Acute variceal hemorrhage: the persistent bleeder. A plea for management.

A group of 1910 patients with acutely bleeding esophagogastric varices were managed in the Kasr El Aini sclerotherapy project; 458 of the patients (24%) were lost to follow-up. The remaining patients were studied in five groups: group I (294/401 patients), rigid versus flexible sclerotherapy; group II (254/336 patients), intravariceal versus paravariceal sclerotherapy; group III (174/227 patients), timing of initial sclerotherapy and the optimum frequency of sclerotherapy sessions; group IV (80/99 patients), splenectomy devascularization operation alone versus combined surgery with sclerotherapy; group V (650/847 patients), management of failures of and recurrences after sclerotherapy. The mean period of follow-up was 72 months. Rigid sclerotherapy was significantly superior to flexible sclerotherapy for emergency control of acute bleeding but was associated with significantly more morbidity. Paravariceal injection achieved insignificantly better initial control of bleeding and had more morbidity than intravariceal injection, which obliterated the varices in a significantly larger proportion of patients. Emergency injection of the acute bleeder should be carried out soon after admission, with sclerotherapy sessions repeated every 2 weeks. Combined sclerotherapy with splenectomy and devascularization was significantly more effective for controlling bleeding than surgery alone. Surgery should be done without delay for continued bleeding after the second attempt of sclerotherapy and in patients who rebleed after their third sclerotherapy session. Survival, however, was not significantly improved by the different modalities of sclerotherapy.

The effect of prophylactic heparinization on the venous blood flow using the Doppler ultrasonic flowmeter.

The effect of prophylactic heparinization on the postoperative venous blood flow was prospectively studied in 100 lower limbs of 50 patients. Patients were randomized into two groups of 25 patients each: a control group and a heparin group. Changes in the venous blood flow were monitored using the Doppler ultrasonic flowmeter. The study illustrated the protective role of prophylactic heparinization in maintaining a near normal venous blood flow after surgery. The postoperative reduction in venous blood flow in heparinized patients was significantly less than the decrease in blood flow in non-heparinized patients during the same postoperative period. This significant difference between the two groups of patients applied to the steady and the augmented blood flow rates. The beneficial role of prophylactic heparinization was shown to act significantly in patients undergoing minor surgery, in obese subjects and in those suffering malignant disease. Patients undergoing major surgery also benefited significantly from prophylactic heparinization apart from their steady venous blood flow during the first postoperative day.

The effect of experimental haemorrhagic shock on the bacterial content of thoracic duct lymph.

The effect of haemorrhagic shock on the simultaneous appearance of enteric micro-organisms in the central lymph and the portal blood was studied in 30 dogs. Irreversible haemorrhagic shock results in portal bacteraemia but the lymph remains sterile. Thoracic duct drainage is harmful and hastens the onset of irreversibility.