Internal bleeding of the gastrointestinal tract treatment. II

Bleeding from the gastrointestinal intestinal tract- This dangerous phenomenon, which develops with ulcerative, vascular, mechanical and other lesions of the gastrointestinal tract. Abundant outflow of blood into the lumen of the digestive organs can lead to severe complications and lethal outcome.

Stopping and therapy of gastrointestinal bleeding (GI) is carried out promptly or using methods of conservative medicine after receiving the results of laboratory, hardware and instrumental diagnostics.

Why does the stomach bleed

Bleeding in the intestines, stomach or other digestive organs can develop for the following reasons:

The most common causes of gastrointestinal bleeding are duodenal and stomach ulcers. They cause up to 35% of all bleeding from the gastrointestinal tract. Risk factors for the development of peptic ulcers are frequent stress, alcohol consumption and smoking.

In children, the most common causes of bleeding are volvulus (in infants) and intestinal polyposis (in preschool children).

Some causes of intestinal bleeding (for example, hemorrhoids, anal fissures, or polyps) provoke only scant bloody issues or small amounts of blood in the stool. With ulcers, vascular pathologies, tumors and ruptures of the walls of the gastrointestinal tract blood is coming abundantly, mixing with secretions (vomiting, feces) in an altered or unchanged form.

Classification

Bleeding from the digestive tract is divided into groups depending on the etiology, source of hemorrhage and severity. According to the etiology of bleeding are divided:

• on those caused by diseases of the gastrointestinal tract (ulcerative and non-ulcerative genesis);
• on blood circulation provoked by violations in the portal vein ();
• for bleeding in vascular diseases;
• on the hematopoietic systems caused by pathologies, incl. hemorrhagic diathesis.

In accordance with the classification of bleeding by localization, the following types of this disorder are distinguished:

• bleeding from upper divisions digestive tract (stomach, esophagus, duodenum);
• bleeding from the lower digestive organs (small and large intestines, rectum, hemorrhoids).

Most often, bleeding from the upper gastrointestinal tract develops. Esophageal, duodenal and gastric bleedings are diagnosed in 8-9 out of 10 patients with hemorrhages in the digestive tract.

Classification of bleeding according to severity

Some experts also distinguish the fourth, most severe stage of bleeding. It is characterized by a complete loss of consciousness in the patient and the development of coma.

Massive, accompanied by a strong loss of blood, is called profuse.

Additionally, bleeding in the gastrointestinal tract can be classified according to the following criteria:

• duration of bleeding (acute or chronic bleeding);
• availability external manifestations pathologies (hidden or obvious);
• the frequency and number of cases of blood loss (single or repeated, recurrent).

What are the signs and symptoms

TO early symptoms bleeding in the gastrointestinal tract include:

• general weakness, adynamia;
• dizziness, fainting, confusion and loss of consciousness;
• tinnitus, flies in the eyes;
• nausea, vomiting;
• discoloration of gastric and intestinal secretions (vomit and feces);
• sweating;
• strong thirst;
• increased heart rate;
• pallor of the skin, cyanosis of the lips, blueness and a decrease in the temperature of the fingertips.

The severity of the symptoms of pathology depends on the intensity of bleeding, BCC and the amount of blood lost. Due to the larger initial volume of circulating blood, signs of bleeding in adults may manifest later and less clearly than in children. Even minor blood loss small child may necessitate immediate resuscitation.

Symptoms of internal bleeding in the stomach often appear simultaneously with signs of massive blood loss and a decrease in circulating blood volume. Against the background of manifestations of blood loss, there may be pain syndrome in the affected gastrointestinal tract, an increase in the volume of the abdomen due to the accumulation of fluid (ascites), fever caused by intoxication, weight loss, a sharp change or loss of taste sensations, and other pathological phenomena that indicate the cause of the gastrointestinal tract.

The main symptom of gastric bleeding is hematemesis, the nature of which can indicate the cause of the pathology and the duration of bleeding.

Vomiting various pathologies upper gastrointestinal tract, which lead to blood loss:

"Coffee grounds" is a product of the treatment of blood from the stomach with hydrochloric acid.

At ulcerative lesions during vomiting, stomach pains decrease. Bleeding is not accompanied by irritation of the peritoneum and tension of the muscles of the anterior wall of the abdomen. With massive blood loss and stomach cancer, the color of the stool also changes.

Repeated vomiting with blood 1-2 hours after the first episode indicates continued bleeding, and vomiting 4-6 hours later indicates its recurrence.

With gastric bleeding, the symptoms of blood loss in most cases are more pronounced than with bleeding in the intestines. This is due to the fact that frequent causes of damage to the walls of the small, large and rectum are injuries of hemorrhoids, polyposis and small cracks in the mucosa. They can provoke prolonged, but insignificant blood loss, which is accompanied by a slight decrease in hemoglobin concentration and the development of compensatory tachycardia while maintaining normal blood pressure and the patient's well-being.

Symptoms of intestinal bleeding, accompanied by massive blood loss, may be:

• black feces;
• allocation of melena (unformed tar-like stool with strong bad smell);
• weakness, loss of consciousness, pallor of the skin and other manifestations of acute blood loss.

Visual changes in the color and structure of feces are visible only with blood loss of more than 100 ml / day and damage to the rectum and colon (fissures, polyps, bleeding hemorrhoids). With a single outflow of blood (with a stomach ulcer and pathologies of the lower digestive tract), the blood is excreted with the stool unchanged. With prolonged massive bleeding, a tar-like stool is released a few hours after its onset ( dark stool with small clots).

The nature of stool changes in various intestinal pathologies:

In the chronic course of the pathology, symptoms of anemia may occur:

• weakness, fatigue;
• decrease in working capacity;
• frequent dizziness;
• inflammation of the mouth and tongue;
• pallor of mucous membranes and skin.

Diagnostics

Finding out the cause of the gastrointestinal bleeding syndrome requires a thorough clinical examination, laboratory tests, as well as the use of hardware and instrumental methods diagnostics.

Clinical examination

In the initial diagnosis, internal bleeding in the stomach or intestines is performed clinical examination patient, during which the following data are analyzed:

• the patient's history;
• list of medications taken;
• color and consistency of secretions;
• skin color (pallor, yellowness);
• the presence of vascular "asterisks", hemorrhagic manifestations and other vascular pathologies on the skin.

If there is a suspicion of intestinal or stomach bleeding, palpation of the painful abdomen and rectal examination is carried out with caution. Inaccurate procedure can significantly increase blood loss.

Laboratory research

TO laboratory analysis that are carried out with bleeding in the stomach, esophagus and lower gastrointestinal tract include:

• general blood analysis;
• blood biochemistry (liver and kidney tests, markers inflammatory processes and etc.);
• coagulogram;
• coprogram;
• analysis of antibodies to double-stranded DNA, etc.

Instrumental Methods

The most informative hardware diagnostic methods that are used for suspected intragastric and intraintestinal hemorrhage are:

• x-ray examination of the esophagus and stomach;
• celiacography;
• MR angiography of the gastrointestinal tract vessels;
• static and dynamic scintigraphy of the digestive tract;
• CT scan of the abdominal organs;
• radiography of the nasopharynx, bronchi and lungs.

Most quickly bleeding in the stomach can be diagnosed using endoscopy of the upper gastrointestinal tract. In pathologies of the lower tract, irrigoscopy, sigmoidoscopy and colonoscopy are used.

If it is impossible to establish the source of hemorrhage using endoscopy and hardware methods, a diagnostic laparotomy is performed.

How to stop bleeding

Stopping bleeding should be carried out by doctors of a medical institution or an ambulance team. Even before rendering emergency care it is necessary to call an ambulance, describing the patient's condition and the nature of the discharge.

Algorithm for providing emergency first aid if bleeding is suspected, it includes the following actions:

• lay the patient on his back, raising his legs with the help of folded clothes or a pillow;
• do not give the victim to drink and eat;
• put a compress of ice wrapped in a cloth on the painful area;
• during first aid, monitor the nature of breathing and heart rate;
• in case of loss of consciousness, bring the patient to his senses with a cotton swab dipped in ammonia;
• when waiting for an ambulance for a long time, carry the patient on a stretcher towards the medical team.

During emergency care for gastric bleeding, it is forbidden to wash the stomach. If intestinal pathology is suspected, an enema should not be given to the patient.

An attempt to stop the bleeding without the help of doctors can lead to the death of the patient.

How to treat

With gastrointestinal bleeding, treatment is aimed at stopping it, eliminating the root cause of the pathology, restoring the body's hemostasis and normal blood volume.

The danger to the patient is not only the loss of red blood cells that carry oxygen, but also a sharp decline BCC, which leads to massive thrombosis of small vessels and the development of DIC.

Conservative treatment

Conservative treatment gastric bleeding and intestinal blood loss is performed as an adjunct to surgery. It is used as the main method of therapy for the following indications:

• hemorrhagic syndromes;
• cardiovascular diseases;
• inoperable malignant tumors;
• congenital pathologies hematopoietic systems.

In therapy, hemostatic agents, cytostatics, anti-inflammatory and other drugs can be used.

With the loss of a large volume of blood, the patient is prescribed droppers with saline solutions and transfusion of blood components.

Surgery

If bleeding in the gastrointestinal tract is suspected, the patient is taken to surgery department clinics where diagnostics and treatment tactics are determined.

Depending on the diagnosis, the patient can undergo the following operations:

• endoscopic sclerosis, electrocoagulation and ligation of dilated vessels of the intestine, esophagus, etc.;
• suturing ulcer defect And partial resection stomach;
• stitching of duodenal ulcer;
• subtotal resection of the large intestine with stoma.

Diet

The tactics of treatment with diet therapy depends on the underlying disease. With pathologies of the stomach, the patient is assigned table No. 1, No. 1a (immediately after stopping the bleeding), No. 1b or No. 2. For bowel diseases, diet No. 3 or No. 4 is recommended.

If the release of blood is a complication of hepatic pathology, the patient is assigned table number 5 and its variations.

Consequences and complications

Complications of bleeding from the gastrointestinal tract include:

• DIC;
• anemia of moderate and severe degree;
• acute organ failure;
• coma.

Development risk severe consequences and lethal outcome increases with untimely access to a doctor.

How to prevent the phenomenon

To prevent the development of this dangerous pathology, it is necessary to regularly undergo medical examinations, follow the rules for taking medications and lead a healthy lifestyle.

Appeal to a gastroenterologist at the first manifestations of ulcerative and vascular diseases(malaise, nausea, pain in the stomach, etc.) increases the likelihood of a favorable prognosis for the effectiveness of therapy.

To track intestinal bleeding in the early stages, it is recommended to regularly take a stool test for occult blood.

In which blood is poured into the lumen of the stomach. In general, the term "gastrointestinal bleeding" is commonly used in medicine. It is more general and refers to all bleeding that occurs in the digestive tract (esophagus, stomach, small and large intestines, rectum).

Facts about stomach bleeding:

• This condition is one of the most common reasons for hospitalization of patients in surgical hospitals.
• Today, more than 100 diseases are known that may be accompanied by bleeding from the stomach and intestines.
• Approximately three-quarters (75%) of all bleeding from the stomach or duodenum occur due to ulcers.
• Bleeding develops in about one in five patients who suffered from a stomach or duodenal ulcer and did not receive treatment.

Features of the structure of the stomach

Anatomy of the stomach

• input department (cardia)- the transition of the esophagus to the stomach and the area of ​​​​the stomach immediately adjacent to this place;
• fundus of the stomach – top part an organ that looks like a vault;
• body of the stomach- the main part of the body;
• exit part (pylorus)- the transition of the stomach into the duodenum and the area of ​​\u200b\u200bthe stomach immediately adjacent to this place.

• mucous membrane. It is very thin, as it consists of only one layer of cells. They produce stomach enzymes and hydrochloric acid.
• muscles. Due to the muscle tissue, the stomach can contract, mix and push food into the intestines. At the junction of the esophagus to the stomach and the stomach to the duodenum, there are two muscle sphincter. The upper one prevents the contents of the stomach from entering the esophagus, and the lower one prevents the contents of the duodenum from entering the stomach.
• The outer shell is a thin film of connective tissue.

Functions of the stomach

• hydrochloric acid- destroys proteins, activates some digestive enzymes, promotes food disinfection;
• pepsin- an enzyme that breaks down long protein molecules into shorter ones;
• gelatinase- an enzyme that breaks down gelatin and collagen.

Blood supply to the stomach

The venous plexus is located at the junction of the esophagus with the stomach. In some diseases, the veins of which it consists expand and are easily injured. This leads to severe bleeding.

Types of stomach bleeding

• ulcerative- due to peptic ulcer, the most common;
• non-ulcerative due to other reasons.

Depending on the duration of bleeding:

• sharp- develop quickly, require emergency medical care;
• chronic- less intense, last for a long time.

• explicit- appear brightly, all symptoms are present;
• hidden- there are no symptoms, this is usually characteristic of chronic gastric bleeding - only the patient's pallor is noted.

Causes of stomach bleeding

Cause of stomach bleeding	Development mechanism	Features of manifestations
Diseases of the stomach itself
Stomach ulcer	Approximately 15% -20% of patients with gastric ulcer is complicated by bleeding. Causes of bleeding in gastric ulcer: direct damage to the vessel by gastric juice; development of complications occlusion of the vessel lumen by a thrombus, causing it to collapse.	The main symptoms of stomach ulcers: pain that occurs or becomes stronger immediately after eating; vomit, after which the patient becomes easier; heaviness in the stomach- due to the fact that food accumulates in the stomach and leaves it more slowly;
Malignant tumors of the stomach	Stomach cancer may occur on its own or be a complication of peptic ulcer disease. When the tumor begins to disintegrate, bleeding occurs.	The main symptoms of stomach cancer: most often the disease develops in elderly people; weakness, loss of appetite, weight loss, discomfort in the stomach; vomiting of eaten food; pain in the upper abdomen, especially on the left; a feeling of heaviness, a feeling of fullness in the stomach.
Diverticulum of the stomach	diverticulum is a bulge in the wall of the stomach. In order to understand what it looks like, one can imagine rubber surgical gloves: each "finger" is a "diverticulum". This disease is rare. Bleeding occurs as a result of damage to the vessel during inflammation of the wall of the diverticulum.	The main symptoms of a diverticulum of the stomach: often the diverticulum is asymptomatic and is detected only during the examination; belching, swallowing air while eating; an incomprehensible feeling of discomfort in the abdomen; dull weak pains; sometimes the diverticulum appears enough severe pain, pallor, weight loss.
Diaphragmatic hernia	Diaphragmatic hernia is a disease in which part of the stomach rises through a hole in the diaphragm into the chest cavity. Causes of bleeding in diaphragmatic hernia: damage to the lining of the esophagus gastric juice, which is thrown into it; Ulcer complicating diaphragmatic hernia.	Bleeding with diaphragmatic hernia develops in approximately 15%-20% of patients. In most cases, it is hidden, that is, it is not accompanied by any symptoms. But it can also be strong enough.
Polyps of the stomach	Polyps of the stomach These are fairly common benign tumors. Bleeding occurs as a result of: polyp ulceration under the influence of gastric juice; polyp injury; circulatory disorders(for example, if a large pedunculated polyp twists or "falls" into the duodenum and is strangulated).	Before bleeding, polyps usually do not manifest themselves in any way. If they are large enough, then the passage of food through the stomach is disturbed.
Mallory-Weiss syndrome	Mallory-Weiss Syndrome - bleeding that occurs when the mucosa ruptures at the junction of the esophagus to the stomach. Causes: prolonged vomiting with alcohol poisoning, eating a large amount of food; a predisposing factor is a diaphragmatic hernia - a condition in which part of the stomach comes out through the diaphragmatic opening of the esophagus into the chest cavity.	Bleeding can be very intense, so much so that the patient may die if emergency medical care is not provided.
Hemorrhagic gastritis	A type of gastritis, in which erosions (superficial defects) appear on the gastric mucosa, there is a risk of bleeding.	Main symptoms: discomfort, pain in the upper abdomen after eating, especially spicy, sour, smoked, fried, etc .; decreased appetite and weight loss; heartburn, belching; nausea and vomiting; bloating, heaviness in the abdomen; the presence of blood in the vomit, in the stool.
stress ulcer	Stress renders Negative influence to many internal organs. A person who is often nervous has a higher likelihood of getting sick with various pathologies. During severe stress V extreme situation the adrenal cortex begins to produce hormones (glucocorticoids), which increase the secretion of gastric juice, cause circulatory disorders in the organ. This can lead to superficial ulcers and bleeding.	It is often very difficult to identify a stress ulcer, as it is not accompanied by pain and other pronounced symptoms. But the risk of bleeding is high. It can be so intense that it can lead to the death of the patient if emergency assistance is not provided.
Vascular diseases
Varicose veins of the esophagus and upper stomach.	The venous plexus is located at the junction of the esophagus with the stomach. This is the junction of the branches of the portal vein (collecting blood from the intestines) and the superior vena cava (collecting blood from the upper half of the body). When the pressure in these veins increases, they expand, are easily injured, and bleeding occurs. Causes varicose veins veins of the esophagus: liver tumors; portal vein thrombosis; chronic lymphocytic leukemia; compression of the portal vein in various diseases.	There are no symptoms in the early stages. The patient does not suspect that he has varicose veins of the esophagus. Bleeding develops unexpectedly, against the background of a condition full health. It can be so strong that it quickly leads to death.
Systemic vasculitis: periarteritis nodosa; Schönlein-Henoch purpura.	Systemic vasculitis- This is a group of autoimmune diseases in which vascular damage occurs. Their walls are affected, resulting in increased bleeding. Some of the systemic vasculitis manifests as gastrointestinal bleeding.	With systemic vasculitis, symptoms of gastric bleeding are combined with symptoms of the underlying disease.
Atherosclerosis, high blood pressure.	With damage to the vessels and an increase in blood pressure, there is a risk that the wall of one of the vessels during an injury or another pressure surge will burst and bleeding will develop.	Gastric bleeding is preceded by symptoms characteristic of arterial hypertension: headache; dizziness; "Tinnitus", "flies before the eyes"; weakness, increased fatigue; periodic reddening of the face, a feeling of heat; sometimes there are no symptoms; when measuring blood pressure with a tonometer, it turns out to be higher than 140 mm. rt. Art.
Blood clotting disorder
Hemophilia	hereditary disease, manifested by a violation of blood clotting and severe complications in the form of hemorrhages. Only men suffer.
Acute and chronic leukemias	Leukemias are blood tumors in which hematopoiesis in the red bone marrow is disturbed. The formation of platelets, platelets, which are necessary for normal clotting, is disrupted.
Hemorrhagic diathesis	This is a large group of diseases, some of which are inherited, while others occur during life. All of them are characterized by impaired blood clotting, increased bleeding.
Avitaminosis K	Vitamin K plays an important role in the blood clotting process. With its deficiency, there is increased bleeding, hemorrhages in various organs, internal bleeding.
Hypoprothrombinemia	Involved in the process of blood clotting a large number of different substances. One of them is prothrombin. Its insufficient content in the blood may be congenital or be associated with various acquired pathological conditions.

Symptoms of stomach bleeding

Symptom / group of symptoms	Description
General symptoms internal bleeding- develop with bleeding in any organ.	weakness, lethargy; pallor; cold sweat; lowering blood pressure; frequent weak pulse; dizziness and tinnitus; lethargy, confusion: the patient reacts sluggishly to the environment, belatedly answers questions; loss of consciousness. The more intense the bleeding, the faster these symptoms develop and increase. With severe acute bleeding, the patient's condition deteriorates very quickly. All symptoms increase within a short time. If you don't provide emergency assistance, death may occur. With chronic gastric bleeding, the patient may be disturbed for a long time by slight pallor, weakness and other symptoms.
Vomiting blood	The appearance of vomit and blood impurities depends on the source and intensity of bleeding.: Gastric bleeding is characterized by vomiting, resembling "coffee grounds". Vomit takes on this appearance due to the fact that the blood entering the stomach is exposed to hydrochloric acid. If there is unaltered red blood in the vomit, then two options are possible: bleeding from the esophagus or intense arterial bleeding from the stomach, in which the blood does not have time to change under the action of hydrochloric acid. Scarlet blood with foam may indicate pulmonary hemorrhage. Definitively establish the source of bleeding, make the correct diagnosis and provide effective help Only a medical specialist can!
Admixture of blood in the stool	For gastric bleeding, melena is characteristic - black, tarry stools. It acquires this appearance due to the fact that the blood is exposed to gastric juice containing hydrochloric acid. If there are streaks of fresh blood in the stool, then probably there is not gastric, but intestinal bleeding.

How severe can be the condition of a patient with gastric bleeding?

• Light degree. The patient's condition is satisfactory. He is conscious. Worried about mild dizziness. Pulse no more than 80 beats per minute. Blood pressure is not lower than 110 mm. rt. Art.
• Average degree gravity. The patient is pale, the skin is covered with cold sweat. Relieves dizziness. Pulse increased to 100 beats per minute. Arterial pressure - 100-110 mm. rt. Art.
• Severe stomach bleeding. The patient is pale, severely retarded, answers questions belatedly, does not respond to the environment. Pulse more than 100 beats per minute. Blood pressure below 100 mm. rt. Art.

The patient's condition can only be adequately assessed by a doctor after examination and examination. Mild bleeding can become severe at any time!

Diagnosis of gastric bleeding

Which doctor should be consulted in case of stomach bleeding?

• for pain and discomfort in the upper abdomen, nausea, indigestion - see a general practitioner, gastroenterologist;
• with increased bleeding, the appearance of a large number of bruises on the body - to the therapist, hematologist.

The only symptom that can indicate the presence of chronic bleeding in the stomach is black, tarry stools. In this case, you should immediately contact the surgeon.

When do you need to call an ambulance?

• Sharp weakness, pallor, lethargy, rapid deterioration.
• Loss of consciousness.
• Vomiting "coffee grounds".

The ambulance doctor will quickly examine the patient, take the necessary measures to stabilize his condition and take him to the hospital.

What questions can the doctor ask?

Questions you may be asked at the appointment:

• What are the concerns about this moment? When did they arise? How has your condition changed since then?
• Have you had gastrointestinal bleeding in the past? Have you been to doctors with similar problems?
• Do you have a stomach or duodenal ulcer? If yes, for how long? What treatment did you receive?
• Do you have the following symptoms: upper abdominal pain, nausea, vomiting, belching, heartburn, indigestion, bloating?
• Have you had surgery for diseases of the stomach and abdominal veins? If so, on what occasion, when?
• Do you suffer from any liver disease, bleeding disorder?
• How often and how much do you drink alcohol?
• Do you have nosebleeds?

How does a doctor examine a patient with stomach bleeding?

What examination can be ordered?

Study title	Description	How is it carried out?
Fibrogastroduodenoscopy	Endoscopic examination, during which the doctor examines the mucous membrane of the esophagus, stomach, duodenum. Most often, it is possible to establish the place and source of bleeding.	The study is carried out on an empty stomach. The patient lies on the couch on the left side. Anesthesia of the mucous membrane is carried out with a spray. A special mouthpiece is placed between the teeth. The doctor inserts a fibrogastroscope, a flexible tube with a miniature video camera at the end, into the patient's stomach through the mouth. At this time, the patient should breathe deeply through the nose. Usually the review does not take much time.
Radiography of the stomach	To identify the cause of gastric bleeding, x-rays with contrast are taken. The doctor can assess the condition of the walls of the organ, identify ulcers, tumors, diaphragmatic hernia and other pathological conditions.	The study is carried out on an empty stomach. The stomach must be empty, otherwise the contrast will not fill it evenly. The patient drinks a solution of barium sulfate, a substance that does not transmit x-rays. After that do x-rays in different positions: standing, lying. The images clearly show the contours of the stomach filled with contrast.
Angiography	X-ray contrast study of blood vessels. It is performed when there is a suspicion that gastric bleeding is a consequence of atherosclerosis or other vascular disorders.	through a special catheter desired vessel inject a contrast solution. Then X-rays are taken. The painted vessel is clearly visible on them.
radioisotope scanning	It is carried out according to indications when it is not possible to detect the place of bleeding in other ways. Red blood cells labeled with a special substance are injected into the patient's blood. They accumulate at the site of bleeding, after which they can be identified by taking pictures using a special apparatus.	A solution with labeled red blood cells is injected into the patient's vein, after which pictures are taken.
Magnetic resonance imaging	It is carried out according to indications, when a doctor needs to make a correct diagnosis. Additional Information. With the help of MRI, you can get pictures with layered sections or a three-dimensional image of a certain area of ​​the body.	The study is performed in a specialized department using a special installation.
General blood analysis	Variations that can be found in general analysis blood for gastric bleeding: a decrease in the number of erythrocytes (red blood cells) and hemoglobin (anemia associated with blood loss); a decrease in the number of platelets (platelets) - indicates a decrease in blood clotting.	Blood is taken in the usual way from a finger or from a vein.
Blood coagulation test - coagulogram	The study is used in cases where there is a suspicion that gastric bleeding is associated with a violation of blood clotting.	Blood is examined using a special apparatus. A number of indicators are evaluated, on the basis of which conclusions are drawn about the state of the coagulation system.

Treatment of stomach bleeding

There are two tactics for treating stomach bleeding:

• without surgical intervention(conservative);
• operation.

Only a doctor can make the right decision. He conducts an examination and examination, establishes the cause and place of bleeding, determines the degree of its severity. Based on this, a further course of action is selected.

Treatment without surgery

Event	Description	How is it carried out?
Strict bed rest	Rest helps to subside bleeding, and during movement it can intensify.
Cold in the epigastric region		The most commonly used is an ice pack wrapped in a cloth.
Gastric lavage ice water	Under the influence of cold, vasoconstriction occurs, which helps to stop bleeding.	Gastric lavage is carried out using a probe - a tube that is inserted into the stomach through the mouth or through the nose.
Introduction to the stomach through a tube of adrenaline or norepinephrine	Adrenaline and noradrenaline are “stress hormones”. They cause vasospasm and stop bleeding.	A probe is inserted into the patient's stomach through which medications can be administered.
Intravenous administration of hemostatic solutions	Special hemostatic solutions contain substances that increase blood clotting.	Medicines are administered intravenously using a dropper.
donated blood; blood substitutes; frozen plasma.	Transfusion of blood and blood substitutes is carried out in cases where the patient has lost a lot of blood as a result of gastric bleeding.
Other drugs designed to combat existing disorders in the body

Endoscopic treatment

Methods of endoscopic treatment:

• Injection of a bleeding stomach ulcer with solutions of adrenaline and norepinephrine which cause vasospasm and stop bleeding.
• Electrocoagulation- cauterization of small bleeding areas of the mucous membrane.
• Laser coagulation- cauterization with a laser.
• stitching threads or metal clips.
• Application of special medical glue.

Surgery for stomach bleeding

• attempts to stop bleeding without surgery do not work;
• severe bleeding and a significant decrease in blood pressure;
• severe disorders in the patient's body that can lead to deterioration of the condition: coronary heart disease, impaired blood flow in the brain;
• repeated bleeding after they have already been stopped.

• Sewing up the bleeding area.
• Removal of part of the stomach (or the entire organ, depending on the cause of bleeding).
• Plastic surgery of the transition site of the stomach into the duodenum.
• Operation on vagus nerve which stimulates the secretion of gastric juice. As a result, the condition of the patient with peptic ulcer improves, the risk of recurrence decreases.
• Endovascular operations. The doctor makes a puncture in inguinal region, starts a probe through the femoral artery, reaches the bleeding loan and blocks its lumen.

Rehabilitation after stomach surgery

In most cases rehabilitation measures carried out according to the scheme:

• on the first day, the patient is allowed to move his arms and legs;
• usually starts on the second day breathing exercises;
• on the third day the patient can try to stand up;
• on the eighth day, with a favorable course, the stitches are removed;
• on the 14th day they are discharged from the hospital;
• Subsequently, the patient is physical therapy, physical activity is prohibited for a month.

• Day 1: It is forbidden to eat and drink water. You can only moisten your lips with water.
• 2nd day: you can only drink water, half a glass a day, teaspoons.
• 3rd day: you can take 500 ml of water, broth or strong tea.
• 4th day: you can take 4 glasses of liquid per day, dividing this amount into 8 or 12 doses, jelly, yogurt, mucous soups are allowed.
• From the 5th day, you can use any amount of liquid soups, cottage cheese, semolina;
• From the 7th day, boiled meat is added to the diet;
• From the 9th day, the patient switches to the usual sparing diet, excluding irritating foods (spicy, etc.), products prepared on the basis of whole milk.
• Subsequently, frequent meals in small portions are recommended - up to 7 times a day.

Prevention of stomach bleeding

- this is the outflow of blood from damaged vessels of the stomach into the lumen of the organ. Depending on the intensity, it can manifest itself as weakness, dizziness, anemia, coffee grounds vomiting, and black stools. It is possible to suspect gastric bleeding on the basis of anamnesis and clinical tests, but it is possible to make an accurate diagnosis only after performing esophagogastroduodenoscopy. Treatment for minor hemorrhages is conservative (hemostatics, transfusion of fresh frozen plasma, etc.), for profuse hemorrhages - only surgical (endoscopic coagulation, clipping, extended surgery).

General information

Gastric bleeding is a dangerous complication of many diseases not only of the gastrointestinal tract, but also of the blood coagulation system and other body systems. The frequency of pathology in the world is approximately 170 cases per 100 thousand of the adult population. Previously, it was believed that the main cause of the development of gastric hemorrhage is peptic ulcer.

However, despite the development of new successful treatments for this disease, the frequency of bleeding from this part of the gastrointestinal tract has remained unchanged over the past twenty years. This is due to the wide variety of medicines, their uncontrolled intake, which is why the first place among the causes of gastrointestinal bleeding came medicinal erosion and ulceration of the gastric mucosa. Mortality ranges from 4% to 26%, this complication is the leader among the causes emergency hospitalization to the hospital.

Causes

For many years, peptic ulcer of the stomach and duodenum remained the main causative factor development of gastrointestinal bleeding. IN last years the incidence of peptic ulcer disease has significantly decreased, however, the continuing high stress tension in society, low medical literacy of the population, uncontrolled reception non-steroidal anti-inflammatory drugs led to an unexpected increase in the frequency of gastric bleeding by almost three times.

Today, the main causes of pathology are non-ulcerative lesions of the gastric mucosa: drug erosion, stress lesions, Mallory-Weiss syndrome. Chronic renal failure can lead to the formation of bleeding ulcers. Other causes include ischemia of the gastric mucosa against the background of cardiovascular diseases, cirrhosis of the liver, malignant neoplasms(as well as the accompanying chemotherapy), chemical and physical burns of the gastric mucosa. Traumatic brain injury, shock, significant general hypothermia, sepsis, severe psycho-emotional stress, myocardial infarction, hyperparathyroidism, terminal oncopathology can provoke the development of bleeding from the gastrointestinal tract.

Mortality risk factors are the patient's age over 60; low blood pressure, severe bradycardia or tachycardia (a combination of hypotension with tachycardia is especially dangerous); chronic insufficiency functions of the heart, liver, kidneys, lungs; disturbances of consciousness; long-term prior treatment with anticoagulants and antiplatelet agents. It has been proven that in patients who have not completed a course of anti-Helicobacter therapy, the risk of rebleeding over the next 2 years is almost 100%.

Classification

Gastric bleeding can be acute or chronic. Acute hemorrhage is usually profuse, quickly leads to a deterioration in the patient's condition, and requires the immediate initiation of intensive care. Chronic bleeding is not abundant, causes gradual anemia, and may not manifest itself in any way, except for moderate weakness and fatigue.

Pathology can be hidden and obvious. Latent bleeding does not have a pronounced clinic, the patient may not be aware of it for a long time. A fecal occult blood test can confirm the presence of this condition. Explicit bleeding is usually manifested by hematemesis, chalky, symptoms of severe anemia. According to the severity of blood loss, hemorrhage is classified as mild, moderate and severe.

Symptoms of stomach bleeding

The clinic largely depends on the intensity and duration of hemorrhage. Short-term non-intensive bleeding can only be manifested by dizziness when changing body position, flashing flies before the eyes, and weakness. With blood loss of moderate intensity, blood accumulates in the cavity of the stomach, partially enters the duodenum. Under the influence of gastric juice, hemoglobin is oxidized, turning into hematin.

When the accumulated blood reaches a certain volume, vomiting of bloody contents occurs, the color of which, due to the admixture of hematin, resembles “coffee grounds”. If the bleeding is intense, the stomach cavity fills up very quickly and hemoglobin does not have time to oxidize. In this case, the vomit will contain a large amount of scarlet blood. The blood that has entered the duodenum, passing through the entire digestive tract, also undergoes changes, painting the chair black.

In addition to vomiting "coffee grounds" and melena, chronic bleeding is manifested by weakness, increased fatigue, decreased performance, pallor of the skin and mucous membranes. Acute bleeding involves the rapid onset of these symptoms, the patient complains of flies before the eyes, cold sticky sweat. With significant blood loss, disturbances of consciousness (up to coma) can be noted, hemorrhagic shock develops. With profuse bleeding or untimely patient seeking medical help, it is possible death.

Diagnostics

If the patient has one of the predisposing diseases, the gastroenterologist may suspect gastric bleeding if there are complaints of weakness, fatigue, pallor. First of all, clinical tests are prescribed: a detailed blood test with the determination of the level of Hb and platelets, a stool test for occult blood, a coagulogram. These tests can reveal a significant decrease in hemoglobin levels, disorders of the blood coagulation system.

However, the main diagnostic method is gastroscopy - an endoscopic examination of the gastric mucosa. Consultation with an endoscopist with endoscopy will allow you to detect varicose veins of the esophagus and upper stomach, which could serve as a source of bleeding. In addition, it is possible to detect erosion and gastric ulcers, ruptures of the mucous membrane (with Mallory-Weiss syndrome). To identify diseases that can lead to gastric bleeding, ultrasound of the abdominal organs and other auxiliary diagnostic methods are used.

Treatment of stomach bleeding

Treatment of moderate hemorrhage that does not cause significant deterioration of the patient's condition can be carried out on an outpatient basis or in the department of gastroenterology. To stop bleeding conservatively, hemostatic drugs are prescribed, and iron preparations are used to correct posthemorrhagic anemia. In the event of acute profuse hemorrhage, mandatory hospitalization with the use of surgical hemostasis is required.

Upon admission to the department, the patient is provided with complete rest, reliable venous access, intensive replenishment of the volume of circulating blood with crystalloid, colloid solutions and blood products (fresh frozen plasma, cryoprecipitate, erythrocyte mass) begins. An ice pack is placed on the stomach area. After relative stabilization of the condition, an emergency stop of gastroduodenal bleeding is carried out by clipping or ligation of bleeding vessels during gastroduodenoscopy, stitching of a bleeding stomach ulcer. If the cause of bleeding is a stomach ulcer, it is excised, and in some cases, a stomach resection (2/3 of the organ is removed and an anastomosis is created between the stomach stump and the intestines).

After the implementation of instrumental hemostasis, antisecretory and symptomatic therapy is prescribed, aimed at preventing the occurrence of recurrent gastric bleeding. The patient should be informed that untimely recognized gastric bleeding can lead to the development of severe anemia, hemorrhagic shock, acute renal failure, and subsequently to multiple organ failure and death. That is why it is so important to follow all the recommendations of a gastroenterologist, to conduct a full course of antisecretory therapy.

It was noted that in the group of young and middle-aged patients, the use of endoscopic hemostasis in combination with antisecretory therapy leads to best results, recurrence rate in these age groups minimum. However, in elderly patients, the effectiveness of this technique is not so high, and fairly frequent cases of repeated bleeding in aged patients lead to an increase in mortality from this complication up to 50%.

Forecast and prevention

The outcome depends on the severity of hemorrhage, the timeliness of diagnosis and treatment. In chronic low-intensity bleeding, the prognosis is relatively favorable; timely treatment of the underlying disease significantly improves the patient's quality of life and reduces the risk of fatal complications. Profuse bleeding has a very poor prognosis. This is due to difficulties in diagnosis, late onset adequate therapy. Acute profuse hemorrhages often end in death.

Prevention is the prevention of diseases that can cause the development of this complication. It is necessary to visit a therapist annually for early detection of peptic ulcer, other diseases of the gastrointestinal tract, and the blood system. Patients with gastric ulcer are advised to undergo timely courses of anti-Helicobacter and antisecretory therapy.

Gastrointestinal bleeding is the outflow of blood from a tissue defect into the organs of the gastrointestinal tract.

This is one of the most common reasons for hospitalization in the surgical department. Moreover, bleeding from the stomach or esophagus occurs in 80-90% of cases.

Bleeding can occur in many diseases. These include peptic ulcer, cancer, liver cirrhosis, etc. This condition is extremely dangerous for the patient.

Even despite the correct treatment, 14% of patients die from this pathology. Therefore, it is important to know the first signs of developed bleeding and seek help in time.

Types of gastrointestinal bleeding

What are the types of gastrointestinal bleeding?

Depending on the localization of the source, there are:

• bleeding from the upper gastrointestinal tract (from the esophagus, stomach, duodenum);
• bleeding from the lower gastrointestinal tract (from the small or large intestine).

Depending on the reason:

• ulcerative;
• non-ulcer.

Depending on the clinical manifestations:

• obvious (there are causes of bleeding);
• hidden.

By duration:

• sharp;
• chronic.

Depending on the severity:

Causes

The cause of gastrointestinal bleeding can be many pathologies. These include:

• peptic ulcer;
• tumors and polyps;
• intestinal tuberculosis;
• ulcerative colitis and Crohn's disease;
• malignant neoplasms in the organs of the abdominal cavity and small pelvis;
• amyloidosis and syphilis of the intestine;
• erosion;
• diverticula;
• thrombosis or embolism of the arteries supplying the intestines;
• anal fissure and hemorrhoids;
• radiation therapy for tumors of the gastrointestinal tract;
• ankylostomiasis (helminthiasis);
• cirrhosis of the liver with the expansion of the veins of the esophagus, stomach or rectum;
• esophagitis;
• damage to the digestive tract by foreign bodies;
• hernia esophageal opening diaphragms;
• pericarditis;
• autoimmune diseases;
• leukemia;
• long-term use of NSAIDs or glucocorticoids;
• hemophilia;
• alcohol intoxication;
• lack of vitamin K, platelets;
• chemical poisoning;
• stress;
• elderly age.

Symptoms

What are the first signs of bleeding from the digestive tract? Symptoms vary depending on the location of the source of blood loss.

With bleeding from the upper gastrointestinal tract (esophagus, stomach, duodenum) the patient is worried about vomiting mixed with blood and black stools (tarry).

If the source of bleeding is in the esophagus, then in the vomit there is an admixture of unchanged blood (with arterial bleeding). When blood flows out of the veins of the esophagus, the blood in the vomit is colored dark.

If the source of blood loss is located in the stomach, then vomiting takes the form of "coffee grounds". This color of vomit is formed by the interaction of blood with hydrochloric acid of the stomach.

Tar-like stool appears 8 hours after the onset of bleeding. For the occurrence of altered feces, it is necessary that at least 50 ml of blood flow into the digestive tract.

If the volume of blood loss is more than 100 ml, then bright red blood appears in the stool.

It is also characterized by a decrease in blood pressure, the appearance of sweat, tinnitus, dizziness, pale skin, increased heart rate, and a low content of red blood cells in the blood.

For bleeding from the lower GI tract (small or large intestine) symptoms are less pronounced. With such localization of the source, a drop in blood pressure, an increase in heart rate is observed infrequently.

With such bleeding, the patient has feces with unchanged blood. The brighter the blood, the lower the source is. If the bleeding comes from the small intestine, then the blood in the feces is dark in color.

For hemorrhoids or anal fissure bloody traces can be found on paper. At the same time, blood is not mixed with the stool.

If before bleeding the patient complained of sharp pains in the abdomen, then most likely there is an infectious pathology or chronic inflammation in the body.

Also, such signs are characteristic of thrombosis or embolism of the vessels supplying the intestines.

If soreness appears immediately after a bowel movement, the presence of hemorrhoids or a fissure in the anal area can be assumed.

In addition to blood impurities, other symptoms may be present:

• fever, chills, soreness in the abdomen, diarrhea, false urge to defecate - with infectious processes;
• sweating, diarrhea, fever, weight loss - with intestinal tuberculosis;
• inflammation and pain in the joints, damage to the oral mucosa, rashes and indurations on the skin, fever, eye damage - with chronic pathologies inflammatory bowel.

Which doctor to contact

If these symptoms appear, you should immediately call an ambulance or consult a therapist. After examination and confirmation of bleeding, the patient is sent to a surgical hospital.

Diagnostics

How to confirm the presence of gastrointestinal bleeding? Questioning about the nature of vomit and feces will help to guess about the outflow of blood.

The appearance of the patient is also indicative: pale or icteric skin, cold sticky sweat, etc.

If bleeding from the lower GI tract is suspected, a digital rectal examination is performed.

It allows you to detect traces of blood on the glove, hemorrhoids, cracks in the area anus, neoplasms, enlarged hemorrhoids.

The diagnosis can be confirmed using laboratory and instrumental research methods.

The laboratory includes:

• complete blood count - a decrease in the content of erythrocytes, hemoglobin, platelets;
• urinalysis is normal;
• biochemical analysis blood - an increase in the level of ALT, AST, alkaline phosphatase, GGT indicates hepatic pathology. Reducing the amount of protein and cholesterol - about cirrhosis;
• analysis of feces and vomit for occult blood;
• coagulogram - analysis of the blood coagulation system.

Instrumental research methods:

Treatment

With gastrointestinal bleeding, treatment is carried out in a surgical hospital.

To reduce blood loss, it is important to provide first aid correctly:

In the treatment of gastrointestinal bleeding, the administration of drugs that stop the blood is carried out, and the volume of circulating blood is replenished.

In some cases, bleeding is stopped using instrumental methods.

The introduction of hemostatic drugs

In the presence of gastrointestinal bleeding, the patient can be administered Aminocaproic acid, Calcium chloride, Vikasol (vitamin K preparation), Etamzilat.

These drugs are involved in blood clotting processes, which helps stop blood loss.

Fresh frozen plasma or cryoprecipitate may also be administered to stop bleeding. They contain components of the coagulation system.

Hydrochloric acid of the stomach dissolves blood clots, which does not interfere with stopping bleeding. Inhibitors are used to reduce the acidity of gastric juice proton pump or Sandostatin.

Replenishment of circulating blood volume

To replenish the lost blood, the patient is given sodium chloride, Reopoliglyukin (Hemodez, Sorbilact), Peftoran.

These drugs also help to improve blood circulation in tissues, eliminate the lack of fluid in the intercellular space and increase the number of hemoglobin carriers.

Instrumental methods to stop bleeding

Elimination of the source of blood loss can be done by:

• stitching the defect area together with the vessel;
• exposure to the bleeding area with high temperatures (cauterization);
• embolization of a bleeding vessel (introduction of gelatin, alcohol into a bleeding vessel);
• introductions vasoconstrictor drugs at the source of bleeding.

Also, blood loss can be stopped by removing part of the stomach. At the same time, plastic surgery of its pyloric pyloric department is carried out.

In some cases, bleeding from the intestines is stopped by removing part of the intestine with the imposition of an artificial opening.

Prevention

To prevent gastrointestinal bleeding, you must:

• timely identify and treat diseases that can lead to bleeding;
• do not take long-term NSAIDs or glucocorticoids. These drugs should only be taken as directed by a doctor. If there is a need for their long-term use, it is important to drink proton pump inhibitors (omeprazole, esomeprazole, lansoprazole, etc.);
• in the presence of cirrhosis, operations are performed to reduce pressure in the portal vein of the liver. Also for these purposes, prescribe drugs that reduce pressure in the portal vein.

Conclusion

Gastrointestinal bleeding is the outflow of blood from a tissue defect into the organs of the gastrointestinal tract. This condition is quite common.

The cause of blood loss can be many diseases. The most common sources of bleeding include ulcers, erosions, tumors, polyps, diverticula, varicose veins of the esophagus, stomach, and intestines.

The main symptoms of bleeding into the gastrointestinal tract are vomiting with an admixture of blood or "coffee grounds" and admixture of blood in the stool or tarry stool.

Also characterized by a decrease in pressure, rapid pulse, pale skin, dizziness, loss of consciousness, sticky sweat.

For laboratory diagnostics apply a general and biochemical blood test, an analysis of feces and vomit for occult blood, a coagulogram.

FGDS, sigmoidoscopy, colonoscopy, angiography, scintigraphy, CT, MRI of the abdominal organs help to confirm the diagnosis.

Treatment includes stopping bleeding and restoring blood volume. Bleeding can be stopped by endoscopic methods or surgical treatment.

It is important to notice the symptoms of bleeding into the gastrointestinal tract in time, since any delay in treatment is fatal.

Bleeding varying degrees intensity can come from arteries, veins, capillaries. Gastrointestinal bleeding there are hidden (occult), manifested secondary hypochromic anemia, and explicit.

Hidden Symptoms phenomena are often chronic and originate from capillaries, accompanied by iron deficiency anemia, weakness, decrease in hemoglobin and erythrocytes. Hidden pathology can be detected by examining feces or gastric contents for the presence of blood (benzidine or guaiac samples).

Symptoms of developing gastrointestinal bleeding

The patient's response depends on

• volume and rate of gastrointestinal bleeding,
• degree of loss of fluid and electrolytes,
• patient's age,
• comorbidities, especially cardiovascular disease.

Symptoms of minor gastrointestinal bleeding

With acute minor bleeding(less than 50 ml) formed feces are black in color. The general condition of the patient remains satisfactory. Obvious symptoms of profuse bleeding include hematemesis and bloody stools.

Signs of massive gastrointestinal bleeding

Early manifestations of bleeding are sudden weakness, dizziness, tachycardia, hypotension, and sometimes fainting. Later, hematemesis occurs (when the stomach overflows with blood), and then melena.

Melena - excretion of altered blood with stool(tarry stools), observed with bleeding from the duodenum and massive gastrointestinal bleeding with blood loss reaching 500 ml or more.

The loss of about 500 ml of blood (10-15% of the circulating blood volume) during gastrointestinal bleeding is usually not accompanied by a noticeable reaction of the cardiovascular system. Loss of 25% 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:

hypovolemic shock;

acute kidney failure due to reduced filtration, hypoxia, necrosis of the convoluted tubules of the kidneys;

liver failure due to a decrease in hepatic blood flow, hypoxia, degeneration of hepatocytes;

heart failure caused by gastrointestinal bleeding with oxygen and myocardial starvation;

cerebral edema due to hypoxia;

disseminated intravascular coagulation;

intoxication with products of hydrolysis of blood that has poured into the intestines. All these signs of bleeding mean that the patient has developed multiple organ failure.

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

Diagnosis of massive gastrointestinal bleeding

They 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 pay attention 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 gastrointestinal bleeding, the patient feels thirsty, notes dryness of the mucous membranes of the oral cavity.

An approximate assessment of the severity of gastrointestinal bleeding is possible on the basis of external symptoms of gastrointestinal bleeding, determining the shock index by heart rate (see "Acute abdomen"), blood pressure, measuring the amount of blood released with vomiting and liquid stool, 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. When examining blood in early dates(several hours) after the onset of acute gastrointestinal bleeding, the number of erythrocytes and hemoglobin content may remain at normal level. This is due to the fact that during the first hours there is a release of red blood cells from the depot.

Degrees of gastrointestinal bleeding and their symptoms

Given the above data, four degrees of severity of the phenomenon can be distinguished.

I degree. Its symptoms are chronic occult (occult) bleeding, the hemoglobin content in the blood is slightly reduced, there are no signs of hemodynamic disturbances.

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

III degree. Its symptoms are 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. Its manifestations are blood pressure below 80 mm Hg. Art., heart rate over 120 in 1 min, shock index about 1.5, hemoglobin content less than 80 g/l, hematocrit less than 30, oliguria - diuresis less than 40 ml/h.

Differential diagnosis of massive bleeding

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.

Features of the treatment of gastrointestinal bleeding

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

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 of a patient with gastrointestinal bleeding and a simultaneous attempt to stop bleeding by chipping a bleeding ulcer or coagulation of a bleeding vessel;

permanent catheterization Bladder to control diuresis (it should be at least 50-60 ml / h);

determination of the degree of blood loss;

6) oxygen therapy;

hemostatic therapy in the treatment of gastrointestinal bleeding;

autotransfusion (leg bandaging);

cleansing enemas to remove blood that has flowed into the intestines.

Gastric probing in the treatment of massive blood loss

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

Conservative therapy treatment of gastrointestinal bleeding

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 state and age of the patient.

Methods for the treatment of bleeding from the stomach and intestines

Conservative measures should be aimed at preventing and treating shock, suppressing the production of hydrochloric acid and pepsin by intravenous administration of H 2 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).

During endoscopy, gastrointestinal bleeding can be stopped by introducing into the submucosa near the ulcer substances that help stop bleeding (liquid Fibrinogen, Decinon, etc.), by applying Thrombin or medical glue, coagulating a bleeding vessel (diathermocoagulation, laser photo coagulation).

In most cases (about 90%), acute gastrointestinal bleeding can be controlled with conservative measures.

Infusion therapy for gastrointestinal bleeding

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.

In the infusion treatment of gastrointestinal bleeding, moderate hemodilution is sought to be achieved (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 treatment should begin with the transfusion of rheological solutions that improve microcirculation. With mild blood loss, an infusion of Reopoliglyukin, Hemodez is performed in a volume of up to 400-600 ml with the addition of saline and glucose-containing solutions.

In case of moderate blood loss, plasma-substituting solutions, components donated blood. 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. For the treatment of gastrointestinal bleeding, Polyglukin and Reopoliglyukin are prescribed up to 800 ml, the dose of saline and glucose-containing solutions is increased.

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 treatment of gastrointestinal bleeding should exceed the amount of blood lost by an average of 200-250%.

To maintain oncotic blood pressure, intravenous administration of Albumin, Protein, 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.

Conservative treatment of bleeding in erosive gastritis

Diagnosis is based on clinical and typical endoscopic findings. Treatment of gastrointestinal bleeding in erosive gastritis is usually conservative. Antisecretory drugs are prescribed: Omeprazole, H 2 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.

Stomach on the background erosive gastritis periodically washed with cold water (at a temperature of about 4 ° C) to remove blood clots and stop bleeding. Under the full program intensive care. Bleeding erosions and ulcers are coagulated through the endoscope.

The success of treatment for erosive gastritis is 90%. The need for surgery is rare.

Surgical management of gastrointestinal bleeding

IN surgical treatment apply

• selective proximal vagotomy,
• sometimes suturing defects,
• ligation of the arteries supplying the stomach,
• and very rarely - resection of the stomach.

Emergency surgery is indicated for patients with active bleeding(Forrest 1), which cannot be stopped 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. emergency operation 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.

Treatment of bleeding in Mallory-Weiss syndrome

In Mallory-Weiss syndrome, treatment of gastrointestinal bleeding is used in the form of tamponade with a Blakemore probe. If tamponade fails, a gastrotomy operation is performed with suturing of the mucosal defect.

Causes of gastrointestinal bleeding

The source of bleeding that occurs during an exacerbation in individuals young age, more often is 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.

So, the most common sources of bleeding are:

ulcers of the stomach or duodenum,

stress ulcers,

acute erosion of the mucous membrane (erosive gastritis).

Erosive gastritis as a cause of bleeding

Bleeding from erosions (erosive gastritis) and 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. Important role in violation of microcirculation and damage to the mucous membrane, the reverse diffusion of hydrogen ions plays.

Other causes of gastrointestinal bleeding

Less commonly, symptoms of the disease are observed in Mallory-Weiss syndrome ( longitudinal break mucous membrane of the cardial part of the stomach, which occurs with repeated vomiting). Gastrointestinal bleeding is also very rare with Dieulafoy's simple 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 represents a great danger, since bleeding occurs, as a rule, from a large vessel that has undergone erosion, 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 when portal hypertension. Rarely, the source of bleeding can be telangiectasia in Osler-Randu syndrome, vessels of benign and malignant tumors of the stomach, diverticula of the duodenum and stomach, hiatal hernias.

Gastrointestinal bleeding in peptic ulcer 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.