Medical information portal "vivmed". Treatment of bleeding duodenal ulcer

GASTROENTEROLOGY - EURODOCTOR.ru -2005

Bleeding occur when damage to the vessel occurs in the area of ​​​​the ulcer. The mechanism of vascular injury may be different. An ulcer gradually corrodes the wall of the vessel or a heart attack occurs in the wall of the stomach. The frequency of bleeding in patients with peptic ulcer is 10-12%, and bleeding from duodenal ulcers occur 5 times more often than from stomach ulcers. Sometimes bleeding can be the first sign of a peptic ulcer, if before that the ulcerative process was erased.

Bleeding divide on the:

• explicit
• hidden.

Hidden bleeding occurs when a small vessel is damaged. In this case, blood loss is insignificant and such bleeding can be detected only with the help of a special Gregersen reaction. Bleeding can be single and stop after a while on its own. Repeated bleeding occurs in the coming hours or days. The most dangerous is incessant bleeding.

obvious bleeding is always accompanied by significant blood loss and is manifested by three main signs:

• Hematemesis.
• Tar-like stool (melena).
• Signs of general blood loss from the whole body.

Hematemesis usually occurs with bleeding from stomach ulcers, less often with duodenal ulcers, because in order for vomiting to occur, blood from the duodenum must enter the stomach. This occurs only with massive bleeding in the duodenum. The vomit is dark brown in color. The vomit is said to look like "coffee grounds". The color is explained by the digestion of hemoglobin and its transformation under the influence of hydrochloric acid into hematin hydrochloride, which has a dark brown color. If a large amount of blood is poured into the stomach at once, the vomit may contain red blood, although this is more common with bleeding from the esophagus. Hematemesis occurs immediately after bleeding or, with a large amount of blood, immediately during bleeding.

Melena. When blood enters the duodenum from the stomach or when bleeding from the duodenum itself, the blood moves further along the intestine. Under the influence of microorganisms living in the intestine, iron sulphides of iron are formed from hemoglobin iron, which are black in color. At the exit from the intestines, the feces are colored black and have a mushy consistency. This is called tarry stool. If bleeding occurs from the ulcer, the patient's pain decreases or disappears. This disappearance of pain is called Bergman's symptom.

Common symptoms of acute blood loss depend on the amount of blood lost, the rate of bleeding. In an adult weighing 70 kg, the average blood volume is about 5 liters. The loss of 10% of the total blood volume does not show serious general disorders and is considered mild. The patient may experience mild nausea, chills, weakness. Sometimes blood pressure drops slightly. Blood loss up to 15% is compensated by the flow of blood from the depot (spleen, muscles).

Blood loss of 15 to 25% is more severe and causes the development of hemorrhagic shock (associated with blood loss). The patient's consciousness is preserved. There is blanching of the face, skin, cold extremities. The heart rate increases to 100 beats per minute. The amount of urine excreted decreases.

The next degree of blood loss is from 25 to 45%. In this case, severe decompensated hemorrhagic shock develops, which is considered reversible. The body cannot compensate for such blood loss - there is a decrease in blood pressure, tachycardia, shortness of breath, a sharp decrease in the amount of urine. Patients are conscious but may be agitated and restless.

Loss of more than 50% of circulating blood volume is considered a very serious condition. The patient is unconscious. The skin is sharply pale, covered with cold sticky sweat. The pulse is thready. Blood pressure may not be measurable. In the absence of urgent assistance, this condition becomes irreversible.

If the bleeding from the ulcer is small, but repeated for a long time, the patient develops iron deficiency anemia, which in turn worsens the course of the ulcer process.

Diagnosis of bleeding from an ulcer is performed using various methods, but the main one is fibrogastroduodenoscopy, which is mandatory and urgently performed if bleeding from a gastric or duodenal ulcer is suspected.

Possibilities of modern endoscopic technique make it possible to subject a bleeding vessel to diathermocoagulation or laser coagulation and stop the bleeding. General blood and urine tests, X-ray of the lungs, ECG are prescribed. The degree of blood loss is determined by various methods and tables. If it is impossible to stop the bleeding by conservative methods, surgical treatment is performed with the removal of part of the stomach.

GRADUATE WORK

Bleeding with peptic ulcer of the duodenal bulb

Completed by: doctor-intern

Popov V.S.

Yakutsk - 2004

Introduction

Peptic ulcer of the stomach and duodenum is a common worldwide disease that affects mainly young and middle-aged people. Often, peptic ulcer is the cause of disability, it can cause severe complications, in some cases causing a fatal outcome of the disease. The urgency of the problem of treatment of acute ulcerative gastroduodenal bleeding is primarily determined by the high level of overall mortality, which reaches 10-14%. Despite the generally recognized effectiveness of modern "anti-ulcer" drugs, the number of patients with ulcerative gastroduodenal bleeding increases from year to year and amounts to 90-103 per 100,000 adults per year (Pantsyrev Yu.M. et al., 2003).

Bleeding is one of the frequent complications of peptic ulcer of the stomach and duodenum, it occurs in 10-15% of patients. Bleeding of ulcerative nature is from 45-55% of all gastrointestinal bleeding, occurs more often in men than in women, without much difference depending on age. According to B.S. Rozanova (1950, 1960), among various sources, ulcerative bleeding is at least 75%, and in men, the ulcer is the cause of bleeding in 92%, and in women - in 62% of cases. However, recently there has been a tendency towards an increase in the frequency of non-ulcer bleeding, possibly due to improved diagnosis and differential diagnosis as a result of the widespread introduction of fibrogastroduodenoscopy. Most often, bleeding is complicated by large penetrating ulcers of the duodenum and the lesser curvature of the stomach (especially subcardial ulcers) due to the peculiarities of the blood supply to these departments and the possibility of erosion of a large arterial vessel. In this case, bleeding from duodenal ulcers occurs 4-5 times more often than from stomach ulcers. If bleeding of non-ulcerative origin tends to stop on its own, then ulcerative bleeding is often persistent or recurs at short intervals, and with increasing intensity, which leads to massive blood loss. This is accompanied by unsatisfactory results of both conservative and surgical treatment, especially with delayed interventions - mortality in severe blood loss can reach 10-15%. The factors that directly affect the outcome of treatment for a bleeding ulcer include the nature of the pathology, the volume and rate of blood loss, the age of the patient, as well as the presence and nature of concomitant diseases.

The problem of choosing the type and scope of the operation remains very relevant and justifies the need to continue the search for the choice of the optimal method of surgical intervention in patients with a bleeding ulcer of the duodenal bulb.

Purpose of the work: to study the features of the course and spread of a bleeding ulcer of the duodenal bulb in the Republic of Sakha (Yakutia) based on the materials of the surgical department of the Republic of Belarus No. 2 - CEMP, to determine the most optimal methods of surgical intervention in patients with a bleeding ulcer of the duodenal bulb to improve the results of surgical treatment.

Research objectives

1. To study the features of the course and spread of a bleeding ulcer of the duodenal bulb.

2. Determine the role of laboratory and instrumental research methods in the diagnosis of a bleeding ulcer of the duodenal bulb.

3. Determine the indications for surgical intervention in case of a bleeding ulcer of the duodenal bulb.

4. To study the effectiveness of the use of modern methods of treatment for bleeding ulcers of the duodenal bulb.

5. To analyze the results of treatment of patients with bleeding duodenal ulcer for the period from 1999 to 2003.

1. Literature review

Peptic ulcer is a group of diseases of the gastrointestinal tract, characterized by the formation of sites of destruction of the mucous membrane under the action of hydrochloric acid and pepsin, i.e. the disease consists in the formation of an ulcer in a particular area of ​​\u200b\u200bthe stomach or duodenum.

In men, peptic ulcer is much more common than in women. In fact, peptic ulcer disease is the destiny of young and middle-aged people (25-50 years).

Peptic ulcer of the duodenum is one of the main problems of gastroenterology. Currently, it is an important social problem, due to its frequency, chronic course, the presence of threatening complications, as well as due to the frequent disability of patients and the defeat of people, mainly at the age of 30-40.

In our time, peptic ulcer disease is one of the most common diseases in all countries of the world and occurs as a result of an increase in the load of requirements for a person, his psyche, and frequent stressful situations.

If at the end of the 10th and at the beginning of the 20th century gastric ulcers prevailed and the ratio of duodenal ulcers and stomach ulcers was 1:20, then at the end of the 20th century their ratio is approximately equal to 5:1. And according to some data, a duodenal ulcer develops 10 times more often than in the stomach (V.N. Smotrov, 1944; Lorie, 1958; I.K. Rakhmanulova, 1967).

Women get peptic ulcer less often than men. This is due to the biological properties of sex hormones. As evidenced by the favorable course of peptic ulcer during pregnancy.

The ratio of duodenal ulcer in men and women ranges from 3:1 to 10:1 (Tmeley, 1960).

Up to 5% of the adult population suffers from peptic ulcer (during mass preventive examinations, ulcers and cicatricial changes in the walls of the stomach and duodenum are found in 10–20% of those examined). Within one year, about 80% of those suffering from duodenal ulcers notice an exacerbation of the disease, and 33% of patients with gastric ulcers later develop duodenal ulcers.

Localization of duodenal ulcer:

a). Most of the ulcers of the duodenum is located in its initial part (in the bulb); their frequency is the same on both the anterior and posterior walls.

b). Approximately 5% of duodenal ulcers are postbulbar.

in). Ulcers of the pyloric canal require treatment as duodenal, although anatomically they are located in the stomach. Often, these ulcers are not amenable to drug therapy and require surgical treatment (mainly due to developing stenosis of the gastric outlet).

Classification of the degree of bleeding activity according to G.P. Gidirin:

Etiology and pathogenesis

The causes of peptic ulcer are diverse and not fully understood, the main importance in this process is damage to the protective barrier of the gastric mucosa, as well as dysregulation of the acid-producing, acid-neutralizing evacuation function of the stomach and duodenum, genetic, bacterial and other factors. In the vast majority of cases, the cause of duodenal ulcers is increased acidic gastric secretion.

a). Social factors:

Smoking - increases the risk of developing the disease and reduces the likelihood of healing peptic ulcers. It is possible that nicotine suppresses pancreatic bicarbonate secretion, which causes a decrease in duodenal pH, accelerated gastric emptying, hypersecretion of pepsinogen, and reflux into the stomach due to a decrease in pyloric sphincter tone.

Alcohol - directly irritates the mucous membrane and stimulates gastric secretion.

b). Physiological factors:

Gastric acidity is essential in the pathogenesis of ulcers; however, most patients find normo- or hypoacidity associated with increased diffusion of hydrogen ions (H+) into the stomach wall. With a duodenal ulcer, basal or stimulated secretion, as a rule, does not differ in hyperacidity.

Gastrin. With a duodenal ulcer, the level of fasting blood gastrin is within the normal range and increases after eating. In patients with gastric ulcer, the level of gastrin is increased both on an empty stomach and after eating.

Reflux of bile in the stomach is important in reducing the protective mucosal barrier. Damage to the protective barrier allows acidic gastric contents to come into contact with the irritated mucosa and damage it.

in). Genetic factors:

Close relatives have a 10 times higher risk of developing the disease;

Individuals with blood type 0(1) are 30 to 40% more likely to develop duodenal ulcer.

G). Infection:

The etiological role of Helicobacter pylori in the development of recurrent gastric and duodenal ulcers was found. Gram-negative spiral microorganism isolated in 90% of patients with duodenal ulcer or antral gastritis type B and in 60 - 70% of those suffering from gastric ulcer. Helicobacter pylon affects the epithelium of the stomach. The causative agent opsonizes secretory JgA of serum Jg, acts as a “barrier destroyer”, promoting acid back diffusion and the development of a gastric wall ulcer.

A bleeding ulcer of the stomach and duodenum is a severe complication of peptic ulcer, sometimes life-threatening. Bleeding with peptic ulcer is much more likely to occur in the stronger sex, while women experience a similar phenomenon five to six times less often.

How can you tell if a patient is bleeding? What should be done if characteristic symptoms are detected? How can I help you get well soon? You will learn about this from our article.

The symptoms of a bleeding stomach ulcer are the same as those observed with any internal hemorrhage - weakness, dizziness, blanching of the skin, nausea and vomiting. In this case, the color of the vomit may be a specific shade of "coffee with milk", as a result of mixing blood with gastric juice.

With profuse bleeding, the patient develops bloody vomiting of brown color. It can be either single or repetitive. In rare cases, when an artery is damaged and the bleeding is too great, vomiting of red blood with dark clots may begin.

However, with little bleeding, vomiting may not occur. In this case, the patient's stool will help to recognize a bleeding ulcer - it becomes dark, sometimes liquid.

A few days before the onset of bleeding, the patient begins to suffer from a severe exacerbation of peptic ulcer. After the onset of bleeding, relief often occurs, there are even cases when the patient did not show signs of an ulcer at all. There are other symptoms - intense thirst, decreased sweat and fat excretion, a decrease in the amount of morning urine, pain when pressing on the abdomen.

There are four degrees of bleeding ulcers.

With a small, up to five percent, blood loss, a slight increase in heart rate is observed. Blood pressure remains normal, the patient feels well. This is the first degree.

The second is determined by blood loss up to fifteen percent. In this case, the patient complains of lethargy and general weakness. In this state, one should not get out of bed once again, and if there is a need to get up, he needs to be accompanied by someone - fainting is possible. Upper arterial pressure drops to 90 millimeters of mercury, tachycardia begins.

In the third degree, blood loss can reach thirty percent. The patient's condition is severe, the pressure drops to 60. The skin and mucous membranes turn pale, the pulse is weakly palpable.

The fourth degree of a bleeding ulcer is accompanied by an extremely serious condition of the patient. The pressure drops below 60, the pulse is not palpable. The patient may then fall into a coma.

The reasons

Most often, a bleeding ulcer of the stomach and duodenum is observed in patients with peptic ulcer, in which, among other things, pathologies of the development of the cardiovascular system are observed. An ulcer can become bleeding if the disease initially arose due to improper or uncontrolled intake of glucocorticosteroids. The causes of bleeding from an ulcer are simple - inflammation in the affected area, increased capillary permeability and a small number of platelets in the blood. Often, bleeding occurs due to corrosive gastric juice walls of the artery. Less commonly, a bleeding ulcer can be localized in the vein. But most often there is latent diapedetic bleeding - it is not accompanied by any symptoms, since the blood enters the stomach cavity through small vessels in the area of ​​​​the ulcer.

A bleeding ulcer may occur as a result of mechanical or chemical damage to the mucous membranes of the stomach. There are even cases when peptic ulcer occurred as a result of psychological or nervous strain. Less common are various neurotrophic and thromboembolic lesions, as well as hypovitaminosis.

A bleeding stomach ulcer is dangerous because it causes a significant deterioration in the patient's condition. With small blood loss, with an ulcer of the first and second degree, general malaise may occur, but the patient's condition remains satisfactory due to internal defense mechanisms. The result of the third or fourth degree, when the body is no longer able to cope with the disease on its own, may be liver or kidney failure, cerebral edema, myocardial infarction and hypovolemic shock.

First aid

If you suspect that the patient has started bleeding, you should immediately provide first aid to him. The actions in this case should be similar to those prescribed for any internal hemorrhage.

Lay the patient on a flat, hard surface, place a roller under their feet to ensure a rush of blood to the head and avoid oxygen starvation of the brain. The patient at this time needs complete rest, any physical activity can provoke increased bleeding.

Give the patient food or water should not be, as it can stimulate the digestive processes. But you can put a heating pad with ice or a bottle of cold water on his stomach. Every fifteen minutes, the cold should be removed for three minutes, and then applied again. So you can achieve vasoconstriction in the affected area and a temporary cessation of ulcerative bleeding.

In no case do not wash the affected stomach and do not give any medications! A bleeding ulcer should be treated by a qualified physician. Keep the patient conscious until the ambulance arrives. If you notice that he is ready to faint, moisten a piece of cotton wool with a small amount of ammonia and bring it to the patient's nose. Giving a sniff of ammonia directly from the bottle is strictly prohibited!

After the arrival of the ambulance team, examination of the victim and confirmation of symptoms of ulcerative bleeding, the first aid procedure continues. To begin with, the patient is given two tablespoons of an ice-cold solution of aminocaproic acid, a good hemostatic drug. After a while - a teaspoon of calcium chloride and two crushed dietary tablets.

If, for one reason or another, the patient cannot take these drugs, he may be offered to swallow pieces of ice. However, the effectiveness of this tool is ambiguous. On the one hand, cold compresses blood vessels, but, on the other hand, swallowing movements can further damage the gastric mucosa and increase bleeding.

Treatment

If the ambulance doctor comes to the conclusion that the patient has ulcerative bleeding, you should immediately resort to hospitalization: there is no time to take tests in the clinic, and the patient's condition may worsen at any time.

To confirm the results of the preliminary diagnosis, tissue is taken for a biopsy and a macropreparation is made.

For the first two or three days in the hospital, the patient must abstain from food. Subsequently, a special diet is prescribed. If the patient has lost too much blood, or if the bleeding cannot be stopped, a transfusion is given.

To stop bleeding, the following drugs are used:

"Aminocaproic acid" is the most popular remedy for stopping internal bleeding. This drug promotes vasoconstriction and accelerates blood clotting. The tool is not only hypoallergenic, but can also be used to suppress some specific allergic reactions. In addition, the drug stimulates the liver to eliminate toxins.

Vikasol is a chemically formed substitute for vitamin K. It ensures the normalization of blood clotting in case of a lack of platelets. With peptic ulcer, it is used to prevent bleeding.

"Calcium chloride". This medicine is dispensed in pharmacies strictly by prescription. It was originally used as an anti-allergic agent, but its positive effect was soon discovered in internal bleeding. Calcium chloride is now most commonly used as an antidote for certain chemical food poisonings.

"Atropine". This is a multi-purpose medicine that helps to cope with various spasms - including peptic ulcer. Well stops the blood and promotes rapid regeneration of damaged tissues. It is sometimes used in ophthalmology to dilate the pupil for the purpose of examining the fundus.

Unfortunately, all these drugs are not suitable for the elderly, as a result of which one has to resort to conservative treatment.

There are three main ways to stop ulcer bleeding:

1. mechanical - the imposition of special clips, alloying or gluing damaged mucous membranes;
2. injection - the introduction of hemostatic drugs, as well as adrenaline, novocaine or physiological solutions, to maintain the normal functioning of the patient's heart;
3. surgical - direct surgical intervention is resorted to only when an elderly patient has massive blood loss. The form of the operation (suturing the ulcer, resection of the stomach, excision or flashing of the vessels) is chosen by the doctor himself, depending on the location of the lesion.

Treatment with folk remedies

As such, there are no folk remedies for a bleeding stomach ulcer - this is a very dangerous disease and primary treatment should be carried out exclusively in a hospital with the use of medicines.

Treatment with folk remedies is allowed only after the hemorrhage in the stomach cavity stops and the patient is transferred from the hospital to home treatment. At the same time, never neglect the drugs prescribed for rehabilitation treatment.

The most popular and safe remedies for gastric and duodenal ulcers are juices. It is best to take potato, carrot, cabbage or pumpkin juice, they have practically no contraindications, do not cause irritation of the mucous membranes, but at the same time, they can have a significant positive effect on ulcer healing.

Also, traditional healers recommend treating peptic ulcers with vegetable oils - sea buckthorn or olive. The former, taken orally in a teaspoon three times a day, quickly and effectively heals an ulcer and promotes scarring, while the latter is added to light salads or used for cooking.

Herbs are also popular in folk medicine: there are a lot of extracts, infusions and decoctions based on aloe, flax or pumpkin seeds, marigold flowers (marigold) or wild rose, walnuts and other medicinal products of natural origin.

Treatment with honey and propolis stands apart. It is extremely effective, but it should be used with caution - side effects in the form of allergic reactions are possible.

Nutrition and diet

After a patient with a bleeding stomach ulcer is discharged from the hospital, it is necessary to provide him with proper nutrition.

First, it is necessary to exclude from the diet all foods that can somehow contribute to the resumption of bleeding. These include alcohol, salt, sugar, wheat flour products, and milk. Tea and coffee can be drunk, but in limited quantities. You should also completely stop smoking and medicines based on aspirin - they can cause re-bleeding.

The convalescent diet should include:

• eggs - soft-boiled or in the form of an omelet;
• lean meats or poultry;
• a variety of soups with milk, chicken or vegetable broth;
• semi-liquid cereals in milk or water (semolina, oatmeal, rice) with a spoonful of butter;
• a large number of various stewed vegetables - carrots, zucchini, potatoes, beets;
• sweet fruits and berries;
• low-fat dairy products;
• weak sweet tea (possible with milk);
• still mineral water.

A bleeding ulcer diet should be rich in vitamins, minerals, and bioflavonoids. All these substances are found in fresh vegetables, fruits and berries. It is advisable to purchase them not in a store, but in the market, from an authorized seller. If you have a familiar summer resident, negotiate with him and purchase products from his site.

Remember: at the slightest suspicion of bleeding, you need to deliver the patient to the hospital as soon as possible!

An ulcer of the duodenal process of the intestine in most cases is complicated by bleeding. According to statistics, the problem appears in every 10th patient with ulceration of the walls of the organ. Ulcerative bleeding in the duodenum develops when the vessels of the ulcerated tissues are damaged. A complication of the disease manifests itself brightly and intensely - sharp pains, blackening and thinning of the stool, chilling, nausea, less often fainting after / during defecation.

It is not uncommon for complications of lesions of the duodenal mucosa to pass into the stage of bleeding.

The reasons

Manifestations of a bleeding wound can be:

• sudden massive (profuse) blood loss caused by exacerbations or factors affecting the development of peptic ulcer (sins in the diet, stress, alcohol);
• small blood loss, which occurs more often from the use of unauthorized medicines, junk food.

The reasons for the opening of duodenal bleeding can be external and intra-intestinal.

Provoking factors for the development of blood loss are:

• neurotrophic damage to the walls of the organ;
• nonspecific ulcerative colitis or exacerbation of other gastrointestinal diseases;
• deficiency of vitamins C, P, K with a violation of their balance in the body;
• atherosclerosis of the vessels of the gastroduodenal area;
• psycho-emotional and physical stress;
• injury to the abdomen.

Symptoms

The clinical picture with the opened bleeding depends on its intensity. The more abundant the blood loss, the stronger and sharper the complicated peptic ulcer manifests itself:

1. Blood loss up to 10%:

• the patient is calm or slightly agitated;
• slight pallor of the face;
• cold extremities;
• rapid pulse;
• lowering blood pressure;
• reduction in the number of urination.

1. Blood loss up to 45%:

• severe pallor of the skin;
• obvious cyanosis of the nose, lips;
• dyspnea;
• pulse - over 140 bpm;
• BP - below 100 mm Hg. Art.;
• oliguria.

1. Blood loss over 50%:

• loss of consciousness;
• profuse, cold, clammy sweating;
• severe shortness of breath;
• weak pulse;
• lack of systolic pressure;
• oligoanuria.

The main symptoms of the disease:

1. Bloody vomiting, which occurs due to the reflux of intestinal contents into the stomach. The vomit turns dark brown, similar to gore. With the intensification of blood loss, the appearance of scarlet vomiting is possible.
2. Melena or tarry stools. It is formed as a result of bleeding from a duodenal ulcer with a blood loss of more than 800 ml. The stool acquires a liquid or mushy, sticky consistency with an unhealthy sheen. With massive bleeding, the stool will be scarlet.
3. Pain syndrome - sudden, sharp, strong. After that, Bergman's syndrome develops - a sudden cessation of pain.

Kinds

Ulcerative bleeding with damage to the duodenal process occurs due to damage to blood vessels in the tissues of the organ. If a small vessel in the area of ​​the ulcer is damaged, the tissues lose little blood, which is often asymptomatic. If a large plexus suffers, then obvious bleeding develops with signs of acute blood loss.

Therefore, bleeding with an ulcer of the duodenal process can be:

• Hidden, arising against the background of damage to a small capillary. Blood loss in this case is minimal, but the condition can be maintained for a long time. You can understand that a bleeding ulcer has appeared using the Gregersen reaction. With the elimination of the irritating factor and proper nutrition, the wound bleeds less and begins to gradually scar on its own. The risk of relapse is high.
• Explicit, in which the main symptoms of bleeding appear: vomiting, melena, pain, weakness. This condition requires immediate medical attention, otherwise, if half of the blood volume is lost, death occurs.
• Prolonged, manifested by changes in the composition of the blood, anemia, deterioration in the healing process, chronic fatigue and a significant decrease in the quality of life.

The degree of ulcer bleeding 12 duodenal ulcer

There are 4 degrees of bleeding severity, determined by the amount of blood lost:

1. Mild, when the patient's condition is satisfactory, weakness and dizziness are possible. BCC deficiency is detected - up to 20%, hemoglobin - 100 g / l with hematocrit - up to 0.30.
2. Medium, when the patient's condition worsens. BCC deficit rises to 30%; hemoglobin drops to 70 g / l with a hematocrit of 0.30-0.35.
3. Severe, when the patient's condition is severe with intensification of pain radiating to the heart. BCC deficiency rises to 40%, hemoglobin drops to 70-50 g/l with hematocrit below 0.25. Blood pressure drops to 60 with an increase in heart rate (up to 150 beats / min.).
4. Extremely severe, when the patient loses consciousness, turns blue, covered with sticky, cold sweat, the pulse and blood pressure are not palpable. The BCC deficit exceeds 40%. Hemoglobin - below 50 g / l with a hematocrit of 0.20.

Diagnostics

Methods for determining duodenal bleeding depend on the degree and severity of the problem.

Standard diagnostics include:

• Gregersen reaction for feces;
• fibrogastroduodenoscopy;
• general analysis of urine, blood;
• blood chemistry and liver tests.

Treatment of the disease

The therapeutic scheme is based on the sequential elimination of bleeding, prevention of recurrence and treatment of ulcers. Therapy can be performed conservatively and/or surgically.

The basis of medical treatment is:

• taking medications for Helicobacter pylori;
• a course of drugs aimed at stabilizing acidity in the stomach and stimulating mucosal regeneration processes;
• following a strict diet.

Surgery

To eliminate massive or long-term, refractory to drug treatment, blood loss is carried out endoscopically. The most commonly used method is laser coagulation. Rarely, the area of ​​tissue that oozes blood is removed.

Medicines

The treatment regimen for conditions caused by blood loss in duodenal ulcer can be adjusted depending on the severity and degree of blood loss. Typical medicines:

1. Antisecretors - to reduce the secretory activity of the stomach, relieve acidity and inflammation:

• histamine blockers: Ranitidine, Famotidine, Cimetidine;
• PPI: Pariet, Omeprazole;
• anticholinergics: "Gastrin".

1. Enveloping and astringent medications - to create a protective film on the intestinal mucosa: De-Nol, Vikalin, Vikair.
2. Prokinetics - for the resumption of motor skills and relief of symptoms in the form of chronic nausea and vomiting: Cerucal, Trimedat, Motilium.
3. Antibiotics: Amoxicillin, Tetracycline, Metronidazole.
4. Antacids for heartburn and cleaning the gastrointestinal tract: Maalox, Phosphalugel, Almagel.
5. Analgesics, antispasmodics - to relieve pain: "No-Shpa", "Baralgin".
6. Preparations for the general restoration of the mucosa and the body: "Actovegin", multivitamin complexes containing vitamins of group B.

Folk remedies

To increase the effectiveness of drug treatment, relieve symptoms and reduce the risk of recurrent bleeding, it is recommended to use the following traditional medicine recipes:

Etiology and pathogenesis. Bleeding of varying degrees of intensity can occur from arteries, veins, capillaries. Distinguish bleeding hidden (occult), manifested by secondary hypochromic anemia, and obvious Latent bleeding is often chronic and originates from the capillaries, accompanied by iron deficiency anemia, weakness, decreased hemoglobin and erythrocytes.

Occult bleeding can be detected by examining feces or gastric contents for the presence of blood (benzidine or guaiac test).

Sources of gastrointestinal bleeding are most often gastric or duodenal ulcers, stress ulcers, acute erosion of the mucous membrane (erosive gastritis). Less often, bleeding is observed in Mallory-Weiss syndrome (longitudinal rupture of the mucous membrane of the cardial part of the stomach, which occurs with repeated vomiting). Bleeding is very rare with a simple Dieulafoy ulcer (a small round ulcer on the anterior or posterior wall of the stomach, located above a relatively large diameter artery in the stomach wall), which is relatively rare (0.7-2.2%), but representing a great danger, so as bleeding occurs, as a rule, from a large vessel that has undergone arrhythmia, is usually massive and often recurrent. To stop it, surgical treatment is required - transgastric ligation of a bleeding vessel or excision of a bleeding ulcer.

In 3-10% of patients, bleeding occurs from varicose veins of the esophagus with portal hypertension.

Rarely, the source of bleeding can be telangiectasia in Osler-Rendu syndrome, vessels of benign and malignant tumors of the stomach, diverticula of the duodenum and stomach, hiatal hernias.

Bleeding in peptic ulcer disease is the most dangerous complication. It occurs due to arrosion of the branches of the gastric arteries (right or left). With a duodenal ulcer, the source of bleeding is aa. pancreaticoduodenales in the bottom of the ulcer.

In case of acute minor bleeding (less than 50 ml), the formed feces are black in color. The general condition of the patient remains satisfactory. Obvious signs of profuse bleeding include hematemesis and bloody stools. Bloody vomiting (hematemesis) - the release of unaltered or altered (coffee grounds-colored) blood with vomit, observed with bleeding from the stomach, esophagus, duodenum. Melena - the release of altered blood with feces (tarry stools), is observed with bleeding from the duodenum and massive gastric bleeding with blood loss reaching 500 ml. and more.

The reaction of the patient's body depends on the volume and speed of blood loss, the degree of loss of fluid and electrolytes, the age of the patient, concomitant diseases, especially cardiovascular.

The loss of about 500 ml of blood (10-15% of the circulating blood volume) is usually not accompanied by a noticeable reaction of the cardiovascular system. The loss of 25% of BCC causes a decrease in systolic blood pressure to 90-85 mm Hg. Art., diastolic - up to 45-40 mm Hg. Art. Massive bleeding with such a significant loss of blood causes: 1) hypovolemic shock; 2) acute renal failure due to a decrease in filtration, hypoxia, necrosis of the convoluted tubules of the kidneys; 3) liver failure due to a decrease in hepatic blood flow, hypoxia, degeneration of hepatocytes; 4) heart failure caused by oxygen starvation of the myocardium; 5) cerebral edema due to hypoxia; 6) disseminated intravascular coagulation; 7) intoxication with products of hydrolysis of blood that has poured into the intestines. All these signs mean that the patient has developed multiple organ failure.

Clinical picture and diagnosis. Early signs of acute massive blood loss are sudden weakness, dizziness, tachycardia, hypotension, and sometimes fainting. Later, hematemesis occurs (when the stomach overflows with blood), and then melena. The nature of the vomit (scarlet blood, dark cherry-colored clots or coffee grounds-colored gastric contents) depends on the conversion of hemoglobin under the influence of hydrochloric acid into hydrochloric hematin. Repeated hematemesis and subsequent appearance of melena are observed with massive bleeding. Vomiting that repeats at short intervals indicates ongoing bleeding; repeated vomiting of blood after a long period of time is a sign of resumption of bleeding. With heavy bleeding, the blood contributes to the rapid opening of the pylorus, the acceleration of intestinal peristalsis and the release of feces in the form of "cherry jelly" or an admixture of little-changed blood.

Acute gastrointestinal bleeding, the main symptom of which is only melena, has a more favorable prognosis than bleeding, which is manifested primarily by profuse repeated hematemesis. The highest probability of an unfavorable prognosis is with the simultaneous appearance of hematemesis and melena.

The source of bleeding that occurs during an exacerbation in young people is more often a duodenal ulcer, in patients older than 40 years - a stomach ulcer. Before bleeding, the pain often increases, and from the moment the bleeding begins, it decreases or disappears (Bergman's symptom). The reduction or elimination of peptic pain is due to the fact that the blood neutralizes hydrochloric acid.

Bleeding may be the first sign of a previously asymptomatic gastric or duodenal ulcer (about 10%) or a manifestation of an acute ulcer (stress ulcer).

On examination, attention is drawn to the fear and anxiety of the patient. The skin is pale or cyanotic, moist, cold. The pulse is speeded up; blood pressure may be normal or low. Breathing is rapid. With significant blood loss, the patient feels thirsty, notes dryness of the mucous membranes of the oral cavity.

An approximate assessment of the severity of blood loss is possible on the basis of external clinical manifestations of bleeding, determining the shock index by heart rate (see "Acute abdomen"), blood pressure, measuring the amount of blood released with vomiting and loose stools, as well as aspiration of contents from the stomach . Indicators of hemoglobin, hematocrit, central venous pressure (CVP), circulating blood volume (CBV), hourly diuresis allow you to more accurately assess the severity of blood loss and the effectiveness of treatment. In the study of blood in the early stages (several hours) after the onset of acute bleeding, the number of red blood cells and hemoglobin content may remain at a normal level. This is due to the fact that during the first hours there is a release of red blood cells from the depot.

Based on the above data, four degrees of severity of blood loss can be distinguished.

Grade 1 - chronic occult (occult) bleeding, hemoglobin content in the blood is slightly reduced, there are no signs of hemodynamic disturbances.

II degree - acute minor bleeding, heart rate and blood pressure are stable, hemoglobin content is 100 g / l or more.

III degree - acute blood loss of moderate severity (tachycardia, a slight decrease in blood pressure, a shock index of more than 1, a hemoglobin content of less than 100 g / l).

IV degree - massive heavy bleeding (blood pressure below 80 mm Hg, heart rate over 120 per minute, shock index about 1.5, hemoglobin content less than 80 g / l, hematocrit less than 30, oliguria - diuresis less than 40 ml / h).

Examination and treatment of patients with acute bleeding is carried out in the intensive care unit, where the following priority measures are taken:

catheterization of the subclavian vein or several peripheral ones to quickly replenish the BCC deficit, measure CVP;

probing the stomach to wash it and control the possible resumption of bleeding;

emergency esophagogastroduodenoscopy and a simultaneous attempt to stop bleeding by chipping a bleeding ulcer or coagulation of a bleeding vessel;

continuous catheterization of the bladder to control diuresis (it should be at least 50-60 ml / h);

• determination of the degree of blood loss;
• oxygen therapy;
• hemostatic therapy;
• autotransfusion (leg bandaging);
• cleansing enemas to remove blood that has flowed into the intestines.

Probing of the stomach and washing it with cold water (3-4 l) is performed (removal of spilled blood, clots) to prepare for endoscopic examination and stop bleeding. Cold water refers to water at a temperature of 4 °C, stored in a refrigerator or cooled to the specified temperature by adding pieces of ice. The introduction of a probe into the stomach and aspiration of the contents at certain intervals allow you to monitor the dynamics of bleeding.

Esophagogastroduodenoscopy is the most informative method for diagnosing bleeding. According to endoscopic examination, there are three stages of ulcerative bleeding (according to Forrest), which are important in the algorithm for choosing a treatment method:

• Stage I - actively bleeding ulcer.

Stage II - signs of stopped fresh bleeding, thrombosed vessels are visible at the bottom of the ulcer, a blood clot covering the ulcer or blood in the stomach or duodenum.

Stage III - no visible signs of bleeding. Sometimes these stages are referred to as Forrest 1; 2; 3.

X-ray examination in the diagnosis of ulcerative bleeding is less informative. It fades into the background in terms of accuracy and information content.

Gastrointestinal bleeding should be differentiated from pulmonary bleeding, in which hematemesis has a frothy character, is accompanied by a cough, and various wet rales are often heard in the lungs.

Treatment. When choosing a treatment method, it is necessary to take into account endoscopy data (bleeding stage at the time of endoscopy according to Forrest), bleeding intensity, its duration, relapses, general condition and age of the patient.

Conservative measures should be aimed at the prevention and treatment of shock, suppression of the production of hydrochloric acid and pepsin by intravenous administration of H2-receptor blockers - ranitidine (and its analogues - gistak, ranital), famotidine (quatemal). If oral administration of drugs is possible, it is advisable to prescribe more effective proton pump blockers for bleeding ulcers - omeprazole, anticholinergics (gastrocepin), antacids and drugs that reduce the blood supply to the mucous membrane (vasopressin, pituitrin, somatostatin).

With endoscopy, bleeding can be stopped by introducing into the submucosa near the ulcer substances that help stop bleeding (liquid fibrinogen, decynon, etc.), apply thrombin or medical glue, coagulate the bleeding vessel (diathermocoagulation, laser photocoagulation). In most cases (about 90%), acute bleeding can be controlled with conservative measures.

Infusion therapy is carried out in order to normalize hemodynamics, to ensure adequate tissue perfusion. It includes replenishment of BCC, improvement of microcirculation, prevention of intravascular aggregation, microthrombosis, maintenance of plasma oncotic pressure, correction of water and electrolyte balance and acid-base balance, detoxification.

With infusion therapy, they strive to achieve moderate hemodilution (hemoglobin content should be at least 100 g / l, and hematocrit should be within 30%), which improves the rheological properties of blood, microcirculation, reduces peripheral vascular resistance to blood flow, facilitates the work of the heart.

Infusion therapy should begin with the transfusion of rheological solutions that improve microcirculation. With mild blood loss, an infusion of rheopolyglucin, hemodez is performed in a volume of up to 400-600 ml with the addition of saline and glucose-containing solutions.

With moderate blood loss, plasma-substituting solutions, components of donor blood are administered. The total volume of infusions should be 30-40 ml per 1 kg of the patient's body weight. The ratio of plasma-substituting solutions and blood in this case should be equal to 2:1. Assign polyglucin and reopoliglyukin up to 800 ml, increase the dose of saline and glucose-containing solutions.

In severe blood loss and hemorrhagic shock, the ratio of transfused solutions and blood is 1:1 or 1:2. The total dose of funds for infusion therapy should exceed the amount of blood lost by an average of 200-250%.

To maintain the oncotic pressure of the blood, intravenous administration of albumin, protein, and plasma is used. The approximate volume of infusions can be determined by the value of the CVP and hourly diuresis (after therapy, it should be more than 50 ml / h). Correction of hypovolemia improves central hemodynamics and adequate tissue perfusion, provided that the deficiency of oxygen capacity of the blood is eliminated.

Surgery bleeding ulcer. Emergency surgery is indicated for patients with active bleeding (Forrest 1) that cannot be controlled by endoscopic and other methods; it must be carried out in the early stages from the onset of bleeding, since the prognosis for late interventions deteriorates sharply.

In case of hemorrhagic shock and ongoing bleeding, the operation is performed against the background of massive blood transfusion, plasma-substituting solutions and other anti-shock measures. Urgent surgery is indicated for patients in whom conservative measures and blood transfusion (up to 1500 ml in 24 hours) did not allow to stabilize the patient's condition.

After stopping bleeding (Forrest 2-3), surgery is indicated for patients with a long history of ulcers, recurrent bleeding, callous and stenosing ulcers, if the patient is over 50 years old. It is necessary to decide on the choice of an operation option taking into account concomitant diseases, which can increase the risk of both early and late surgical intervention.

With a bleeding ulcer of the stomach, the following operations are recommended: stem vagotomy with economical resection of the stomach and gastrojejunal anastomosis according to Roux or Billroth-I. In debilitated patients, a less traumatic operation is preferable - stem vagotomy, gastrotomy with excision of the ulcer and pyloroplasty. Finally, in an extremely severe general condition, gastrotomy with stitching of a bleeding vessel or excision of an ulcer with subsequent suturing is acceptable.

Bleeding duodenal ulcer produce a stem or selective proximal vagotomy with stitching of bleeding vessels and pyloroplasty; with combined ulcers of the duodenum and stomach - stem vagotomy in combination with antrumectomy and Roux-en-Y anastomosis.

If conservative therapy was effective, bleeding did not resume, then patients are operated on in a planned manner after preoperative preparation carried out for 2-4 weeks in order to heal the ulcer or reduce periulcerous inflammation. Mortality after surgery ranges from 5 to 15%.

With Mallory-Weiss syndrome apply tamponade with a Blakemore probe. If tamponade fails, a gastrotomy operation is performed with suturing of the mucosal defect.

Bleeding from erosions(erosive gastritis) stress ulcers can be threatening. Erosions, which are small superficial multiple defects of the mucous membrane with a size of 2-3 mm, are located mainly in the proximal part of the stomach. The appearance of erosions and stress ulcers is preceded by severe mechanical trauma, extensive burns, shock, hypoxia, severe surgical trauma, exogenous and endogenous intoxication. The main cause of erosive gastritis is mucosal hypoxia caused by impaired microcirculation, increased capillary permeability and ischemia of the stomach wall. The mucous membrane is edematous, usually covered with multiple petechiae and hemorrhages. Against the background of a weakening of the protective mucous-bicarbonate barrier, damage to the mucous membrane occurs with hydrochloric acid and pepsin. An important role in the violation of microcirculation and damage to the mucous membrane is played by the reverse diffusion of hydrogen ions.

Diagnosis is based on clinical and typical endoscopic findings. Treatment is usually conservative. Antisecretory drugs are prescribed: omeprazole, H2 receptor inhibitors (ranitidine, famotidine), sucralfate, antacids, drugs that reduce the blood filling of the mucous membrane (secretin, octapressin), adrenaline solution inside for local effects on capillaries. The stomach is periodically washed with cold water (at a temperature of about 4 ° C) to remove blood clots and stop bleeding. According to the full program, intensive therapy is carried out. Bleeding erosions and ulcers are coagulated through the endoscope. The success rate of treatment is 90%. The need for surgery is rare. Apply selective proximal vagotomy, sometimes suturing defects, ligation of the arteries that feed the stomach, and very rarely - resection of the stomach.