Massive gastrointestinal hemorrhage.

Dissatisfaction with the high morbidity and mortality of traditional methods of handling massive gastrointestinal hemorrhage has led to the exploration of means other than surgical to attain hemostasis. Some, such as selective arterial infusion of surgical Pituitrin, have quickly won general acceptance in hospitals where facilities and interested personnel are available. Others, such as alkalinization, have become popular because of their inherent simplicity. Systemic hypothermia, requiring intensive patient care, has not been without considerable risk of significant complications. Iced saline lavage has never been subjected to critical evaluation. It is possible that the emptying of the stomach through mechanical destruction of the intragastric clot by repeated irrigations, reducing the antral stimulation by relief of distension, may be as important as the temperature of the solution in the stomach. Gastric irrigations with norepinephrine solutions have awaited the results of physiologic studies showing that the cardiovascular and renal effects of injected levarterenol are avoided, and that permanent damage to the gastrointestinal mucosa does not result. Trials have been confined largely to very poor-risk patients, and the hemostasis that has resulted has not been explainable, in all cases, on the basis of the physiologic activity of the agent (e.g., control of bleeding from tumor vessels). Evacuation of gastric content prior to introduction of the norepinephrine solution seems important. Lower gastrointestinal bleeding from benign disease has also responded to advances in applied pharmacology, with intra-arterial infusion of surgical Pituitrin again coming into progressively wider use. Intraperitoneal instillation of norepinephrine has also proved useful, even in patients who have adhesions from prior surgery or inflammatory disease, but closer monitoring of blood pressure and urine output are necessary because some of this solution is absorbed by the parietal peritoneum and not deactivated by the liver before entering the systemic circulation. Taken together, selective arterial infusion of vasopressin and topical application of norepinephrine can be considered complementary rather than competitive therapies. Because of the more extensive experience with selective angiographic infusion, it should be the first choice in institutions where it is readily available. For patients in whom arterial puncture is inadvisable, and where angiography is not readily available, topically applied norepinephrine becomes the treatment of preference. We have demonstrated effectiveness of intraperitoneal norepinephrine in a patient in whom selective arterial infusion of surgical Pituitrin had failed. And the reverse would probably also hold true on occasion. Pharmacologic techniques represent a therapeutic advance, reducing the frequency with which surgical intervention becomes mandatory. But they are not a substitute for surgery...