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We read with interest the paper on prediction of therapeutic failure after adrenaline injection plus heater probe treatment in patients with bleeding peptic ulcer by Wong and colleagues (
). Even though the authors qualified their generalisation, the statement that “elderly patients often succumb to their concomitant illnesses rather than the bleeding itself” needs to be challenged as being unnecessarily defeatist, given the fact that timeliness of surgical intervention1 and, as shown below, postoperative management at the intensive care level, may be more crucial to survival than comorbidity as such.
Case report
A 70 year old woman with congestive cardiac failure (including radiographically validated left ventricular failure) and chronic obstructive airways disease experienced an episode of haematemesis and melaena with an associated blood pressure of 78/48 mm Hg on the 1 March 2002, which was the eighth day of her hospital stay. Endoscopy revealed a large actively bleeding duodenal ulcer, which was managed with endoscopic haemostasis, rapidly followed by definitive laparotomy and under running of the bleeding vessel. She was then transferred to a neighbouring hospital for postoperative intensive care management, and this included a 24 hour period of artificial ventilation. On the 11th postoperative day, having been repatriated to our hospital, she was clinically much improved even though her arterial blood tensions while breathing room air were as follows: partial oxygen tension (paO2) 4.9 kPa (normal range 10–14), partial carbon dioxide tension (paCO2) 6.9 kPa (normal range 4.5–6.1), and oxygen saturation 70%, with concurrent transcutaneous oxygen saturation 72% (normal range 95–98%). Her clinical status continued to improve on diuretics, angiotensin converting enzyme inhibitors, bronchodilators, and supplemental oxygen. On her 25th postoperative day, lung function tests revealed a one second forced expiratory volume (FEV1) of 0.86 litres (40% predicted), forced vital capacity (FVC) of 1.59 litres (61% predicted), and an FEV1/FVC ratio of 54% (typically less than 70% in airflow obstruction). She could now perform a modified version of the “shuttle” walk2 for a distance of 30 m briskly, without stopping for breath, and also without supplemental oxygen. Repeat arterial blood gas tensions on 30 March 2002 showed paO2 7.7 kPa and paCO2 5.8 kPa while breathing room air.
Comment
On the basis of age, comorbidity, shock at presentation, and endoscopic stigmata of recent haemorrhage, this patient had a high risk of death with or without surgical intervention.3 Only timely intervention and impeccable postoperative care could tip the scales in her favour, hence the successful outcome documented here.