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Acute bleeding from the upper gastrointestinal (GI) tract (esophagus, stomach, and small intestine) occurs frequently, necessitates hospital admission, and carries a 10 to 20 percent risk of death. Although about 85 percent of these bleeds stop spontaneously, early intervention is needed for patients who do not stop bleeding. A study was undertaken of 469 patients admitted to a major urban hospital with a diagnosis of acute upper GI bleeding. Within this group, there were 53 patients readmitted. The causes of bleeding were diagnosed by endoscopy (visualization of the interior of the body cavity with an illuminated optic instrument). The most common causes of upper GI bleeding were: abnormalities of the stomach mucosal lining (24 percent); esophageal varices, enlarged veins at the lower end of the esophagus (22 percent); gastric ulcer (19 percent); and duodenal ulcer (14 percent). In 504 cases (89.5 percent of admissions) nonoperative treatment was successful. Endoscopy was used in 144 cases. Fifty-eight patients had surgery, including 29 percent of the ulcer patients. Emergency surgery to control bleeding was necessary in 2.5 percent of the cases. The surgical mortality was 5.2 percent, and there was a total of 58 deaths (12.6 percent); 36 deaths were attributed to upper GI bleeding. Factors noted on admission which were correlated with death included a stage of shock with systolic blood pressure less than 80, the need for more than five units of blood replacement, and the presence of esophageal varices. It is concluded that most patients with upper GI bleeding can be treated without surgery when the source of the bleeding is identified. If required, surgery can reduce mortality and illness in these patients. (Consumer Summary produced by Reliance Medical Information, Inc.)

Endoscopy is widely accepted as the primary modality for diagnosis of the source of upper gastrointestinal bleeding. It also facilitates therapy selection and may improve treatment outcome. The ability to achieve hemostasis has greatly expanded the value of endoscopy. The author reviews sclerotherapy of esophageal varices and the various techniques for endoscopic hemostasis of nonvariceal bleeding.

Electrocoagulation of gastric or esophageal bleeding sites was evaluated in dogs using a flexible suction coagulator electrode passed through the endoscope using an electrocautery unit (Cameron-Miller model 80-7910).Acute and chronic coagulation studies in 25 dogs showed that electrocoagulation of both the esophageal and gastric mucosa was safe at an electrocautery unit setting of 5 for three to five seconds. This level of coagulation was successful in stopping bleeding created from actively bleeding esophageal and gastric mucosal defects by taking multiple large biopsy specimens. Based on these data, six patients with active bleeding gastric lesions have undergone mucosal coagulation. This successfully stopped the bleeding initially in all six patients; two patients rebled and required operative intervention within 48 hours. Further clinical evaluation is being implemented to determine its clinical role in the treatment of bleeding in the upper part of the gastrointestinal tract.

Peroral cannulation of the ampulla of Vater with retrograde cholangiography and pancreatography (ERCP) was successfully accomplished in 65 of 85 patients. Cholangiography was normal in six patients thought to have obstructive jaundice and demonstrated choledocholithiasis in eight, cancer of the common bile duct in three, cancer of the head of the pancreas in eight, narrowing of the common bile duct in three, and ampullary cancer in two. Pancreatography was normal in 12 patients, ruling out surgical lesions; pseudocysts were demonstrated in three, pancreatitis in 12, and carcinoma of the body and tail of the pancreas in two. No serious complications resulted.Retrograde cholangiography and pancreatography provided a safe, quick, and accurate diagnostic technique that reduced the duration of preoperative investigation of the jaundiced patient and influenced the choice of operation in patients with pancreatic disease.

Sphincter of Oddi dysfunction (SOD) is one of the causes of post‐cholecystectomy syndrome and biliary pain and is a challenge from both the diagnostic and therapeutic points of view. Sphincter of Oddi dysfunction is typically diagnosed months to years after cholecystectomy. Continued biliary type pain after cholecystectomy may occur in as many as 10–20% of patients. Ten percent or more of these patients may eventually be shown to have SOD. The syndrome is often associated with a variety of other gastrointestinal disorders thought to be caused by dysmotility. According to the Milwaukee classification, patients with biliary pain can be divided into three types. Type I patients show all the objective signs suggestive of a disturbed bile outflow (i.e. elevated liver function tests, dilated common bile duct and delayed contrast drainage during endoscopic retrograde cholangiopancreatography). Type II patients have biliary type pain along with one or two of the criteria from type I. Type III patients have biliary pain only, with no other abnormalities. The present paper will focus primarily on SOD syn‐drome, papillary stenosis and the diagnostic and therapeutic approaches, in particular endoscopic sphincterotomy.

• The use of endoscopic retrograde pancreatography (ERP) provides important information in the management of pancreatic pseudocysts unavailable by other methods. When the pseudocysts communicate with a hollow viscus, the surgeon is better able to deal with the problem if aware of this fact prior to operative intervention. A pancreatic pseudocyst communicating with the stomach was demonstrated by ERP in each of four patients. One of these patients had pancreatic ascites and the other had left-sided pleural effusion, and both were treated successfully by distal pancreatectomy. The other two patients responded to nonoperative treatment. This report emphasizes the potential diagonstic value of ERP in determining the presence and the fate of pseudocysts.(Arch Surg 112:1050-1053, 1977)

The surgical endoscopy unit at Detroit General Hospital has examined 183 patients with acute hemorrhage in the upper gastrointestinal tract during the past 14 months. Most patients (160) were examined within 48 hours of admission. The esophagogastroduodenoscope was used throughout. Successful visualization of the esophagogastroduodenal area was accomplished in 178 patients (97%).The primary cause of bleeding as judged endoscopically was acute gastric erosion due to alcohol or salicylates in 75 patients, benign ulcer disease in 52, Mallory-Weiss syndrome in 27, and esophageal varices in eight. Sixty-eight patients (43%) had more than one source of bleeding. Intraoperative endoscopy in 12 patients circumvented the need for exploratory gastrotomy. The high incidence of superficial lesions correlated well with the high incidence of negative barium study (67%) in these patients.