Br. J. Surg. Vol. 63 (1976) 60-66
Curling’s ulcer: a rare condition I A N F. K. M U I R A N D P E T E R F. J O N E S *
G. W. was a boy of 28 years. On 23 August 1973 he set fire to a vinyl settee on which he was playing with matches. About
was found to have flame burns of his face, the front of his trunk and all four limbs. Approximately 50 per cent of the body surface was burnt, of which 25 per cent was deep burning, including the whole of the hands, abdomen, thighs and the dorsum of the feet. H e weighed 15 kg. The treatment during the shock period followed orthodox lines except that the patient developed stridor, which was treated by humidification of inspired air and administration of 300 mg of hydrocortisone intravenously over a period of 12 hours on the day of admission. There was no hypotension during the shock period and the treatment is summarized in Table I . When transferred to the Royal Aberdeen Children’s Hospital o n the sixth day the temperature was 39 “C, pulse 120/minute, haernoglobin 11.8 g/100 ml, PCV 30 per cent and serum urea 43 mg per cent. His general condition was good. There was burn eschar over the whole of the face, chest, abdomen, arms, hands and the front of both legs and feet; the burns of the hands were exceptionally deep. Wound swabs grew Staphylococcus albus only, O n the eighth day the hands and legs were dressed with sulphamylon, and the remainder of the burns exposed. It was first noted o n this day that the patient was reluctant to eat and from this time onwards food and drink were increasingly refused. His temperature remained around 39 “C and pulse 120-130/minute. On the eleventh day the temperature suddenly fell to 36 “C and then to 35.5 “C (Fig. 1). At 4 p.m. o n the twelfth day (4 September) the pulse suddenly rose to 170, then 180/minute, and he became very pale and passed two large stools of clotted blood. A central venous catheter was rapidly introduced and 400 ml of Hartmann’s solution and 1 litre of blood were transfused over the next 5 hours. During that time blood pressure was maintained but further dark red stools were passed, followed by a remarkable 90-cm length of pure clotted blood bearing the imprints of the valvulae conniventes of the small intestine, and further clots were passed throughout the evening. A litre of blood was transfused between 11 p.m. (4 September) and 2 a.m. ( 5 September), but red clots continued to pass per rectum. It was concluded that the source was probably a duodenal ulcer and that bleeding was continuing at such a rate that surgical arrest was essential. Operation was commenced at 3 a.m. on the thirteenth day after burning. A right paramedian incision was made through the tough burn eschar. The duodenum was distended with blood and clot, and blood was present throughout the small and large bowel. An incision across the pylorus revealed a deep posterior ulcer of the first part of the duodenum, and the gastroduodenal artery was bleeding briskly in its base (Fig. 2). The artery was under-run with three Dexon sutures, much clot was evacuated by sucker from the stomach and duodenum and the incision was closed as a Finney pyloroplasty. Substantial anterior and posterior vagal trunks were identified and crushed with artery forceps. A drain was inserted and the wound was closed with Prolene, with deep retention sutures of nylon. A further 1.5 litres of blood were transfused during the operation. Later that day the haemoglobin was 16 g per cent and during the 24 hours after operation 1200 ml of urine were passed. Intravenous feeding was commenced from the time of operation, and o n the third day after operation oral fluids wwe started. There was no sign of recurrent haemorI hage after the operakion. Partial collapse of the apex and lo&er lobe of the right lung gave rise to some anxiety at this time, but this problem
4 hours later he was admitted to the Royal Northern Infirmary, Inverness, under the care of Mr G. S. Anderson, where he
* Royal
SUMMARY
A case of Curling’s ulceration of the duodenum in a child with 50 per cent burns, requiring operative arrest of’ the bleeding, is reported, and this condition i s reviewed. Inquiry among the surgical units treating burns in Great Britain showed that only 18 cases of alimentary bleeding had been seen in the course of treating some 32 500 patients. The incidence in Europe and Australia appears to be of the same order, bur there is a much higher incidence in some burns units in North America. Possible reasons for these differences are examined. The occurrence and treatment o j Curling’s ulcer in childhood are considered.
IN 1842 T. B. Curling, then Assistant Surgeon to the London Hospital, described 3 severely burned children, aged 4 , 8 and 1 l years, who had suffered haematemesis or melaena between I0 and 18 days after burning. At autopsy each was found to have a posterior penetrating ulcer of the first part of the duodenum, between 4 and 1 inch (1.5-2.5cm) in diameter, in the depths of which lay the eroded gastroduodenal artery. He also described the postmortem findings in a boy of 39 years who had a posterior duodenal ulcer, but who had shown no evidence of bleeding during life. Samuel Cooper of University College Hospital had previously described 2 similar cases in 1839, and in 1840 James Long of Liverpool had reported 2 young women with burns who had perforated duodenal ulcers. These two descriptions appeared in papers on the post-mortem changes found in burning accidents, but it was Curling who pointed out the specific connection between this type of ulcer and the burn injury. He entitled his paper ‘On acute ulceration of the duodenum in cases of burn’, and may justifiably be considered to be the person who established the existence of this striking and serious complication of burns and scalds. An example of such an ulcer in a 2-year-old boy has recently been seen at the Royal Aberdeen Children’s Hospital, and this was the first Curling’s ulcer to be seen in the course of treating some 3000 burns and scalds which required admission to hospital. It would appear therefore that, in spite of being so wellknown, Curling’s ulceration is a rare event, and this experience has prompted the present review of the condition. Case report
60
Aberdeen Children’s Hospital, Aberdeen.
Curling’s ulcer settled with frequent physiotherapy. Also a t this time considerable suppuration began to be evident under the burn eschar, especially over the arms and hands, and swabs yielded a profuse growth of Staphylococcus pyogenes and Escherichiu coli. On the fourth postoperative day it was evident that suppuration around the burn eschar was worse and that the laparotomy wound was not healing, in spite of continued intravenous feeding. On the following day a trickle of bile was seen along the drain track and this became obvious on the following day, and so oral feeding was discontinued. It was now clear that there was total failure of healing of the laparotomy wound, and there was widespread sepsis under the burn eschar. The boy’s condition deteriorated steadily, with spreading pneumonic changes in both lungs, and he died on the twenty-third day after burning.
Definition and pathology The ulcer seen in this patient was similar to those described 133 years ago by Curling, and by many other surgeons and pathologists since then. However, over the years the eponym ‘Curling’s ulcer’ has been widely but incorrectly used as a general term covering all forms of gastroduodenal (and even oesophageal) ulceration associated with burns and scalds. Examples of these different ulcers were described even before the papers of Cooper, Long and Curling. Swan (1823) was the first to describe gastric erosions. Dupuytren (1832) reported a 27-year-old portress, 4 months’ pregnant, who fell asleep in front of the fire where her clothes caught alight; she died within 48 hours, without showing signs of bleeding, and at autopsy multiple small ulcers were seen in the stomach. Further studies, largely in post-mortem series, have shown considerable differences between these gastric and duodenal ulcers (O’Neill et al., 1967; Sevitt, 1967; Thomsen and Serrensen, 1968). 1 . Gastric ulcers were roughly twice as common as those in the duodenum. 2. The gastric ulcers were superficial in character. About one-third of them were multiple, tiny and disseminated, while the other two-thirds were either single erosions or zones of irregular erosion. By contrast, the duodenal ulcers were deeper. About twothirds were single, posterior and penetrating; the other one-third was multiple but one ulcer was always on the posterior wall. 3. Sevitt (1967) found that the gastric ulcers characteristically occurred shortly after injury and that the incidence was related to the severity of burning. Duodenal ulcers tended (especially in children) to occur
after the first week and to have a maximal incidence in those whose burns involved 50 per cent or less of the body surface. 4. In children there was a preponderance of duodenal ulcers. Abramson (1 964) surveyed 90 reports of post-mortems on children and found that in 80 the ulcer was in the duodenum and the majority of these were single, posterior and penetrating. C 40
r
- IOOL
,
31 LI--L21-3 A“g Sept 9
1-4-L5--L6-i74 Days 10
I1
I2
13 0
14 1
IS
After b u r n i n g
2
After operation
Fig. 1. Temperature and pulse chart for the period before and after haemorrhage from Curling’s ulcer.
Fig. 2. Photograph during laparotomy. The incision through the pylorus and duodenum is held open by forceps and retractors; the stomach is held up in the centre of the upper half of the photograph. A sucker enters from the right upper corner and its tip lies in the ulcer crater, keeping it clear of blood. Clot can be seen just below the lower rim of the ulcer.
Table I: FLUID INTAKE AND OUTPUT ON THE 4 DAYS AFTER BURNING Fluids by mouth
Date
Period of time (hr)
(ml)
Blood
Plasma
5% Dextrose
23 August
12
170
-
1200
-
400
100
24 August
12
-
800 400
400
-
-
-
12
430 780
400
-
430
12 12’
170
-
-
1000
400
400
-
-
12 12
140
-
-
500
100
220
500
500
-
3 50
470
25 August 26 August
Volume of urine
Intravenous fluids
-
Ringer-lactate Mannitol 10%
(ml)
250 255
320 440
355
61
Ian F. K. Muir and Peter F. Jones There is much to suggest that these true Curling’s duodenal ulcers are a specific complication of burns, but Lewis (1973) has pointed out that very similar ulcers also occur in children with brain stem compression due to tumours or injury. She reported 16 neurosurgical patients between 3 and 12 years of age with alimentary bleeding; 8 required operation to stop the bleeding and 7 of these had posterior penetrating ulcers with erosion of the gastroduodenal artery. I t is also noticeable that the multiple gastric ulcers and erosions seen in burns bear a strong resemblance to the stress ulcers seen in other severe injuries. It should be emphasized that the majority of ulcers in burned patients are only discovered as an incidental finding at post-mortem examination. Sevitt (1967), for instance, performed autopsies on 29 I burned patients and found 25 acute duodenal ulcers and 42 gastric erosions but only in 3 of the patients with duodenal ulcer had haemorrhage occurred during life. Clinical evidence of acute ulceration as manifested by overt haemorrhage (or occasionally perforation) is in the authors’ experience very rare, and this rarity contrasts strongly with some North American experience. Therefore, further investigation of the incidence of alimentary tract ulceration after burning accidents has been carried out.
Incidence Great Britain
A letter was sent to a senior consultant in each of the major burn units, seeking information about the occurrence of gastroduodenal ulceration and the need for operative intervention to stop haemorrhage. Fourteen centres replied and the information is summarized in Table If. The annual number of admissions to these units varies but most admit between 100 and 200 new patients each year, and the survey extends back over 15 or more years of experience. This means that the total number of burned patients being surveyed
is over 30000, and yet there is only evidence of 18 patients with memorable bleeding. The dramatic nature of the events suffered by the patient reported here would make it unlikely that experienced surgeons would forget similar occurrences, and therefore this survey probably reflects the true incidence of bleeding Curling’s ulcer in Great Britain. The experience at the Burns Unit of the Birmingham Accident Hospital is particularly well documented. During 1948-65 Sevitt (1967) carried out an autopsy examination on 291 of the 477 patients dying in the unit. He found that 68 patients had ulceration of the stomach or duodenum but only one, a girl of 3 with 30 per cent burns, had died from haemorrhage, which occurred suddenly on the twenty-second day from a classic Curling’s ulcer. Two other patients bled during life but died with septicaemia, and one man who died suddenly on the twelfth day was found to have a perforated anterior duodenal ulcer which had been silent during life. There was no clinical evidence of haemorrhage--except possibly coffeeground vomiting-in any of the 42 patients with gastric ulceration. The paper of Bull (1971) shows that the Birmingham Burns Unit has an annual admission rate of some 320 adults and children, so that during the years 1958-65 about 5760 patients were admitted. With 477 deaths the mortality rate was about 8.3 per cent, the incidence of gastric and duodenal ulceration among post-mortems was 9 per cent but the occurrence of overt bleeding was limited to 3 patients among 5760 patients, and only 1 patient died from alimentary haemorrhage. A rather similar incidence was found in the only other relevant report from the British Isles during the past 20 years. Choudhury (1963) reviewed 2165 children admitted to a burns unit in Manchester between 1954 and 1961. There were 68 deaths (3 per cent) and among these were the only 2 children to show melaena: one had a true Curling’s ulcer and the other an ulcer on the greater curvature of the stomach. Braithwaite
Table 1 1 : SUMMARY OF INFORMATION OBTAINED FROM BURN CENTRES IN GREAT BRITAIN Approximate Known clinical No. of patients cases of Region Burn centre admitted Curling‘s ulcer England SW Metropolitan Roehampton 3 000 2 East Grinstead 2 000 SE Metropolitan 2 Mount Vernon NW Metropolitan 3 000 0 Odstock Wessex 3 000 4 Frenchay Western 1000 0 South Wales Chepstow 3 000 1 Midlands Birmingham Accident 6 000 3 Yorkshire Pinderfields 2 000 2 Manchester Booth Hall 2 000 2 Withington 1 000 0 Newcastle Royal Victoria 1 000 0 Scotland Edinburgh Eastern North Eastern
Bangour Sick Children’s Bridge of Earn Aberdeen Hospitals Total
62
2 000 - 2 000
0 1
500 1 000
0
32 500
18
1
Curling’s ulcer and Beales in 1949 reported 1 true Curling’s ulcer among 1500 burns seen in Newcastle. The overall incidence of gastroduodenal ulceration in burns in Great Britain is therefore about 1 in 1000 or less.
Denmark Thomsen and Srarensen (1968) and Srarensen and Thomsen (1969) reported the experience of the burns unit which admits all patients over 16 years old from the municipality of Copenhagen and which also admits each year some 50-75 severely burned patients from other parts of Denmark. They reviewed 1136 admissions from Copenhagen and found evidence of gastro-intestinal bleeding in 1 1 . Reviewing the whole work of the unit over an 8-year period, they found that only 3 patients among 1326 admissions required active treatment for bleeding-one man required a transfusion of 4 litres of blood and then stopped bleeding, one required a partial gastrectomy for multiple gastric erosions and one had a true Curling’s ulcer which was treated by suture of the gastroduodenal artery, vagotomy and pyloroplasty. All these 3 adult patients survived. Sweden
Arturson (1964) reported the treatment of 669 consecutive cases from Uppsala and its environs from 195161. Two fatal cases had gastro-intestinal bleeding.
ltaly Chisotti et al. (1971) treated 2300 burned patients in Milan over a period of 5 years; 883 (38 per cent) had burns involving 30 per cent or more of the body. Sixty-six autopsies were performed and no Curling’s ulcers were found, although in 3 there were multiple gastric erosions. Among the survivors, 18 had haematemesis or melaena but none required operative treatment. These workers stressed the importance of early feeding of burned patients. Czechoslovakia Vrabec et al. (1971) reported the experience of the Burns Unit, Charles University, Prague, where 10 477 patients were treated during 1953-70. Post-mortem examinations of 377 fatalities revealed 29 examples of gastro-intestinal ulceration. There were 4 true Curling’s ulcers, and 7 patients with single and 13 with multiple gastric ulcers; 5 patients had ulcers in both the stomach and the duodenum or colon. Only 2 of these patients died of bleeding and one of perforation, the remainder dying of septicaemia or burn shock. Among more than 10 000 survivors, 7 showed ‘positive clinical symptoms’ of gastroduodenal ulceration.
South Africa Levin (1929) commented on experience over 13 years in the Government Mortuary, Johannesburg, which conducted about 1000 autopsies each year. A careful search for ulceration in deaths due to burning had been maintained but only 2 examples had been foundboth duodenal ulcers in children.
Australia Biggs and Clarke (1964) reviewed 794 children treated at the Royal Children’s Hospital, Melbourne; one child showed gastro-intestinal haemorrhage. United States Jackson and Lee (1963) reported on 629 burned patients treated in Memphis, Tennessee, of whom 242 had burns involving more than 20 per cent of the body surface. Forty autopsies were performed and 15 gastric or duodenal ulcers were found, but only in 2 cases did haemorrhage cause death, although it may have been contributory in another 3. Ryan et al. (1965) studied 1022 patients in New Orleans between 1957 and 1962. A clinical diagnosis of gastric or duodenal ulceration was made in 36 patients (3.5 per cent), and this was confirmed in 30 who came to autopsy. Recent reports from the US Army Research Unit at the Brooke Medical Center, Texas, have given a much higher incidence of gastroduodenal ulceration than elsewhere. The latest report (Pruitt and O’Neill, 1971) showed that among 295 1 burned patients treated, 346 (11.7 per cent) gave evidence of gastroduodenal ulceration, and this group had a mortality rate of 77 per cent. In 246 patients the site of ulceration was confirmed; in 115 the ulceration was in the stomach and commonly multiple, while 91 had duodenal ulcers, which were mostly single. Forty-three patients required urgent surgery: in 36 for continued severe haemorrhage and in 7 for perforation. Partial gastrectomy, or antrectomy with vagotomy, was done in 34 patients, and 16 of the 43 survived.
Middle East War, I973 A brief report from Haifa (Mirschowitz and Mahler, 1974) on 61 burned casualties from tank warfare stated that 4 patients had gastro-intestinal haemorrhage, 2 of whom required surgical arrest of bleeding. One patient had a classic Curling’s ulcer and the other had a bleeding ulcer in the ascending colon and required hemicolectomy. The general policy was one of early burn excision with immediate skin cover, and of the 61 patients, only 4 died, all with 95-100 per cent burns. Curling’s ulcer in childhood There are only a few accounts of this condition in the literature and very few records of successful surgical treatment. The reports of Biggs and Clarke (1964), who found I case among 794 children, and of Choudhury (1964), who reported 2 cases among 2165 children, have already been mentioned. Harkins made the first full survey of the condition in 1938 and it was reviewed in detail by Abramson in 1964. Abramson found 90 autopsy cases in the world literature, of which 80 were duodenal ulcers, the great majority of these being true Curling’s ulcers. Forty-four of the 90 ulcers had bled during life and 12 had perforated. Three children recovered with non-surgical treatment of their ulcer haemorrhage, but only 2 survived who required surgical arrest of 63
Ian F. K. Muir and Peter F. Jones the haemorrhage. Lasserre (1960) was the first person to record a successful operation o n a Curling‘s ulcer; he treated a 6-year-old girl with 24 per cent burns of the buttocks, back and thighs who had repeated melaena from the third to the twentieth days after burning. On the following day she had a barium meal examination which showed a duodenal ulcer, and at operation a classic Curling’s ulcer was found, although it was not actively bleeding. A Polya partial gastrectomy was done, with smooth recovery. Abramson (1964) had a similar experience in a 10-year-old boy with 30 per cent burns who had melaena and repeated transfusions from the seventh to the seventeenth days, when he needed 1500ml of blood to replace the continued loss. At operation an ulcer in the anterosuperior wall of the first part of the duodenum was found and excised, but the profuse bleeding came from a posterior penetrating ulcer, and so the gastroduodenal artery was under-run, the right gastric artery tied off and the incision in the duodenum closed. The boy did not bleed again and recovered. Chenoweth and Dimick (1965) described a 3-yearold girl with 50 per cent flame burns who had a melaena on the fourth day and who began to bleed furiously on the sixth day, blood running out of her mouth. She was so shocked that her abdomen was opened without anaesthesia and a classic Curling’s ulcer was found-not only was the gastroduodenal artery spurting but the ulcer had perforated into the peritoneal cavity, so a Polya gastrectomy was performed, after under-running the bleeding artery. The child did well initially but later succumbed to pseudomonas septicaemia; she had begun to eat and the anastomosis was well healed at autopsy. Bruck and Pruitt (1972) reviewed their experience at the Brooke Center, Texas, where they had treated 477 burned children during 1959-71, and had seen 63 (1 3 per cent) examples of gastroduodenal ulceration, of whom 53 had died. Thirty-two had shown clinical evidence of ulceration, 14 having had massive bleeding and the others lesser degrees of bleeding. Four had clinically silent perforations, 2 being found at operation and 2 at autopsy. Five children had required operation for continued severe bleeding and all had died. It appears, therefore, that only 2 children have so far been successfully treated by surgery for continued haemorrhage due to a Curling’s ulcer.
Discussion It is remarkable that so well known a condition as Curling’s ulcer should prove on investigation to be such a rarity in clinical practice in Great Britain. There is a higher incidence if ulceration is sought at post-mortem examination, but it appears that thousands of burns can be treated without evidence of gastroduodenal haemorrhage or perforation. A very similar situation obtains in other European countries, where large series from Scandinavia, Italy and Czechoslovakia showed an incidence of 0.23 per cent of clinical bleeding among 14 580 patients admitted to burns units in these countries. 64
One report of a higher incidence comes from Ryan et al. (1965) in New Orleans. They treated 1022 burned patients and made a clinical diagnosis of ‘Curling’s ulcer’ in 36, an incidence of 5 per cent. However, among these were 351 patients in whom norethandrolone (an anabolic steroid) had been freely used, and these patients contributed 26 of the 36 ulcers. The reports of high incidence of ulceration come from military sources: a small and possibly unrepresentative report from Israel on tank warfare casualties, and a much larger long term survey from the US Army Surgical Research Institute. It is interesting that when this Institute started its reports in 1953 (Weigel et al., 1953) the incidence of ‘Curling’s ulceration’ was less than 1 per cent, and in 1957 among 1000 burned patients it was 2 per cent (Hummel et al., 1957), but in 1972 an incidence of 1 I per cent was reported. Even when care is taken to exclude multiple erosions, the incidence of true Curling’s ulcer is still much higher in the US Army Institute reports than in European and Australian reports, and there appear to be three possible reasons for this discrepancy. 1 . Administration of corticosteroids It is known that endogenous secretion of corticosteroids is a factor in the causation of stress ulcers, and a burn is a severe form of stress and leads to marked adrenal cortical secretion. Administration of corticosteroids for therapeutic reasons might, therefore, be expected to increase the risk of ulceration. The patient reported here received hydrocortisone for 12 hours in an attempt to diminish upper respiratory tract oedema, norethandrolone was freely used among the patients of Ryal et al. (1965) and Lasserre’s (1960) patient received cortancyl. These facts may be significant. It is unusual nowadays for corticosteroids to be given except for a specific indication such as laryngeal oedema, and there is no evidence that the US Army patients were generally treated with corticosteroids.
2. Infection It has been said in the past that infection increases the risk of alimentary ulceration in burns, but there is no direct evidence to support this. O’Neill et al. (1967) at the US Army Institute specifically investigated this point and found no evidence to support it. Infection was not noticeable in the present patient at the time that he bled. 3. Differences in shock treatment This is one aspect of burns therapy in which there is a clear difference between the prevailing practice in the United States and the United Kingdom. In Britain there is a general tendency to give relatively large volumes of plasma or other colloids in order to maintain not only the urine volume but also the blood volume, haeniatocrit and blood viscosity as near to normal levels as possible (Muir and Barclay, 1974). In the United States the tendency is to give relatively large volumes of electrolyte solutions, with little or
Curling’s ulcer
no colloid during the shock phase. Use of this regime has been shown to yield a high rate of survival during the period of shock, coupled with an ample urinary output. It is clear, however, that this type of management is associated with low blood volumes and a high haematocrit and blood viscosity (Moyer and Butcher, 1967). Even in the presence of a high urine output, it is apparent that these conditions could be associated with poor flow in the visceral microcirculation. It is possible in these circumstances for microvascular occlusion to occur in the vulnerable area of the first part of the duodenum, so exposing it to the progressive effects of peptic digestion which will declare itself clinically some days or weeks later. Friesen (1950) was emphatic that, in experimental burns of dogs, it was haemo-concentration which was the most consistent factor associated with the occurrence of gastroduodenal ulcers. When gastroduodenal ulceration occurs it can transform the prognosis of a burn. Bleeding from the eroded gastroduodenal artery is, naturally, fierce and surgical treatment is likely to be essential. The difficulties of operating through a deeply burnt abdominal wall are considerable, although not insuperable, as Abramson (1964) has shown. The essential procedure is to under-run the bleeding vessel with a non-absorbable suture-in the present case Dexon was used in the belief (Miller, 1974) that it would retain tensile strength longer than catgut but eventually be absorbed. Most surgeons have carried out ulcer-type operations to diminish acidity: however, Wilson et al. (1938) found acid secretion to be diminished in the first 2 weeks after burning in children, and both ONeill et al. (1967) and Sevitt (1967) found a high incidence of bacterial invasion of the ulcers seen at autopsy, which argues against hyperacidity. The logic of performing acid-reducing operations is therefore questionable, and Abramson (1964) simply under-ran the bleeding artery through a duodenotomy and closed this incision. His case is one of only 2 children known to have survived surgery for bleeding Curling’s ulcer, so that there is a good case for limiting the surgical procedure to the one which will secure haemostasis in the simplest and speediest manner. References (1964) Curling’s ulcer in childhood. Surgery 55, 321-336. ARTURSON G. (1964) Analysis of 38 deaths from burns. Acta Chir. Scand. 128, 2541. BIGGS J . s. G. and CLARKE A. M. (1964) Burns in children: 5-year survey of a burns unit. Med. J. Aust. 1, 787-792. BRAITHWAITE F. and BEALES P. H. (1949) Some observations on Curling’s ulcer. Br. J. Plast. Surg. 1, 284-287. BRUCK H. M. and PRUITT B. A. (1972) Curling’s ulcer in children: a 12-year review of 63 cases. J . Trauma 12, 490496. BULL J. P. (1971) Revised analysis of mortality due to burns. Lancet 2, 1 133-1 134. ABRAMSON D. J.
and DIMICK A. R. (1965) Stress Ulcer in infants and children. Ann. Surg. 161, 977-982. CHOUDHURY M. (1963) Two further cases of Curling’s ulcer in major burns in children. Br. Med. J. 1, 448449. COOPER s. (1839) Pathology of burns and scalds. Lond. Med. Gar. I (1838-39), 835-838. CURLING T. B. (1842) On acute ulceration of the duodenum in cases of burn. Med. Chir. Trans. Lond. 25, 260-281. DUPUYTREN BARON (1 832) Legons Orales de Clinique Chirurgical. Vol. 1. Paris, G. Bailliere, p. 459. FRIESEN s. R. (1950) Genesis of gastroduodenal ulceration following burns : an experimental study. Surgery 28, 123-1 58. GRISOTTI A., SAVOIA A. and TAIDELLI G. (1971) Statistical research on Curling’s ulcer. Acta Chir. Plast. (Praha) 13, 83-86. HARKINS H. N. (1938) Acute ulcer of the duodenum (Curling’s ulcer), as a complication of burns. Surgery 3, 608-641. HUMMEL R. P., LANCHANTIN G. F. and ARTZ c. P. (1957) Clinical experiences and studies in Curling’s ulcer. JAMA 164, 141-146. JACKSON T. M. and LEE w. H. (1963) Major thermal burns. Arch. Surg. 87, 937-948. LASSERRE J. (1960) Ulcere hkmorrhagique du duodenum chez une fillette briilee a 25 p. 100 de la surface corporelle: gastrectomie: guerison. Bordeaux Chir. 1, 33-35. LEVIN J. J. (1929) Duodenal ulcers following burns. Br. J. Surg. 17, 110-113. LEWIS E. A. (1973) Gastroduodenal ulceration and haemorrhage of neurogenic origin. Br. J. Surg. 60, 279-283. LONG J. (1840) Post-mortem appearances found after burns. Lond. Med. Gaz. 1 (183940), 743-750. MILLER s. s. (1974) Absorption rates of catgut and dexon in pyloric mucosa. Paper read to Scottish Society for Experimental Medicine, Aberdeen. MIRSCHOWITZ B. and MAHLER E. (1974) The Middle East War, 1973. Newsletter, May 1974, International Confederation for Plastic and Reconstructive Surgery. MOYER c. A. and BUTCHER N. R . (1967) Burns, Shock and Plasma Volume Regulation. St Louis, Mosby, pp. 262-264. MUIR I. F. K. and BARCLAY T. L. (1974) Burns and Their Treatment, 2nd ed. London, Lloyd-Luke, pp. 2028. O’NEILL J. A., PRUITT B. A., MONCRIEF J. A. and SWITZER w. E. (1967) Studies related to the pathogenesis of Curling’s ulcer. J . Trauma 7, 275-287. PRUITT B. A. and O’NEILL J. A. (1971) Diagnosis and treatment of Curling’s ulcer: a report of 346 cases. In: MATTER P., BARCLAY T. L. and KONICKOVA z. (ed.) Research in Burns. Berne, Huber, pp. 465467. RYAN R. F., GAY J. s., VINCENT v. and LONGNECKER c. G. (1965) Stress ulcers of the upper gastrointestinal tract after burns : Curling’s ulcer. Plast. Reconstr. Surg. 35, 385-390.
CHENOWETH A. I.
65
Ian F. K. Muir and Peter F. Jones SEVITT s. (1967) Duodenal
and gastric ulceration after burning. Br. J. Surg. 54, 32-41. S0RENSEN B. and THOMSEN M. (1969) Three cases Of gastrointestinal bleeding following burns. Actu Chir. Scund. (Suppl.) 396, 36-40. SWAN J. (1823) Case of severe burn. Edin. Med. J. 19, 344-345. THOMSEN M. and S0RENSEN B. (1968) The Burns Unit in Copenhagen. IV. Gastrointestinal bleeding complicating burns. Scund. J. Plust. Reconstr. Surg. 2, 24-3 I.
66
and DRUGOVA B. (1971) Curling’s ulcer. Actu Chir. Plust. (Pruhu) 13, 176182. WEIGEL A . E., ARTZ c. P., REISS E., DAVIS J. H. and AMSPACKER w . H. (1953) Gastrointestinal ulcerations complicating burns. Surgery 34, 826-836. WILSON W . C., MACGREGOR A. R . and STEWART C. P. (1938) Clinical course and pathology of burns and scalds. Br. J. Surg. 25, 826-865. VRABEC R., KOLAR J.
Curling’s ulcer: a rare condition I A N F. K. M U I R A N D P E T E R F. J O N E S *
G. W. was a boy of 28 years. On 23 August 1973 he set fire to a vinyl settee on which he was playing with matches. About
was found to have flame burns of his face, the front of his trunk and all four limbs. Approximately 50 per cent of the body surface was burnt, of which 25 per cent was deep burning, including the whole of the hands, abdomen, thighs and the dorsum of the feet. H e weighed 15 kg. The treatment during the shock period followed orthodox lines except that the patient developed stridor, which was treated by humidification of inspired air and administration of 300 mg of hydrocortisone intravenously over a period of 12 hours on the day of admission. There was no hypotension during the shock period and the treatment is summarized in Table I . When transferred to the Royal Aberdeen Children’s Hospital o n the sixth day the temperature was 39 “C, pulse 120/minute, haernoglobin 11.8 g/100 ml, PCV 30 per cent and serum urea 43 mg per cent. His general condition was good. There was burn eschar over the whole of the face, chest, abdomen, arms, hands and the front of both legs and feet; the burns of the hands were exceptionally deep. Wound swabs grew Staphylococcus albus only, O n the eighth day the hands and legs were dressed with sulphamylon, and the remainder of the burns exposed. It was first noted o n this day that the patient was reluctant to eat and from this time onwards food and drink were increasingly refused. His temperature remained around 39 “C and pulse 120-130/minute. On the eleventh day the temperature suddenly fell to 36 “C and then to 35.5 “C (Fig. 1). At 4 p.m. o n the twelfth day (4 September) the pulse suddenly rose to 170, then 180/minute, and he became very pale and passed two large stools of clotted blood. A central venous catheter was rapidly introduced and 400 ml of Hartmann’s solution and 1 litre of blood were transfused over the next 5 hours. During that time blood pressure was maintained but further dark red stools were passed, followed by a remarkable 90-cm length of pure clotted blood bearing the imprints of the valvulae conniventes of the small intestine, and further clots were passed throughout the evening. A litre of blood was transfused between 11 p.m. (4 September) and 2 a.m. ( 5 September), but red clots continued to pass per rectum. It was concluded that the source was probably a duodenal ulcer and that bleeding was continuing at such a rate that surgical arrest was essential. Operation was commenced at 3 a.m. on the thirteenth day after burning. A right paramedian incision was made through the tough burn eschar. The duodenum was distended with blood and clot, and blood was present throughout the small and large bowel. An incision across the pylorus revealed a deep posterior ulcer of the first part of the duodenum, and the gastroduodenal artery was bleeding briskly in its base (Fig. 2). The artery was under-run with three Dexon sutures, much clot was evacuated by sucker from the stomach and duodenum and the incision was closed as a Finney pyloroplasty. Substantial anterior and posterior vagal trunks were identified and crushed with artery forceps. A drain was inserted and the wound was closed with Prolene, with deep retention sutures of nylon. A further 1.5 litres of blood were transfused during the operation. Later that day the haemoglobin was 16 g per cent and during the 24 hours after operation 1200 ml of urine were passed. Intravenous feeding was commenced from the time of operation, and o n the third day after operation oral fluids wwe started. There was no sign of recurrent haemorI hage after the operakion. Partial collapse of the apex and lo&er lobe of the right lung gave rise to some anxiety at this time, but this problem
4 hours later he was admitted to the Royal Northern Infirmary, Inverness, under the care of Mr G. S. Anderson, where he
* Royal
SUMMARY
A case of Curling’s ulceration of the duodenum in a child with 50 per cent burns, requiring operative arrest of’ the bleeding, is reported, and this condition i s reviewed. Inquiry among the surgical units treating burns in Great Britain showed that only 18 cases of alimentary bleeding had been seen in the course of treating some 32 500 patients. The incidence in Europe and Australia appears to be of the same order, bur there is a much higher incidence in some burns units in North America. Possible reasons for these differences are examined. The occurrence and treatment o j Curling’s ulcer in childhood are considered.
IN 1842 T. B. Curling, then Assistant Surgeon to the London Hospital, described 3 severely burned children, aged 4 , 8 and 1 l years, who had suffered haematemesis or melaena between I0 and 18 days after burning. At autopsy each was found to have a posterior penetrating ulcer of the first part of the duodenum, between 4 and 1 inch (1.5-2.5cm) in diameter, in the depths of which lay the eroded gastroduodenal artery. He also described the postmortem findings in a boy of 39 years who had a posterior duodenal ulcer, but who had shown no evidence of bleeding during life. Samuel Cooper of University College Hospital had previously described 2 similar cases in 1839, and in 1840 James Long of Liverpool had reported 2 young women with burns who had perforated duodenal ulcers. These two descriptions appeared in papers on the post-mortem changes found in burning accidents, but it was Curling who pointed out the specific connection between this type of ulcer and the burn injury. He entitled his paper ‘On acute ulceration of the duodenum in cases of burn’, and may justifiably be considered to be the person who established the existence of this striking and serious complication of burns and scalds. An example of such an ulcer in a 2-year-old boy has recently been seen at the Royal Aberdeen Children’s Hospital, and this was the first Curling’s ulcer to be seen in the course of treating some 3000 burns and scalds which required admission to hospital. It would appear therefore that, in spite of being so wellknown, Curling’s ulceration is a rare event, and this experience has prompted the present review of the condition. Case report
60
Aberdeen Children’s Hospital, Aberdeen.
Curling’s ulcer settled with frequent physiotherapy. Also a t this time considerable suppuration began to be evident under the burn eschar, especially over the arms and hands, and swabs yielded a profuse growth of Staphylococcus pyogenes and Escherichiu coli. On the fourth postoperative day it was evident that suppuration around the burn eschar was worse and that the laparotomy wound was not healing, in spite of continued intravenous feeding. On the following day a trickle of bile was seen along the drain track and this became obvious on the following day, and so oral feeding was discontinued. It was now clear that there was total failure of healing of the laparotomy wound, and there was widespread sepsis under the burn eschar. The boy’s condition deteriorated steadily, with spreading pneumonic changes in both lungs, and he died on the twenty-third day after burning.
Definition and pathology The ulcer seen in this patient was similar to those described 133 years ago by Curling, and by many other surgeons and pathologists since then. However, over the years the eponym ‘Curling’s ulcer’ has been widely but incorrectly used as a general term covering all forms of gastroduodenal (and even oesophageal) ulceration associated with burns and scalds. Examples of these different ulcers were described even before the papers of Cooper, Long and Curling. Swan (1823) was the first to describe gastric erosions. Dupuytren (1832) reported a 27-year-old portress, 4 months’ pregnant, who fell asleep in front of the fire where her clothes caught alight; she died within 48 hours, without showing signs of bleeding, and at autopsy multiple small ulcers were seen in the stomach. Further studies, largely in post-mortem series, have shown considerable differences between these gastric and duodenal ulcers (O’Neill et al., 1967; Sevitt, 1967; Thomsen and Serrensen, 1968). 1 . Gastric ulcers were roughly twice as common as those in the duodenum. 2. The gastric ulcers were superficial in character. About one-third of them were multiple, tiny and disseminated, while the other two-thirds were either single erosions or zones of irregular erosion. By contrast, the duodenal ulcers were deeper. About twothirds were single, posterior and penetrating; the other one-third was multiple but one ulcer was always on the posterior wall. 3. Sevitt (1967) found that the gastric ulcers characteristically occurred shortly after injury and that the incidence was related to the severity of burning. Duodenal ulcers tended (especially in children) to occur
after the first week and to have a maximal incidence in those whose burns involved 50 per cent or less of the body surface. 4. In children there was a preponderance of duodenal ulcers. Abramson (1 964) surveyed 90 reports of post-mortems on children and found that in 80 the ulcer was in the duodenum and the majority of these were single, posterior and penetrating. C 40
r
- IOOL
,
31 LI--L21-3 A“g Sept 9
1-4-L5--L6-i74 Days 10
I1
I2
13 0
14 1
IS
After b u r n i n g
2
After operation
Fig. 1. Temperature and pulse chart for the period before and after haemorrhage from Curling’s ulcer.
Fig. 2. Photograph during laparotomy. The incision through the pylorus and duodenum is held open by forceps and retractors; the stomach is held up in the centre of the upper half of the photograph. A sucker enters from the right upper corner and its tip lies in the ulcer crater, keeping it clear of blood. Clot can be seen just below the lower rim of the ulcer.
Table I: FLUID INTAKE AND OUTPUT ON THE 4 DAYS AFTER BURNING Fluids by mouth
Date
Period of time (hr)
(ml)
Blood
Plasma
5% Dextrose
23 August
12
170
-
1200
-
400
100
24 August
12
-
800 400
400
-
-
-
12
430 780
400
-
430
12 12’
170
-
-
1000
400
400
-
-
12 12
140
-
-
500
100
220
500
500
-
3 50
470
25 August 26 August
Volume of urine
Intravenous fluids
-
Ringer-lactate Mannitol 10%
(ml)
250 255
320 440
355
61
Ian F. K. Muir and Peter F. Jones There is much to suggest that these true Curling’s duodenal ulcers are a specific complication of burns, but Lewis (1973) has pointed out that very similar ulcers also occur in children with brain stem compression due to tumours or injury. She reported 16 neurosurgical patients between 3 and 12 years of age with alimentary bleeding; 8 required operation to stop the bleeding and 7 of these had posterior penetrating ulcers with erosion of the gastroduodenal artery. I t is also noticeable that the multiple gastric ulcers and erosions seen in burns bear a strong resemblance to the stress ulcers seen in other severe injuries. It should be emphasized that the majority of ulcers in burned patients are only discovered as an incidental finding at post-mortem examination. Sevitt (1967), for instance, performed autopsies on 29 I burned patients and found 25 acute duodenal ulcers and 42 gastric erosions but only in 3 of the patients with duodenal ulcer had haemorrhage occurred during life. Clinical evidence of acute ulceration as manifested by overt haemorrhage (or occasionally perforation) is in the authors’ experience very rare, and this rarity contrasts strongly with some North American experience. Therefore, further investigation of the incidence of alimentary tract ulceration after burning accidents has been carried out.
Incidence Great Britain
A letter was sent to a senior consultant in each of the major burn units, seeking information about the occurrence of gastroduodenal ulceration and the need for operative intervention to stop haemorrhage. Fourteen centres replied and the information is summarized in Table If. The annual number of admissions to these units varies but most admit between 100 and 200 new patients each year, and the survey extends back over 15 or more years of experience. This means that the total number of burned patients being surveyed
is over 30000, and yet there is only evidence of 18 patients with memorable bleeding. The dramatic nature of the events suffered by the patient reported here would make it unlikely that experienced surgeons would forget similar occurrences, and therefore this survey probably reflects the true incidence of bleeding Curling’s ulcer in Great Britain. The experience at the Burns Unit of the Birmingham Accident Hospital is particularly well documented. During 1948-65 Sevitt (1967) carried out an autopsy examination on 291 of the 477 patients dying in the unit. He found that 68 patients had ulceration of the stomach or duodenum but only one, a girl of 3 with 30 per cent burns, had died from haemorrhage, which occurred suddenly on the twenty-second day from a classic Curling’s ulcer. Two other patients bled during life but died with septicaemia, and one man who died suddenly on the twelfth day was found to have a perforated anterior duodenal ulcer which had been silent during life. There was no clinical evidence of haemorrhage--except possibly coffeeground vomiting-in any of the 42 patients with gastric ulceration. The paper of Bull (1971) shows that the Birmingham Burns Unit has an annual admission rate of some 320 adults and children, so that during the years 1958-65 about 5760 patients were admitted. With 477 deaths the mortality rate was about 8.3 per cent, the incidence of gastric and duodenal ulceration among post-mortems was 9 per cent but the occurrence of overt bleeding was limited to 3 patients among 5760 patients, and only 1 patient died from alimentary haemorrhage. A rather similar incidence was found in the only other relevant report from the British Isles during the past 20 years. Choudhury (1963) reviewed 2165 children admitted to a burns unit in Manchester between 1954 and 1961. There were 68 deaths (3 per cent) and among these were the only 2 children to show melaena: one had a true Curling’s ulcer and the other an ulcer on the greater curvature of the stomach. Braithwaite
Table 1 1 : SUMMARY OF INFORMATION OBTAINED FROM BURN CENTRES IN GREAT BRITAIN Approximate Known clinical No. of patients cases of Region Burn centre admitted Curling‘s ulcer England SW Metropolitan Roehampton 3 000 2 East Grinstead 2 000 SE Metropolitan 2 Mount Vernon NW Metropolitan 3 000 0 Odstock Wessex 3 000 4 Frenchay Western 1000 0 South Wales Chepstow 3 000 1 Midlands Birmingham Accident 6 000 3 Yorkshire Pinderfields 2 000 2 Manchester Booth Hall 2 000 2 Withington 1 000 0 Newcastle Royal Victoria 1 000 0 Scotland Edinburgh Eastern North Eastern
Bangour Sick Children’s Bridge of Earn Aberdeen Hospitals Total
62
2 000 - 2 000
0 1
500 1 000
0
32 500
18
1
Curling’s ulcer and Beales in 1949 reported 1 true Curling’s ulcer among 1500 burns seen in Newcastle. The overall incidence of gastroduodenal ulceration in burns in Great Britain is therefore about 1 in 1000 or less.
Denmark Thomsen and Srarensen (1968) and Srarensen and Thomsen (1969) reported the experience of the burns unit which admits all patients over 16 years old from the municipality of Copenhagen and which also admits each year some 50-75 severely burned patients from other parts of Denmark. They reviewed 1136 admissions from Copenhagen and found evidence of gastro-intestinal bleeding in 1 1 . Reviewing the whole work of the unit over an 8-year period, they found that only 3 patients among 1326 admissions required active treatment for bleeding-one man required a transfusion of 4 litres of blood and then stopped bleeding, one required a partial gastrectomy for multiple gastric erosions and one had a true Curling’s ulcer which was treated by suture of the gastroduodenal artery, vagotomy and pyloroplasty. All these 3 adult patients survived. Sweden
Arturson (1964) reported the treatment of 669 consecutive cases from Uppsala and its environs from 195161. Two fatal cases had gastro-intestinal bleeding.
ltaly Chisotti et al. (1971) treated 2300 burned patients in Milan over a period of 5 years; 883 (38 per cent) had burns involving 30 per cent or more of the body. Sixty-six autopsies were performed and no Curling’s ulcers were found, although in 3 there were multiple gastric erosions. Among the survivors, 18 had haematemesis or melaena but none required operative treatment. These workers stressed the importance of early feeding of burned patients. Czechoslovakia Vrabec et al. (1971) reported the experience of the Burns Unit, Charles University, Prague, where 10 477 patients were treated during 1953-70. Post-mortem examinations of 377 fatalities revealed 29 examples of gastro-intestinal ulceration. There were 4 true Curling’s ulcers, and 7 patients with single and 13 with multiple gastric ulcers; 5 patients had ulcers in both the stomach and the duodenum or colon. Only 2 of these patients died of bleeding and one of perforation, the remainder dying of septicaemia or burn shock. Among more than 10 000 survivors, 7 showed ‘positive clinical symptoms’ of gastroduodenal ulceration.
South Africa Levin (1929) commented on experience over 13 years in the Government Mortuary, Johannesburg, which conducted about 1000 autopsies each year. A careful search for ulceration in deaths due to burning had been maintained but only 2 examples had been foundboth duodenal ulcers in children.
Australia Biggs and Clarke (1964) reviewed 794 children treated at the Royal Children’s Hospital, Melbourne; one child showed gastro-intestinal haemorrhage. United States Jackson and Lee (1963) reported on 629 burned patients treated in Memphis, Tennessee, of whom 242 had burns involving more than 20 per cent of the body surface. Forty autopsies were performed and 15 gastric or duodenal ulcers were found, but only in 2 cases did haemorrhage cause death, although it may have been contributory in another 3. Ryan et al. (1965) studied 1022 patients in New Orleans between 1957 and 1962. A clinical diagnosis of gastric or duodenal ulceration was made in 36 patients (3.5 per cent), and this was confirmed in 30 who came to autopsy. Recent reports from the US Army Research Unit at the Brooke Medical Center, Texas, have given a much higher incidence of gastroduodenal ulceration than elsewhere. The latest report (Pruitt and O’Neill, 1971) showed that among 295 1 burned patients treated, 346 (11.7 per cent) gave evidence of gastroduodenal ulceration, and this group had a mortality rate of 77 per cent. In 246 patients the site of ulceration was confirmed; in 115 the ulceration was in the stomach and commonly multiple, while 91 had duodenal ulcers, which were mostly single. Forty-three patients required urgent surgery: in 36 for continued severe haemorrhage and in 7 for perforation. Partial gastrectomy, or antrectomy with vagotomy, was done in 34 patients, and 16 of the 43 survived.
Middle East War, I973 A brief report from Haifa (Mirschowitz and Mahler, 1974) on 61 burned casualties from tank warfare stated that 4 patients had gastro-intestinal haemorrhage, 2 of whom required surgical arrest of bleeding. One patient had a classic Curling’s ulcer and the other had a bleeding ulcer in the ascending colon and required hemicolectomy. The general policy was one of early burn excision with immediate skin cover, and of the 61 patients, only 4 died, all with 95-100 per cent burns. Curling’s ulcer in childhood There are only a few accounts of this condition in the literature and very few records of successful surgical treatment. The reports of Biggs and Clarke (1964), who found I case among 794 children, and of Choudhury (1964), who reported 2 cases among 2165 children, have already been mentioned. Harkins made the first full survey of the condition in 1938 and it was reviewed in detail by Abramson in 1964. Abramson found 90 autopsy cases in the world literature, of which 80 were duodenal ulcers, the great majority of these being true Curling’s ulcers. Forty-four of the 90 ulcers had bled during life and 12 had perforated. Three children recovered with non-surgical treatment of their ulcer haemorrhage, but only 2 survived who required surgical arrest of 63
Ian F. K. Muir and Peter F. Jones the haemorrhage. Lasserre (1960) was the first person to record a successful operation o n a Curling‘s ulcer; he treated a 6-year-old girl with 24 per cent burns of the buttocks, back and thighs who had repeated melaena from the third to the twentieth days after burning. On the following day she had a barium meal examination which showed a duodenal ulcer, and at operation a classic Curling’s ulcer was found, although it was not actively bleeding. A Polya partial gastrectomy was done, with smooth recovery. Abramson (1964) had a similar experience in a 10-year-old boy with 30 per cent burns who had melaena and repeated transfusions from the seventh to the seventeenth days, when he needed 1500ml of blood to replace the continued loss. At operation an ulcer in the anterosuperior wall of the first part of the duodenum was found and excised, but the profuse bleeding came from a posterior penetrating ulcer, and so the gastroduodenal artery was under-run, the right gastric artery tied off and the incision in the duodenum closed. The boy did not bleed again and recovered. Chenoweth and Dimick (1965) described a 3-yearold girl with 50 per cent flame burns who had a melaena on the fourth day and who began to bleed furiously on the sixth day, blood running out of her mouth. She was so shocked that her abdomen was opened without anaesthesia and a classic Curling’s ulcer was found-not only was the gastroduodenal artery spurting but the ulcer had perforated into the peritoneal cavity, so a Polya gastrectomy was performed, after under-running the bleeding artery. The child did well initially but later succumbed to pseudomonas septicaemia; she had begun to eat and the anastomosis was well healed at autopsy. Bruck and Pruitt (1972) reviewed their experience at the Brooke Center, Texas, where they had treated 477 burned children during 1959-71, and had seen 63 (1 3 per cent) examples of gastroduodenal ulceration, of whom 53 had died. Thirty-two had shown clinical evidence of ulceration, 14 having had massive bleeding and the others lesser degrees of bleeding. Four had clinically silent perforations, 2 being found at operation and 2 at autopsy. Five children had required operation for continued severe bleeding and all had died. It appears, therefore, that only 2 children have so far been successfully treated by surgery for continued haemorrhage due to a Curling’s ulcer.
Discussion It is remarkable that so well known a condition as Curling’s ulcer should prove on investigation to be such a rarity in clinical practice in Great Britain. There is a higher incidence if ulceration is sought at post-mortem examination, but it appears that thousands of burns can be treated without evidence of gastroduodenal haemorrhage or perforation. A very similar situation obtains in other European countries, where large series from Scandinavia, Italy and Czechoslovakia showed an incidence of 0.23 per cent of clinical bleeding among 14 580 patients admitted to burns units in these countries. 64
One report of a higher incidence comes from Ryan et al. (1965) in New Orleans. They treated 1022 burned patients and made a clinical diagnosis of ‘Curling’s ulcer’ in 36, an incidence of 5 per cent. However, among these were 351 patients in whom norethandrolone (an anabolic steroid) had been freely used, and these patients contributed 26 of the 36 ulcers. The reports of high incidence of ulceration come from military sources: a small and possibly unrepresentative report from Israel on tank warfare casualties, and a much larger long term survey from the US Army Surgical Research Institute. It is interesting that when this Institute started its reports in 1953 (Weigel et al., 1953) the incidence of ‘Curling’s ulceration’ was less than 1 per cent, and in 1957 among 1000 burned patients it was 2 per cent (Hummel et al., 1957), but in 1972 an incidence of 1 I per cent was reported. Even when care is taken to exclude multiple erosions, the incidence of true Curling’s ulcer is still much higher in the US Army Institute reports than in European and Australian reports, and there appear to be three possible reasons for this discrepancy. 1 . Administration of corticosteroids It is known that endogenous secretion of corticosteroids is a factor in the causation of stress ulcers, and a burn is a severe form of stress and leads to marked adrenal cortical secretion. Administration of corticosteroids for therapeutic reasons might, therefore, be expected to increase the risk of ulceration. The patient reported here received hydrocortisone for 12 hours in an attempt to diminish upper respiratory tract oedema, norethandrolone was freely used among the patients of Ryal et al. (1965) and Lasserre’s (1960) patient received cortancyl. These facts may be significant. It is unusual nowadays for corticosteroids to be given except for a specific indication such as laryngeal oedema, and there is no evidence that the US Army patients were generally treated with corticosteroids.
2. Infection It has been said in the past that infection increases the risk of alimentary ulceration in burns, but there is no direct evidence to support this. O’Neill et al. (1967) at the US Army Institute specifically investigated this point and found no evidence to support it. Infection was not noticeable in the present patient at the time that he bled. 3. Differences in shock treatment This is one aspect of burns therapy in which there is a clear difference between the prevailing practice in the United States and the United Kingdom. In Britain there is a general tendency to give relatively large volumes of plasma or other colloids in order to maintain not only the urine volume but also the blood volume, haeniatocrit and blood viscosity as near to normal levels as possible (Muir and Barclay, 1974). In the United States the tendency is to give relatively large volumes of electrolyte solutions, with little or
Curling’s ulcer
no colloid during the shock phase. Use of this regime has been shown to yield a high rate of survival during the period of shock, coupled with an ample urinary output. It is clear, however, that this type of management is associated with low blood volumes and a high haematocrit and blood viscosity (Moyer and Butcher, 1967). Even in the presence of a high urine output, it is apparent that these conditions could be associated with poor flow in the visceral microcirculation. It is possible in these circumstances for microvascular occlusion to occur in the vulnerable area of the first part of the duodenum, so exposing it to the progressive effects of peptic digestion which will declare itself clinically some days or weeks later. Friesen (1950) was emphatic that, in experimental burns of dogs, it was haemo-concentration which was the most consistent factor associated with the occurrence of gastroduodenal ulcers. When gastroduodenal ulceration occurs it can transform the prognosis of a burn. Bleeding from the eroded gastroduodenal artery is, naturally, fierce and surgical treatment is likely to be essential. The difficulties of operating through a deeply burnt abdominal wall are considerable, although not insuperable, as Abramson (1964) has shown. The essential procedure is to under-run the bleeding vessel with a non-absorbable suture-in the present case Dexon was used in the belief (Miller, 1974) that it would retain tensile strength longer than catgut but eventually be absorbed. Most surgeons have carried out ulcer-type operations to diminish acidity: however, Wilson et al. (1938) found acid secretion to be diminished in the first 2 weeks after burning in children, and both ONeill et al. (1967) and Sevitt (1967) found a high incidence of bacterial invasion of the ulcers seen at autopsy, which argues against hyperacidity. The logic of performing acid-reducing operations is therefore questionable, and Abramson (1964) simply under-ran the bleeding artery through a duodenotomy and closed this incision. His case is one of only 2 children known to have survived surgery for bleeding Curling’s ulcer, so that there is a good case for limiting the surgical procedure to the one which will secure haemostasis in the simplest and speediest manner. References (1964) Curling’s ulcer in childhood. Surgery 55, 321-336. ARTURSON G. (1964) Analysis of 38 deaths from burns. Acta Chir. Scand. 128, 2541. BIGGS J . s. G. and CLARKE A. M. (1964) Burns in children: 5-year survey of a burns unit. Med. J. Aust. 1, 787-792. BRAITHWAITE F. and BEALES P. H. (1949) Some observations on Curling’s ulcer. Br. J. Plast. Surg. 1, 284-287. BRUCK H. M. and PRUITT B. A. (1972) Curling’s ulcer in children: a 12-year review of 63 cases. J . Trauma 12, 490496. BULL J. P. (1971) Revised analysis of mortality due to burns. Lancet 2, 1 133-1 134. ABRAMSON D. J.
and DIMICK A. R. (1965) Stress Ulcer in infants and children. Ann. Surg. 161, 977-982. CHOUDHURY M. (1963) Two further cases of Curling’s ulcer in major burns in children. Br. Med. J. 1, 448449. COOPER s. (1839) Pathology of burns and scalds. Lond. Med. Gar. I (1838-39), 835-838. CURLING T. B. (1842) On acute ulceration of the duodenum in cases of burn. Med. Chir. Trans. Lond. 25, 260-281. DUPUYTREN BARON (1 832) Legons Orales de Clinique Chirurgical. Vol. 1. Paris, G. Bailliere, p. 459. FRIESEN s. R. (1950) Genesis of gastroduodenal ulceration following burns : an experimental study. Surgery 28, 123-1 58. GRISOTTI A., SAVOIA A. and TAIDELLI G. (1971) Statistical research on Curling’s ulcer. Acta Chir. Plast. (Praha) 13, 83-86. HARKINS H. N. (1938) Acute ulcer of the duodenum (Curling’s ulcer), as a complication of burns. Surgery 3, 608-641. HUMMEL R. P., LANCHANTIN G. F. and ARTZ c. P. (1957) Clinical experiences and studies in Curling’s ulcer. JAMA 164, 141-146. JACKSON T. M. and LEE w. H. (1963) Major thermal burns. Arch. Surg. 87, 937-948. LASSERRE J. (1960) Ulcere hkmorrhagique du duodenum chez une fillette briilee a 25 p. 100 de la surface corporelle: gastrectomie: guerison. Bordeaux Chir. 1, 33-35. LEVIN J. J. (1929) Duodenal ulcers following burns. Br. J. Surg. 17, 110-113. LEWIS E. A. (1973) Gastroduodenal ulceration and haemorrhage of neurogenic origin. Br. J. Surg. 60, 279-283. LONG J. (1840) Post-mortem appearances found after burns. Lond. Med. Gaz. 1 (183940), 743-750. MILLER s. s. (1974) Absorption rates of catgut and dexon in pyloric mucosa. Paper read to Scottish Society for Experimental Medicine, Aberdeen. MIRSCHOWITZ B. and MAHLER E. (1974) The Middle East War, 1973. Newsletter, May 1974, International Confederation for Plastic and Reconstructive Surgery. MOYER c. A. and BUTCHER N. R . (1967) Burns, Shock and Plasma Volume Regulation. St Louis, Mosby, pp. 262-264. MUIR I. F. K. and BARCLAY T. L. (1974) Burns and Their Treatment, 2nd ed. London, Lloyd-Luke, pp. 2028. O’NEILL J. A., PRUITT B. A., MONCRIEF J. A. and SWITZER w. E. (1967) Studies related to the pathogenesis of Curling’s ulcer. J . Trauma 7, 275-287. PRUITT B. A. and O’NEILL J. A. (1971) Diagnosis and treatment of Curling’s ulcer: a report of 346 cases. In: MATTER P., BARCLAY T. L. and KONICKOVA z. (ed.) Research in Burns. Berne, Huber, pp. 465467. RYAN R. F., GAY J. s., VINCENT v. and LONGNECKER c. G. (1965) Stress ulcers of the upper gastrointestinal tract after burns : Curling’s ulcer. Plast. Reconstr. Surg. 35, 385-390.
CHENOWETH A. I.
65
Ian F. K. Muir and Peter F. Jones SEVITT s. (1967) Duodenal
and gastric ulceration after burning. Br. J. Surg. 54, 32-41. S0RENSEN B. and THOMSEN M. (1969) Three cases Of gastrointestinal bleeding following burns. Actu Chir. Scund. (Suppl.) 396, 36-40. SWAN J. (1823) Case of severe burn. Edin. Med. J. 19, 344-345. THOMSEN M. and S0RENSEN B. (1968) The Burns Unit in Copenhagen. IV. Gastrointestinal bleeding complicating burns. Scund. J. Plust. Reconstr. Surg. 2, 24-3 I.
66
and DRUGOVA B. (1971) Curling’s ulcer. Actu Chir. Plust. (Pruhu) 13, 176182. WEIGEL A . E., ARTZ c. P., REISS E., DAVIS J. H. and AMSPACKER w . H. (1953) Gastrointestinal ulcerations complicating burns. Surgery 34, 826-836. WILSON W . C., MACGREGOR A. R . and STEWART C. P. (1938) Clinical course and pathology of burns and scalds. Br. J. Surg. 25, 826-865. VRABEC R., KOLAR J.
