy is made separately, its closure can be incorporated into a standard Heineke-Mikulicz pyloroplasty.
Unstable patients — In patients who areReading hemodynamically You're a Preview unstable after incision, exploration, oversewing of bleeders, and closure of the gastrotomy, the abdomen should Unlock full access with a free trial. left open using a negative pressure dressing or some other temporary closure method to prevent abdominal compartment syndrome and expedite a second look procedure. Leavi Download With Free Trial the abdomen open also decreases operative time and allows the patient to return to inten care unit for further resuscitative efforts as soon as possible.
Patients may be returned to the operating room when hemodynamically stable for vagoto and pyloroplasty (or other drainage procedure), followed by abdominal closure (usually w 24 to 48 hours) [18]. Rarely performed procedures — Gastric resectional procedures and total gastric Sign up to vote on this title devascularization had been used to treat patients with bleeding stress ulcers. However, Useful Not useful these procedures are rarely used because of their high morbidity and mortality. Gastric resection procedures
Most authors advocate for reserving resectional
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Alternatively, a sleeve gastrectomy could be performed in combination with vagotomy an pyloroplasty in patients whose bleeding is confined to the body of the stomach. This wou control bleeding by eliminating a majority of the fundus and body, and have the added be of the acid suppression from vagotomy. Specific techniques of partial gastrectomy are also discussed elsewhere. (See "Partial gastrectomy and gastrointestinal reconstruction".)
Subtotal or total gastrectomy — Subtotal and total gastrectomy are rarely performed n that proton pump inhibitors are in widespread use. However, in the past, a subtotal gastrectomy or even total gastrectomy was performed in dire circumstances to control bleeding. Unfortunately, patients requiring a subtotal gastrectomy had a mortality approaching 80 to 100 percent [29,32]. If performed, most surgeons would advocate for a delayed anastomosis after the gastrectomy, allowing the patient to be resuscitated out of shock before performing a definitive anastomosis 24 to 48 hours later, analogous to dam control laparotomies in trauma patients.
During gastrectomy, leaving a cuff of proximal stomach on the esophagus may be desira because an esophageal-jejunal anastomosis is associated with a higher leak rate t han a gastro-jejunal anastomosis. Before using any mechanical stapling device, the surgeon m remember to call for removal of the nasogastric tube to avoid the disastrous complication entangling the tube by the staple line. A more detailed discussion on total gastrectomy an You're Reading a Preview reconstruction is contained elsewhere. (See "Total gastrectomy and gastrointestinal Unlock full access with a free trial. reconstruction".)
Gastric devascularization — In lieu of resectional procedures, complete gastric Download With Free Trial devascularization can be performed for long-lasting hemostasis. After oversewing any vis bleeding through a gastrotomy, the left and right gastric arteries, and the left and right gastroepiploic arteries are ligated. Although the stomach may initially appear ischemic following ligation, it frequently does not progress to full-thickness necrosis given its rich collateral circulation [33]. (See 'Blood supply' above.) POSTOPERATIVE CARE — Survival of patients with severe stress ulcers is largely dependent upon the ability to reverse the patient's underlying However, if the Sign up condition. to vote on this title patient survives the initial operation with successful control of bleeding, time is useful Useful Notvaluable gained for further resuscitation and correction of any organ dysfunction.
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●As noted above, the initially unstable patient may be returned to the operating room 24 to 48 hours if hemodynamically stable for definitive procedure, anatomical restoration, and abdominal closure. (See 'Unstable patients' above.)
●Enteral feeding can commence when the patient is weaned down on vasopressors provided that a feeding tube is placed distal to an anastomosis. ●A water soluble contrast upper gastrointestinal series should be performed to rule a leak in those patients undergoing gastrectomy prior to starting oral intake.
FOLLOW-UP CARE — Patients who have bleeding control by simple oversewing of the ulcerations, endoscopic therapy, or angiographic intervention only will likely require proto pump inhibitors for several months. During this period, the gastric mucosa remains friable and may take a significant amount of time to heal completely. However, those patients w also underwent vagotomy do not require antisecretory therapy because vagotomy substantially reduces gastric acid secretion. Long-term continuation of the proton pump inhibitor after ulcer healing is complete is controversial. Once acute shock has resolved and patients recover from their underlying illness, the nidus for stress ulceration has been removed as has the need f or long-term antisecretory therapy.
Patients who have had gastric resection and reconstruction can develop complications including osteoporosis, iron deficiency anemia, pernicious You're Reading a Previewanemia, and malnutrition. Thes issues are discussed elsewhere in detail. (See "Bariatric surgery: Postoperative nutritiona Unlock full access with a free trial. management".)
MORBIDITY AND MORTALITY — Surgical acts as a temporizing measure t Downloadintervention With Free Trial halt bleeding, the most acute threat to life, and thereby allows more time to reverse the state. Efficacy of such intervention is therefore directly linked to the successful resolution the underlying shock condition and control of any associated sepsis. Without resolution o underlying disease process, any surgical intervention is destined t o fail.
Thus, it is not surprising that patients who develop overt bleeding from stress ulcers conti to have a poor prognosis, with mortality rates ranging from 30 to 70 percent. Those who Signof up50 to vote on this[29]. title Rebleeding require surgical intervention have mortality rates in excess percent Useful Not useful ranging from rates following surgical interventions vary depending onthe series examined, 20 to 40 percent [29].
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●For patients diagnosed with bleeding stress ulcers, resuscitative efforts start with intravenous proton pump inhibitors, volume repletion, and correction of coagulopathy Antibiotics are given to patients with underlying sepsis. A nasogastric tube is inse gastric lavage and decompression. Endoscopy or angiography can be used as first-l therapy to localize the bleeding sources and stop t hem if possible. (See 'Initial management' above.)
●Surgical consultation is indicated for severe bleeding causing hemodynamic instab free gastrointestinal perforation, or refractory bleeding compromising comorbid med conditions. (See 'Indications for surgery' above.)
●For patients with a bleeding stress ulcer, the goal of the surgery is to control bleedi We typically make a long gastrotomy high on the anterior wall of the stomach in orde identify and oversew all bleeders. A truncal vagotomy with pyloroplasty could be add if the patient’s condition permits. Gastric resection and devascularization procedures rarely performed and are usually reserved for reoperations for stress ulcer bleeding, for patients who present with a gastric perforation. (See 'Surgical approach' above.)
●After bleeding control, the abdomen can be left open to expedite the surgery and to prevent abdominal compartment syndrome in unstable patients. These patients are promptly returned to the intensive care unit f or further resuscitative efforts before be brought back in 24 to 48 hours for second look, anatomical restoration, and abdomin closure. (See 'Postoperative care' above.)
●Following surgical intervention, patients frequently require continued proton pump You're Reading a Preview inhibitors for acid suppression and/or nutritional supplements dictated by the specific full access with a free trial. procedure they undergo. (SeeUnlock 'Follow-up care' above.)
●Patients who develop overt bleeding or perforation from stress ulcers continue to Download With Free Trial a poor prognosis, with mortality rates ranging from 30 to 70 percent. Those who requ surgical intervention have mortality rates in excess of 50 percent. Much of the morb and mortality are attributed to the patient’s underlying disease processes. (See 'Morbidity and mortality' above.) Use of UpToDate is subject to the Subscription and License Agreement . REFERENCES
1. Martin LF, Larson GM, Fry DE. Bleeding from stress gastritis. Has Sign up to voteprophylactic on this title pH contro made a difference? Am Surg 1985; 51:189. Useful Not useful 2. Lucas CE, Sugawa C, Riddle J, et al. Natural history and surgical dilemma of "stress" gas bleeding. Arch Surg 1971; 102:266. 3. Cheung LY. Thomas G Orr Memorial Lecture. Pathogenesis, prophylaxis, and treatment
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8. de Biasi AR, Stansbury LG, Dutton RP, et al. Blood product use in trauma resuscitation: plasma deficit versus plasma ratio as predictors of mortality in trauma (CME). Transfusio 2011; 51:1925. 9. Brown LM, Aro SO, Cohen MJ, et al. A high fresh frozen plasma: packed red blood cell transfusion ratio decreases mortality in all massively transfused trauma patients regardle of admission international normalized ratio. J T rauma 2011; 71:S358. 10. Ritchie WP Jr. Role of bile acid reflux in acute hemorrhagic gastritis. World J Surg 1981; 5:189. 11. Lin HJ, Lo WC, Lee FY, et al. A prospective randomized comparative trial showing that omeprazole prevents rebleeding in patients with bleeding peptic ulcer after successful endoscopic therapy. Arch Intern Med 1998; 158:54. 12. Laursen SB, Jørgensen HS, Schaffalitzky de Muckadell OB, Danish Society of Gastroenterology and Hepatology. National consensus on management of peptic ulcer bleeding in Denmark 2014. Dan Med J 2014; 61:B4969. 13. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 20 107:345. 14. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on th management of patients with nonvariceal upper gastrointestinal bleeding. Ann I ntern Med 2010; 152:101. 15. Neumann I, Letelier LM, Rada G, et al. Comparison of different regimens of proton pump inhibitors for acute peptic ulcer bleeding. Cochrane Database Syst Rev 2013; :CD007999 16. Enquist IF, Karlson KE, Dennis C, et al. Statistically valid ten-year comparative evaluatio three methods of management of massive gastroduodenal hemorrhage. Ann Surg 1965; 162:550. 17. Kanchan T, Geriani D, Savithry KS. Curling's ulcer - have these stress ulcers gone extinc You're Reading a Preview Burns 2015; 41:198. 18. Cortese F, Colozzi S, Marcello R, et al. Gastroduodenal major haemorrhages in critical Unlock full access with a free trial. patients: an original surgical technique. Ann Ital Chir 2013; 84:671. 19. Lee CW, Sarosi GA Jr. Emergency ulcer surgery. Surg Clin North Am 2011; 91:1001. Download Freesurgery Trial for abdominal emergencies 20. Weber DG, Bendinelli C, Balogh ZJ. DamageWith control J Surg 2014; 101:e109. 21. GILCHRIST RK, CHUN N. Severe hemorrhage in presumed peptic ulcer; surgical treatm in the absence of demonstrable lesion. AMA Arch Surg 1954; 69:366. 22. STARZL TE, SANDERS RJ. A maneuver for detection of the site of gastric hemorrhage. Surg Gynecol Obstet 1963; 116:121. 23. Sullivan RC, Waddell WR. Accumulated experience with vagotomy and pyloroplasty for surgical control of hemorrhagic gastritis. Am J Surg 1968; 116:745. 24. Byrne JJ, Guardione VA. Surgical treatment of stress ulcers. Am J Surg 1973; 125:464. Signstress up to vote on after this title 25. Taylor PC, Loop FD, Hermann RE. Management of acute ulcer cardiac surge Ann Surg 1973; 178:1. Useful Not useful 26. Wilson WS, Gadacz T, Olcott C 3rd, Blaisdell FW. Superficial gastric erosions. Response surgical treatment. Am J Surg 1973; 126:133.
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10.1016@S0140-67361632404-7 sgd 1 lbm 3
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Computed tomographic
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Topic 15170 Version 3.0 Sheet Music
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