What to take for stomach bleeding. Intestinal bleeding - causes, symptoms and treatment of dangerous pathology

Gastrointestinal bleeding is not an independent disease, but a complication of many diseases of the gastrointestinal tract. Assistance for gastrointestinal bleeding should be provided as quickly and fully as possible, since this is a serious complication, and in severe cases it can be fatal.

Causes of gastrointestinal bleeding

The cause of gastrointestinal bleeding is damage to the wall of the gastrointestinal tract involving blood vessel or small capillaries in any of its sections. The most common causes of gastrointestinal bleeding are the following diseases:

• Stomach and duodenal ulcers;
• Haemorrhoids;
• Tumors, both benign (polyposis) and malignant (cancer) in any part of the gastrointestinal tract;
• Varicose veins of the esophagus;
• Cracks in the mucous membrane of the esophagus;
• Anal fissures;

Gastrointestinal bleeding in children is most often caused by trauma to the esophagus or stomach, including chemical burns, as well as hemorrhagic disease of the newborn.

Types of gastrointestinal bleeding

Gastrointestinal bleeding is distinguished from the upper part of the gastrointestinal tract, which includes the esophagus and stomach, and the lower part, consisting of the intestines.

Gastrointestinal bleeding in duration can be:

• One-time (episodic);
• Recurrent (periodically renewed);
• Chronic (permanent).

By form:

• Sharp;
• Chronic.

By nature of manifestation:

• Hidden;
• Explicit.

Symptoms of gastrointestinal bleeding

General symptoms of gastrointestinal bleeding are similar to symptoms of blood loss in general. These include pale skin, weakness, tinnitus, cold sweat, tachycardia, shortness of breath, dizziness, spots before the eyes, and decreased blood pressure. Pain, or an increase in existing pain, is not characteristic of gastrointestinal bleeding.

The nature of the released blood itself depends on which particular part of the gastrointestinal tract the integrity of the blood vessel was violated, and on whether the bleeding is hidden or obvious.

First, let's focus on obvious gastrointestinal bleeding.

Gastrointestinal bleeding from the upper gastrointestinal tract manifests itself as bloody vomiting (hematemesis). Vomiting may contain unchanged blood, which is typical for bleeding from the esophagus, or it may have the appearance of coffee grounds, if the bleeding occurred in the stomach, a characteristic appearance is given to it by blood that has coagulated under the influence of hydrochloric acid. However, gastric arterial bleeding of significant force can also take the form of vomiting with unchanged blood, since the blood does not have time to clot.

Gastrointestinal bleeding from the small intestine and colon may manifest itself either as “coffee grounds” vomiting or as melena – bloody diarrhea, having a tar-like consistency and black color. Melena may continue for several days after bleeding in the upper gastrointestinal tract has stopped, and tarry stool will be released as the contents move through the intestines.

If bleeding occurs in the lower gastrointestinal tract ( colon, rectum, anus), then it manifests itself as bloody stool (hematochezia). In this case, the feces contain an admixture of constant scarlet blood, sometimes in significant quantities. However, sometimes bloody stools can occur when there is significant bleeding in the small intestine, when, due to the large amount of blood, the contents of the small intestine move very quickly.

Hidden gastrointestinal bleeding is detected by laboratory tests of stool and gastric juice. Hidden bleeding from upper sections The gastrointestinal tract may look like an admixture of black flakes in the vomit; in all other cases, it is invisible to the naked eye, and only manifests itself common features increasing anemia.

There is no particular difference in the manifestation of gastrointestinal bleeding in children and adults, only anemia in children develops much faster, and due to the body’s lower compensatory capabilities, the consequences can be more dangerous.

First aid for gastrointestinal bleeding

If acute bleeding occurs, first aid for gastrointestinal bleeding is as follows:

• Call an ambulance as soon as possible;
• Immediately put the patient to bed;
• Avoid the entry of any substances into the gastrointestinal tract, including water, medications and food;
• Place an ice pack on your stomach;
• Provide access fresh air to the room where the patient is lying;
• Ensure constant monitoring of him until the ambulance arrives, without leaving him alone.

First aid for gastrointestinal bleeding in children does not differ from that in adults. It is important to provide peace for the child, which is somewhat more difficult than for an adult, especially if the child is small. If gastrointestinal bleeding in children is suspected to be caused by trauma, it is necessary to try to determine the traumatic factor (sharp object, chemical substance) as accurately as possible.

Emergency medical care for gastrointestinal bleeding depends primarily on the severity of the bleeding and its nature, as well as on the patient’s condition. In the event that the bleeding is significant, with scarlet (arterial) blood, and it cannot be stopped within a certain time by conventional means, the patient is taken to the emergency surgery department.

Treatment of gastrointestinal bleeding

Treatment of gastrointestinal bleeding, depending on its nature, is carried out surgically or conservative means.

In case of significant bleeding, if it is not possible to stop the blood loss, resort to resuscitation techniques and emergency surgery. Before surgery, it is desirable to at least partially replenish the volume of lost blood, for which purpose infusion therapy is carried out by intravenous infusion of blood products or blood substitutes. In case of a threat to life, emergency surgery without such preparation is possible. The operation can be performed either classically, open method, and endoscopic (FGS, laparoscopy, sigmoidoscopy, colonoscopy), depending on the indications. Surgical treatment of gastrointestinal bleeding consists of ligating the veins of the esophagus and stomach, applying a sigmostoma, resection of a section of the stomach or intestine, coagulation of the damaged vessel, etc.

Conservative treatment of gastrointestinal bleeding consists of the following measures:

• Administration of hemostatic agents;
• Evacuation of blood from the gastrointestinal tract by introducing a nasogastric tube and cleansing enemas (if the bleeding is not from the lower gastrointestinal tract);
• Replenishment of blood loss;
• Support of vital body systems;
• Treatment of the underlying disease that led to bleeding.

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Treatment OGCC is one of the difficult and complex problems, since they occur quite often and it is not always possible to find out the cause and choose the right treatment method. A patient with acute gastrointestinal bleeding, after mandatory hospitalization in a hospital, is sequentially subjected to a set of diagnostic and therapeutic measures aimed at establishing the cause and stopping the bleeding, and replenishing blood loss.

Emergency care for patients at the prehospital stage should begin with the following measures: 1) strict bed rest and transportation on a stretcher, and in case of collapse - Trendelenburg position, prohibition of water and food intake; 2) cold on the epigastric region; 3) intravenous or intramuscular administration of vikasol 3-4 ml of a 1% solution, calcium chloride 10 ml of a 10% solution and dicinone 2-4 ml or more of a 12.5% ​​solution; 4) oral ingestion of epsilon-aminocaproic acid (500 ml of a 5% solution) or intravenous administration of 100 ml of its 5% solution, antacids and adsorbents (Almagel, phosphalugel, etc.); 5) with a sharp drop in blood pressure, the Trendelenburg position.

At the prehospital stage, according to indications, they are supplemented with intravenous administration of antihemophilic plasma (100-150 ml), fibrinogen (1-2 g in 250-300 ml of isotonic sodium chloride solution), epsilon-aminocaproic acid (200 ml of 5% solution) and other hemostatic agents.

In case of critical hypovolemia, infusion of vasoconstrictors is 2 ml of 0.1% solution of adrenaline hydrochloride. The most important thing in the complex of general measures, of course, is the question of therapeutic nutrition patient with gastrointestinal tract. Adopted in past years starvation diet is currently considered incorrect.

The method of oral feeding of patients for several days (at least three) with frequent small portions of liquid viscous protein mixtures, milked gelatin, and also a very chilled milk diet that does not mechanically irritate the stomach remains very common, and then in the early days it is included in the food supply. mode mashed potatoes, meat juice, fresh eggs. It is necessary, especially after the bleeding has stopped, to prescribe high-calorie foods. The latter, on the one hand, neutralizes the acidity of the stomach, reduces gastric motility, introduces enough calories into the body, and on the other hand, it spares the patient’s strength impaired as a result of bleeding.

It is preferable to prescribe a diet according to Meulengracht or Yarotsky (a mixture of egg whites, butter and sugar) - White bread, butter, porridge, mashed potatoes, meat and fish soufflé, milk in combination with the use of alkalis, iron supplements and antispasmodic medications, syrups, fortified cocktails followed by the inclusion of whole milk, sour cream.

In a hospital, care for a patient with acute gastrointestinal tract disease begins with organizational measures in the emergency department. Patients are taken to the ward on stretchers intensive care, where they are provided with strict bed rest. In severe cases, it is necessary, first of all, to take Urgent measures to bring the patient out of a state of collapse: stop bleeding, treat anemia and ulcers.

It should be noted that with a small amount of ulcer bleeding, especially in young people, in most cases it is necessary to use complex conservative treatment, which usually gives a good effect. For this purpose, strict bed rest is established, cold is applied to the stomach area and pieces of ice are periodically allowed to be swallowed, antihemorrhagic drugs, a hemostatic sponge, thrombin, intravenous administration of gelatin, vitamin K preparations or 5 ml of Vikasol, 10 ml of 10% are prescribed. th solution of calcium chloride, intravenous epsilon-aminocaproic acid and hemostatic blood transfusion.

It is advisable to use atropine when the danger of bleeding has not passed. If possible, you should refrain from administering drugs that significantly increase blood pressure. In patients with a tendency to arterial hypertension Carry out controlled hypotension for several days. To prevent thrombus lysis, GI is administered nutritional mixtures(chilled milk, cream, protein preparations, Bourget mixture) through a permanent gastric tube, which also serves to monitor recurrent bleeding. From the very first day of caring for the patient, it is advisable to cleanse the intestines with the help of careful enemas, repeated daily.

Blood accumulated in the intestines necessarily undergoes rotting, contributes to the development of alkalosis, hyperazotemia and increased general intoxication. It is also advisable to empty the stomach with a probe, which also reduces intoxication and reduces the high position of the diaphragm. Peripheral puncture or catheterization is performed main vein, continue infusion therapy, blood is taken to determine the group, Rh and for biochemical studies, hemogram, coagulogram and assessment of the degree of blood loss.

Having determined the blood group and Rh factor, they begin blood replacement transfusion. In the absence of indications for emergency or urgent surgery, conservative treatment and monitoring of patients is carried out. Therapeutic measures should be aimed at reducing the likelihood of recurrent bleeding and comprehensive antiulcer treatment.

At intervals of 4-6 hours, cimetidine (200-400 mg) or Zontak (50 mg) is administered intravenously, and omeprazole 20 mg 2 times a day is administered orally. A good hemostatic effect is also given by secretin (iv dropwise) - 100 mg of secretin in 50 ml of 0.1% sodium chloride solution. It is necessary to quickly replenish the blood volume while maintaining the COP in case of massive blood loss, as well as rheological properties.

Endoscopy is not only diagnostic, but also medical procedure. The type of bleeding is determined endoscopically: 1) pulsating or 2) free flow of blood from the vessels of the ulcer. Determining the size of the bleeding vessel is of great importance. The presence of a visible bleeding vessel with a diameter of 2 mm or more usually indicates the need for surgical treatment, since it usually cannot be coagulated.

After identifying the source of bleeding and removing the clot, an attempt is made to locally endoscopically stop the bleeding through catheter embolization of the artery, electrocoagulation, diathermolaser coagulation, local application of hemostatics (thrombin, aminocaproic acid, 5% solution of novocaine with adrenaline, as well as treatment of the bleeding ulcer with Lifusol, film formers - Levazan, etc.). Photocoagulation around the vessel (B.S. Savelyev, 1983) often makes it possible to completely stop ulcerative bleeding. Local treatment bleeding also involves gastric lavage.

Apply local hypothermia stomach ice-cold isotonic sodium chloride solution (cryolavage), antacids(cimetidine, ranitidine, omeprazole, etc.), reducing the secretion of HCI, proteolysis inhibitors, intragastric administration of vasopressors, thrombin. For bleeding from varicose veins of the esophagus, endo- and perivasal administration of sclerosing drugs (varicocid, thrombovar) and, less commonly, diathermocoagulation are used. IV drip infusion of secretin (0.3 units/kg/hour) has become widespread.

A large amount of the contents of the duodenum, released in response to the administration of secretin, is thrown into the stomach and neutralizes its acidic contents. The possibility of using somatotropin, which causes vasospasm and a decrease in blood flow in the gastric mucosa, to stop bleeding is being studied. To reduce local fibrinolysis, thrombin with aminocaproic acid and proteolytic enzyme inhibitors are used orally or administered through a probe (every 6-8 hours).

To diagnose ongoing or recurrent bleeding, continuous aspiration of gastric contents is performed, giving the patient 100 ml of water every hour and assessing the color of the aspirated liquid. The probe is kept in the stomach for up to 2 days after bleeding has apparently stopped. Local hypothermia leads to a decrease in the secretion of SA and pepsin, decreased peristalsis, and a reduction in blood flow to the stomach due to spasm of arterial vessels. Gastric hypothermia can be achieved in two ways - open and closed.

With the open method, a coolant, often Ringer's solution, is injected directly into the stomach. However, due to the danger of regurgitation and EBV disorders, the closed method is more widely used. A double-lumen probe with a stomach-shaped latex balloon attached to the end is inserted into the stomach. In this case, the liquid (usually a solution of ethyl alcohol) is cooled in a special apparatus to a temperature of 0 to 2 °C and continuously circulates in a closed system without entering the lumen of the stomach. The hemostatic effect is achieved when the temperature of the stomach wall decreases to 10-15 °C.

For endoscopic bleeding control, both monoactive and biactive electrocoagulation methods can be used. The latter is accompanied by more superficial damage to the organ wall and is therefore safer. Laser photocoagulation (argon laser, neon YAG laser) has advantages over diathermocoagulation. Diathermo- and laser coagulation are also used to thicken a blood clot after bleeding has stopped, which reduces the threat of recurrent bleeding.

It is very important to quickly restore the BCC (V.A. Klimansky, 1983). For this purpose, polyglucin is administered intravenously, often in a stream at a rate of 100-150 ml/min, the daily dose of which can reach 1.5-2 liters. Thanks to its high COD, intercellular fluid is attracted into the vascular bed and retained there for quite a long time. As a result, it quickly increases blood volume and thereby restores central hemodynamics. If it is possible to stop the bleeding, administration of colloid solutions (artificial hemodilution) is recommended. This leads to stable hemodynamic restoration.

With adequate therapy with blood substitutes, even a significant decrease in hemoglobin concentration (to 50-60 g/l) and hematocrit to 20-25 does not in itself pose a danger to the patient’s life. In this regard, at the first stage of treatment of patients, the use of donor red blood cells is not provided, but in the future, to eliminate dangerous level anemia resulting from blood loss itself and artificial hemodilution. The only way to quickly eliminate this is the transfusion of donor red blood cells and fresh citrated blood.

It is considered advisable to use not whole blood, but red blood cells (suspension), diluted with a 5% solution of rheopolyglucin or albumin in a 1:1 ratio, which significantly facilitates transfusion and increases the effectiveness of hemotherapy. Naturally, to combat anemia in the absence of the required amount of red blood cells, whole donor blood can be used. Blood transfusions must be given both before and during surgery.

The simplest and most informative criteria for the volume of blood transfusion used in practice are hemoglobin and peripheral blood hematocrit. It should only be borne in mind that in the coming hours after bleeding due to hemoconcentration they exceed true values by 15-30%.

Indications for blood transfusion, its volume and rate of administration are determined depending on the degree of hypovolemia and the time period that has passed since the onset of bleeding. Single group blood should be transfused. For every 400-500 ml of donor blood administered, 10 ml of a 10% calcium chloride solution should be administered to neutralize sodium citrate (V.N. Chernov et al., 1999).

It is very important to ensure adequate tissue perfusion if a deficiency in the oxygen capacity of the blood is established. The average oxygen consumption to satisfy the metabolic needs of the body is 300 ml/min of blood, with its total content in the blood up to 1000 ml/min, if the blood hemoglobin is 150-160 g/l. Therefore, when circulating hemoglobin decreases to 1/3 of what it should, the circulatory system copes with the delivery of oxygen to the tissues.

A relatively safe hemoglobin level is 600 g, an acceptable level is 400 g (if you are confident that bleeding will stop). The indicated hemoglobin values ​​ensure efficient transport of oxygen in the body without signs of hypoxemia and metabolic acidosis. The hemoglobin level is a reliable criterion for determining indications for blood transfusion.

If blood transfusion is necessary (if the bleeding is sure to stop) more than 1 liter, preference is given to transfusion of freshly stabilized or canned blood for no more than 3 days of storage, as well as direct transfusion. The effectiveness of blood transfusion increases with the simultaneous use of hemodez or rheopolyglucin. Excess free acids in preserved blood are neutralized by transfusion of a 5% sodium bicarbonate solution.

Recently, the method of artificial controlled hypotomy has been widely used in the treatment of gastrointestinal tract diseases. The introduction of gangliobilocators (pentamine, arfonade) for this purpose reduces blood pressure and slows blood flow, increasing blood flow into the vascular bed. All this increases thrombus formation and leads to hemostasis.

Hemodez, rheopolitlyukin, etc. are used to stop bleeding, since, along with improving the blood supply to tissues, they contribute to the dissolution of a blood clot and increased bleeding from unligated vessels. Large molecular plasma substitutes (polyglucin, etc.) promote red blood cell aggregation and increase intravascular coagulation, so they cannot be used in cases of severe blood loss. The total dose of polyglucin with its fractional administration, alternating with blood and plasma does not exceed 2 thousand ml (A.A. Shalimov, V.F. Saenko, 1986).

In cases of massive blood loss with the development of severe hemorrhagic shock, a combination of blood and plasma substitutes with ringer lactate or isotonic sodium chloride solution in a volume 2 times greater than the blood loss or the estimated amount of blood transfusion is effective. In this case, you can limit yourself to a minimum blood transfusion - 30% of the total reimbursement.

Without compensation for blood loss, the administration of sympathomimetic agents (adrenaline hydrochloride, norepinephrine hydrotartrate, mezatone, etc.) is contraindicated. These substances are not used at all or are administered only after replenishing blood loss in combination with ganglion blocking agents. Only for patients in serious condition, especially the elderly, with a pressure drop below critical level(below half of the original), and in patients with maximum blood pressure below 60 mm Hg. Art. their use is justified, since prolonged hypotension can lead to irreversible brain disorders.

With increased fibrinolytic activity and a decrease in fibrinogen content against the background of ongoing bleeding, such patients are advised to receive a transfusion of up to 5 g or more of fibrinogen in combination with aminocaproic acid (5% solution 200-300 ml). In cases of acute fibrinolysis, 5-8 g or more of fibrinogen and 200-300 ml of a 5% solution of aminocaproic acid are administered.

At increased content free heparin, a 1% solution of protamine sulfate is used, which is administered in a dose of 5 ml intravenously under mandatory monitoring of blood clotting ability. If, after its administration, the time of plasma recalcification and prothrombin time is shortened, then the administration can be repeated at the same dose, until these parameters are normalized. In cases where protamine sulfate does not affect blood clotting or it immediately returns to normal, repeated administration of the drug should be abandoned.

When bleeding from the veins of the esophagus, the use of pituitrin is effective, which helps reduce blood flow in the abdominal organs. All patients with gastrointestinal tract are prescribed siphon enemas of sodium bicarbonate 2-3 times a day to remove blood that has spilled into the intestines. This event is mandatory, since the breakdown products of red blood cells, especially ammonia, have toxic effect to the liver. Potassium released during the breakdown of red blood cells has a toxic effect on the heart muscle, and the breakdown products of red blood cells themselves reduce blood clotting and, therefore, can support bleeding.

Tissue hypoxia that occurs during bleeding may itself also contribute to bleeding. Therefore, it is necessary to saturate the patient’s body with oxygen (oxygen supply through a catheter inserted into the nasal part of the pharynx). Intensive infusion-transfusion therapy is carried out, the main goal of which is to normalize hemodynamics and ensure adequate tissue perfusion. It is aimed at replenishing the bcc, including through the inclusion of deposited blood in the active blood flow; impact on the physicochemical properties of blood in order to improve capillary circulation, prevent intravascular aggregation and microthrombosis; maintaining plasma oncotic pressure; normalization vascular tone and myocardial contractility; correction of EBV, CBS and detoxification.

This is facilitated by the now accepted tactics of controlled moderate hemodelution - maintaining hematocrit within 30%, but about 100 g/l. In all cases, infusion therapy should begin with the transfusion of rheological solutions that improve microcirculation.

In case of bleeding, it is advisable to transfuse single-group, Rh-compatible red blood cells from early storage periods. It is advisable to transfuse blood by drop method, however, in patients who are in a state of collapse, jet transfusion is used and even into several veins at the same time.

In the absence of blood and before all the necessary studies have been carried out (determination of blood group and Rh, individual compatibility tests), allowing for the safe transfusion of blood and red blood cells, native and dried plasma, as well as small doses (up to 400 ml) of polyglucin should be used. The latter equalizes blood pressure and increases blood volume. Large amounts of polyglucin should not be used in severe hemorrhagic shock, since it changes the state of the blood coagulation system, increases its viscosity and promotes intravascular thrombosis (A.A. Shalimov, V.F. Saenko, 1988). In severe cases of bleeding and collapse, transfusion of a 5% or 10% albumin solution up to 200-300 ml and direct blood transfusion are indicated. The amount of blood transfused depends on the degree of blood loss.

In case of massive blood loss, large amounts of blood, its preparations and blood substitutes are often transfused in various combinations. Replenishment of blood volume is carried out under the control of central venous pressure. To do this, a section of the medial saphenous vein of the arm is performed on the patient and a polyvinyl chloride catheter is inserted into the superior vena cava or subclavian vein by puncture. The catheter is connected to the Waldmann apparatus. Normally, venous pressure is 70-150 mmH2O. Art. CVP below 70 mm water. Art. indicates that the capacity of the vascular bed does not correspond to the blood mass. High central venous pressure is a sign of excessive blood loss or cardiac weakness. Transfusion of blood or plasma expanders in such cases poses a risk of pulmonary edema.

In case of mild blood loss, the body is able to compensate for the blood loss on its own, so you can get by with a transfusion of 500 ml of plasma, Ringer-Locke solution and isotonic sodium chloride solution (up to 1 thousand ml), rheopolyglucin, hemodez in a volume of up to 400-600 ml. In case of blood loss moderate severity(degree) a transfusion of a total of 1500 ml is required, and in severe cases - up to 2.5-3 thousand ml of hemotherapeutic agents, and transfusions of blood, plasma and plasma substitutes should be alternated.

Low molecular weight plasma substitutes - hemodez, reopoliglucin, neocompensan. The total volume of infusions can be determined at the rate of 30-40 ml per 1 kg of patient body weight. The ratio of solutions and blood is 2:1. Polyglucin and rheopolyglucin are administered up to 800 ml, the dose of saline and glucose solutions is increased.

In patients with severe blood loss and hemorrhagic shock, infusion therapy is carried out at a ratio of solutions to blood of 1:1 or even 1:2. The total dose of transfusion therapy should exceed blood loss by an average of 30-50%. To maintain blood oncotic pressure, it is necessary to use albumin, protein, and plasma.

Correction of hypovolemia restores central hemodynamics.

With massive blood transfusions, the toxic effect of citrated blood is possible. When blood is infused from several donors, immune conflicts and the development of homologous blood syndrome with a fatal outcome are possible.

Blood loss within 10% of the bcc does not require compensation with blood and blood substitutes. If the loss of blood volume is 20% and the hematocrit is 30%, an infusion of blood products (plasma, albumin, etc.) is sufficient.

Blood loss up to 1500 ml (25-35% of the bcc) is replaced with red blood cell mass (half the volume) and a double volume of blood substitutes (colloid and crystalloid solutions) is administered.

Massive blood loss (about 40% of the total blood volume) poses a great danger to the patient’s life. Whole blood is used after replenishment of the HO and PO of the blood; in the next 24 hours, the deficiency of extracellular fluid is compensated for with an isotonic solution of glucose, sodium chloride and lactasol (in order to reduce metabolic acidosis).

Transfusion therapy should be carried out taking into account changes in the blood volume and its components in different periods after bleeding. In the first 2 days, hypovolemia is observed as a result of a deficiency of blood volume and central circulation. Transfusion of whole blood and blood substitutes is indicated. On days 3-5, oligocythemic normo- or hypovolemia is observed, so it is advisable to transfuse red blood cells. After 5 days, transfusion of red blood cells and whole blood is indicated. It is recommended that correction of volemic disorders be carried out under the control of CVP measurements.

Treatment of patients with gastrointestinal tract diseases is carried out in an intensive care unit.
Thus, if hemostatic therapy is effective, bleeding does not recur, patients with indications for surgical treatment of ulcer are operated on as planned, after appropriate preparation, within 10-12 days.

Surgical tactics for acute gastrointestinal tract diseases still pose a difficult problem. The decision on how to treat a patient with ulcerative bleeding must always be made taking into account the rate and severity of the bleeding.

At one time S.S. Yudin (1955) wrote: “If there is sufficient evidence indicating the ulcerative nature of the bleeding, in people who are not too young and not too old, it is better to operate than to wait. And if you operate, it’s best to do it right away, i.e. on the first day. No amount of blood transfusions can correct what the loss of time causes.

Without blood transfusions, many of those operated on and in early dates, but by simply replacing lost blood it is often impossible to save patients who have gone beyond the limits of what can be tolerated.” Finsterer (1935) believed that a patient with acute gastrointestinal tract disease and a history of ulcers should undergo surgery. In the absence of a history of ulcers, conservative treatment should be used initially. Bleeding that does not stop after treatment, as well as repeated bleeding, are indications for surgery.

B.S. Rozanov (1955) noted that not a single surgeon can deny the danger of surgical intervention for ulcerative bleeding. Nevertheless, the maximum danger lies not so much in the operation itself, but in the waiting and duration of posthemorrhagic anemia. A patient with acute gastrointestinal bleeding in the intensive care unit is brought out of a state of hemorrhagic shock. After the condition improves and hemodynamic parameters stabilize, endoscopy is performed. It should be early, since diagnosis becomes more difficult as the duration of bleeding increases.

If the conservative method is carried out strictly, then the effect is very convincing, of course, if the pace and massiveness of the hemorrhage allow only conservative tactics. Unfortunately, this does not always happen. In 25-28% of patients admitted to the hospital for ulcerative bleeding, it appears in such a pronounced acute form that the above-mentioned conservative measures alone, including the Meulengracht technique, cannot stop it. In such situations it is required quick application other, more reliable means, surgical intervention, which at one time was characterized by high mortality.

The best time for operations, by general agreement, is the first 48 hours from the start of bleeding (“golden hours”) (B.A. Petrov, Finsterer). In more late dates Such significant post-hemorrhagic changes have time to develop in the patient’s body that surgery after 48 hours is high risk and will give worse immediate results. In later days, it is more advantageous to use conservative measures to restore not only hemodynamics in the patient’s body, but also general reparative abilities, and then operate as planned in calm conditions, bearing in mind that bleeding from the ulcer will almost certainly recur and only resection with excision of the ulcer can guarantee against recurrence bleeding, and provided that the ulcer was not a manifestation of Zollinger-Ellison syndrome.

Surgical tactics for acute gastrointestinal tract disease include determining the indications for surgery, the timing of the operation and the choice of its method (G.A. Ratner et al., 1999).

Treatment of all patients with acute gastrointestinal tract disease begins with a set of conservative measures. If conservative treatment of bleeding ulcers is ineffective, early surgical treatment is possible (Yu.M. Pantsyrev et al., 1983). A number of authors (A.A Alimov et al., 1983) consider the continuation of bleeding after a transfusion of 2 liters of blood or its resumption after a break as a criterion for ineffectiveness. Transfusion of large amounts of blood leads to an increase in mortality not only from bleeding, but also as a result of bleeding, including from the “massive transfusion” syndrome.

For acute gastrointestinal tract disease, surgical tactics are reduced to three directions (S.G. Grigoriev et al, 1999).

1. Active tactics- urgent surgery at the height of bleeding during the first day (S.S. Yudin, B.S. Rozanov, A.T. Lidsky, 1951; S.V. Geynats, A.A. Ivanov, 1956; B.A. Petrov, 1961; I.V. Babris, 1966; A.A. Shalimov, 1967; Finsterer, Bowers, 1962; Harley, 1963; Spiceretal., 1966).

2. Tactics of some waiting(wait and see) with urgent surgery. This tactic is followed by a large group of surgeons. It involves stopping bleeding using conservative means and surgery in the intermediate period at 10-14 weeks. (F.G. Uglov, 1960; V.I. Struchkov, 1961; M.E. Komakhidze and O.I. Akhmeteli, 1961; M.K. Pipiya, 1966; D.P. Shotadze, 1966, etc.) . If the bleeding does not stop with conservative measures, then patients are operated on at the height of bleeding during the first day.

3. Conservative tactics at the time of acute bleeding. This tactic was supported by E.L. Berezov (1951); M.A. Khelimsky (1966); Salaman and Karlinger (1962), etc. The authors believe that one should not operate at the height of bleeding, but persistently strive to stabilize the patient’s condition, operating after 2-4 weeks.

One of the main tasks facing the surgeon on duty is diagnosis, identification of the causes and localization of the source of acute gastrointestinal tract obstruction.

The second task, the solution of which influences the choice of treatment tactics and the infusion therapy program, is to determine the degree of blood loss in patients with acute gastrointestinal bleeding. Most often, practical surgeons determine the degree of blood loss and judge the severity of bleeding by clinical signs and laboratory parameters. However, the most accurate way to determine blood loss is to study the blood volume and its components, the most stable of which is HO deficiency (A.I. Gorbashko, 1989).

The diagnostic significance of a deficiency of blood volume and its components is that a severe degree of blood loss in the first hours is observed, as a rule, with arrosive ulcerative bleeding.
The tactical significance of the intensity and degree of blood loss is that with a severe degree of blood loss that has developed in short term, emergency surgical intervention is indicated, since delay in finally stopping hemorrhage can lead to relapse and irreversible condition.

The therapeutic value of determining the size of hemorrhage is very high, since a clear understanding of the deficiency of blood circulation and its components allows for scientifically based infusion therapy before, during and after surgery.

The next task that influences the outcome of treatment is the choice of treatment tactics by the surgeon. Unfortunately, until now there is no uniform tactic when choosing a treatment method and sometimes they use a not entirely correct, so-called active expectant tactic, according to which emergency surgery is indicated in patients admitted to the hospital with ongoing bleeding. If the bleeding has stopped, treatment may not be surgical. However, if hemorrhage recurs, then surgery is indicated.

Thus, according to the so-called active expectant tactics, patients with ongoing bleeding are operated on urgently, and this is usually a state of hemorrhagic shock and a violation of compensatory mechanisms. This tactic has all but been abandoned as untenable.

We adhere to active individualized tactics in the treatment of acute gastrointestinal tract diseases of various etiologies, the essence of which is as follows. We perform emergency surgery with severe blood loss (30% or more blood loss) at any time of the day and regardless of whether the bleeding continues or has stopped, as well as with ongoing bleeding in patients with moderate and mild blood loss.

We use early emergency surgery in patients with moderate blood loss (HO deficiency from 20 to 30%) and in patients with severe blood loss who refuse emergency surgery at night.

We perform planned surgery on those patients who are not candidates for emergency or early urgent surgery. These are patients who arrive later than 2 days. with stopped bleeding, when favorable timing for early surgery has already been missed: persons with a mild degree of blood loss and stopped hemorrhage, in whom ulcerative disease was detected for the first time and they require conservative treatment. This group includes patients with stopped bleeding and the presence of severe concomitant CV diseases, respiratory system in the stage of decompensation, diabetes mellitus and a number of other serious diseases.

Active individualized tactics have justified themselves in organizational and tactical terms; they make it possible to rationally distribute the forces and resources of the surgical team on duty and successfully complete the main task of providing care to patients with a life-threatening condition. Through the works of S.S. Yudina, B.S. Ryazanov has proven that with active surgical tactics, mortality can be reduced to 5-6%. Planned surgery in patients with severe and moderate blood loss is recommended to be performed no earlier than 3-4 weeks. after bleeding has stopped. The most unfavorable period for performing planned operations is the 2nd week. posthemorrhagic period.

The next task, the solution of which contributes to the achievement of favorable outcomes in the treatment of profuse gastrointestinal tract, is the choice of surgical intervention, which depends on the duration of the disease, the degree of blood loss, the timing of admission from the onset of bleeding, the localization of the source of hemorrhage and the patient’s condition.

According to leading experts, indications for emergency surgical intervention for ulcerative bleeding are:

A) failure and futility of persistent conservative treatment, including diathermocoagulation (bleeding cannot be stopped or after stopping there is a threat of its recurrence);
b) massive blood loss, localization of the ulcer in dangerous areas with abundant blood supply, unfavorable endoscopic signs (deep ulcer with exposed or thrombosed vessels); elderly patients, as well as patients in a state of hemorrhagic shock, with massive bleeding, when conservative measures are ineffective; with recurrent bleeding that occurred after it stopped as a result of conservative treatment in the hospital.

In this case, a distinction is made between emergency surgery, which is performed in case of intense bleeding (primary or recurrent) regardless of the effect of anti-shock therapy, and early surgery - within the first 1-2 days. from the onset of bleeding after stabilization of hemodynamics and planned surgery - 2-3 weeks later. after stopping bleeding and a course of conservative treatment.

The best results are observed with early operations, which are performed with stable hemodynamics. Mortality during emergency operations is 3-4 times higher than during early operations, especially in elderly and senile patients.

Currently, there are developed and refined indications for emergency surgical intervention for gastrointestinal tract diseases of ulcerative etiology. According to these indications, emergency surgical intervention is performed in case of heavy ulcerative bleeding, when the presence of an ulcer is proven on the basis of EI, and ulcerative bleeding is combined with pyloroduodenostenosis or a relatively rare perforation; with the ineffectiveness of conservative treatment and repeated bleeding, even if the nature of the bleeding is not known.

A certain importance is attached to the age of the patient. In people over 50 years of age, conservative treatment does not guarantee complete stoppage of bleeding. It is advisable to carry out urgent surgery for massive bleeding within 24-48 hours, when, despite the transfusion of 1500 ml of blood, the patient’s condition does not stabilize, the blood volume and hemoglobin remain at the same level or decrease, and urine is excreted at 60-70 ml/hour.

The indications for urgent surgery should be especially urgent in patients over 60 years of age, in whom the autoregulatory mechanisms of adaptation to blood loss are reduced, and the source of bleeding is often large callous ulcers localized in the area of ​​large vessels.

Patients with profuse bleeding should be operated on at an early, optimal time for the patient, while performing the entire mentioned complex of therapeutic measures. This position is cornerstone at the present time. When discussing this issue at the 1st All-Union Plenum of the Society of Surgeons (Tbilisi, 1966), this tactic enjoyed overwhelming support. When choosing a method of surgical intervention, it is necessary to take into account the characteristics of the clinical situation, which determine the degree of surgical risk, the amount of blood loss, the patient’s age and concomitant diseases, technical conditions, and the personal experience of the surgeon. The purpose of the operation is, firstly, to stop bleeding and save the patient’s life, and secondly, to cure the patient of ulcerative disease.

Three types of operations are mentioned for these conditions in the literature: gastrectomy, suturing of all major arteries of the stomach if it is impossible to perform resection due to the severity of the patient's condition (or intraorgan suturing of the ulcer), vagotomy with ulcer ligation with pyloroplasty for a high (subcardial) located bleeding gastric ulcer when the operation is technically difficult or develops into a total (unwanted) gastrectomy.

Of course, gastrectomy is the most rational. However, it is not always possible to perform it, for example, with a low-lying duodenal ulcer. Then one has to limit oneself to suturing all the main arteries of the stomach or vagotomy with suturing of the ulcer and pyloroplasty. Their production, however, never gives confidence in a radical stop of bleeding.

In weakened elderly patients burdened with concomitant diseases, it is recommended to perform ligation of the bleeding vessel, pyloroplasty and vagotomy.
A number of authors (M.I. Kuzin, M.L. Chistova, 1987, etc.) take a differentiated approach: for duodenal ulcers - suturing of the bleeding vessel (or excision of the anterior wall ulcer) in combination with pyloroplasty and vagotomy; for combined ulcers of the duodenum and stomach - vagotomy with pyloroplasty; for gastric ulcers: 1) in patients with a relative degree of surgical risk, gastric resection with removal of the bleeding ulcer; 2) in elderly patients with high degree risk or through a gastrotomy opening, suturing a bleeding vessel in a high-lying ulcer in combination with vagotomy and pyloroplasty.

In severe clinical situations during operations at the height of bleeding, gentle operations aimed at saving the patient’s life can be used: gastrotomy with suturing of the bleeding vessel, wedge-shaped excision of the ulcer. For seriously ill patients with excessive risk of surgery, embolization of the bleeding vessel is performed during angiography.

The most undesirable situation that arises during surgery for gastrointestinal tract disease is that during the operation the surgeon does not find an ulcer. However, data from individual autopsies of the deceased show that the ulcer was still there, although the operator did not feel it, and it was from this that the fatal bleeding occurred. Therefore, during laparatomy for bleeding, if the ulcer cannot be palpated, it is recommended to perform a diagnostic long longitudinal gastroduodenotomy. Only if no ulcer is found, it is necessary to suture the wound of the stomach, duodenum and abdominal wall, intensifying all hemostatic measures.

The choice of surgical intervention for acute gastrointestinal tract diseases of ulcerative etiology should be individualized. For bleeding of ulcerative etiology, gastrectomy is considered the optimal intervention. IN as a last resort, if there are no conditions necessary for gastric resection or the patient’s condition does not allow (extremely serious condition), it is recommended to use palliative operations: excision of the edge of the ulcer, puncture of the ulcer, suturing, selective ligation of the gastroduodenal artery or coagulation of the bottom of the ulcer.

It is considered advisable to supplement suturing of ulcers (especially duodenal ulcers) with vagotomy. In these cases, gastric resection to switch off or the application of GEA is not indicated. Gastric resection is not opposed to organ-saving operations; they should complement each other, which improves the immediate results of treatment.

Gastric resection is performed on those patients who have indications for this operation and if the patients are able to endure it. Indications for resection are chronic ulcers stomach, penetrating and stenotic ulcers of the duodenum, malignant tumors and multiple acute ulcers. It is considered preferable to perform gastric resection using the Billroth-II method.

Significant technical difficulties arise when bleeding from a low localization ulcer. To close the duodenal stump, the method proposed by S.S. can be used. Yudin’s method of forming a “snail”. After the operation, patients are transfused with fresh blood and blood substitute fluids in sufficient quantities.

Surgery for acute gastrointestinal tract disease is performed under superficial intubation anesthesia in combination with muscle relaxants, controlled breathing, small doses of narcotics and a full supply of oxygen. Such anesthesia creates conditions for restoring the depressed functions of vital organs. Surgery is performed under the protection of a drip blood transfusion, since patients with acute gastrointestinal tract bleeding are extremely sensitive to additional blood loss during surgery. During surgery in a bleeding patient, in addition to careful handling of tissue, careful hemostasis is important.

During surgical intervention for gastrointestinal tract, it is necessary to consistently and thoroughly inspect the abdominal organs, especially the stomach and duodenum, their anterior and posterior walls. To examine the posterior wall, it becomes necessary to dissect the gastrocolic ligament. At the same time, identifying large and callous ulcers does not present any particular difficulties. Small ulcers are sometimes whitish, dense, or in the form of a retracted scar.

In some cases, an inflammatory infiltrate is palpated around the ulcer. If it is not possible to identify an ulcer, then there is a need to inspect the intestines in order to identify a possible source of bleeding localized in it (ulcer, tumor, Meckel's diverticulum).

The liver and spleen should also be checked - cirrhotic changes on their part can also cause dilated veins of the esophagus and bleeding from them. If the source of bleeding is not identified, a gastrotomy is performed to inspect the gastric mucosa. After clarifying the ulcerative etiology of bleeding, a surgical method is chosen.

In recent years, the question of choosing a method of surgery for ulcerative bleeding has undergone a radical revision. Many surgeons consider the operation of choice to be SV with ulcer suturing and pyloroplasty. Some authors even use PPV in combination with duodenotomy, suturing the bleeding vessel while preserving the pylorus (Johnston, 1981). After such operations, the mortality rate is on average 9%, for the same number of gastric resections it is 16% (A.A. Shalimov, V.F. Saenko, 1987).

In case of gastrointestinal tract ulcerative etiology and a state of relative compensation, duodenotomy or gastrotomy is performed, preserving the pylorus, the source of bleeding is trimmed and PPV is performed. If the ulcer is located on the pylorus, a hemipylorectomy according to Jad is performed with excision of the ulcer and PPV. In severely weakened patients, a wide gastroduodenotomy is performed, the bleeding vessel in the ulcer is sutured, an incision of the stomach and duodenum is used for pyloroplasty, and the operation is completed with SV. For bleeding gastric ulcers, it is considered possible for a seriously ill patient to excise the ulcer and perform vagotomy and pyloroplasty. Gastric resection is resorted to in the compensated condition of the patient and in the presence of a large ulcer, if there is a suspicion of its malignancy.

When using SV, the operation begins with gastroduodenotomy and bleeding control. In the best way is the exteriorization of the ulcer by mobilizing its edges, suturing the ulcer and suturing the CO over the ulcer.

If it is impossible to perform this technique, it is recommended to limit yourself to lining the bleeding vessel. Then pyloroplasty and vagotomy are performed. Recurrent bleeding is usually the result of poor vessel ligation and ulcer ligation. There are cases when, during gastric surgery for bleeding, no signs of ulcerative, tumor or other damage to the stomach or duodenum are found. It should be remembered that the operation itself - laparotomy - reduces blood flow in the stomach, which sometimes explains the absence of bleeding during revision (A.A. Shalimov, V.F. Saenko, 1987).

If the source of bleeding is unclear, before performing a “blind” gastrectomy, it is recommended to resort to intraoperative endoscopy or wide gastroduodenotomy. If the source of bleeding cannot be detected, it is considered necessary to especially carefully examine the cardiac part of the stomach and the esophagus. To revise the gastric mucosa, they use the Staril technique: after mobilizing the greater curvature and wide gastrotomy, the gastric mucosa is turned out with a clamp through the posterior wall.

Organ-preserving operations are indicated for duodenal ulcers, acute ulcers and erosive hemorrhagic gastritis, benign tumors, polyps of the stomach and intestines, for ulcers in children, young men and asymptomatic ulcers, for patients who are too bleeding and admitted late and people with severe concomitant diseases with a sharply increased risk.

Currently, gastric resection is still the leading method of treating ulcers, including those complicated by bleeding. The method of gastric resection for acute gastrointestinal tract disease is chosen to be the one that the surgeon has the best command of. With acute gastrointestinal tract disease, mortality during emergency surgical interventions remains high and ranges from 12.7 to 32.7% (A.I. Gorbashko, 1985). The prognosis of acute gastrointestinal tract disease depends on many factors, and above all on the nature of the disease, the severity of blood loss, the age of patients and concomitant diseases, timely and accurate diagnosis.

Active diagnostic tactics and the widespread introduction of endoscopy have made it possible to more confidently predict the possibility of recurrent bleeding and, therefore, correctly resolve the issue of the place of conservative and surgical treatment methods in each specific case. Until recently, it was believed that profuse ulcer bleeding posed an immediate threat to life.

Indeed, even today, despite the introduction of organ-preserving methods of surgical treatment of ulcers, mortality after operations at the height of bleeding remains high, averaging 8-10% (A.A. Grinberg, 1988). In terms of reducing mortality, further development is certainly promising conservative methods stopping bleeding, which makes it possible to operate on patients after appropriate preoperative preparation.

In cases of non-ulcer bleeding, it is promising to improve conservative methods of stopping bleeding: endoscopic diathermo- and laser coagulation, selective vascular embolization, etc.

One of the important conditions aimed at improving the results of treatment of acute gastrointestinal tract diseases is pre-, intra- and postoperative infusion therapy. The leading measure of complex treatment is the restoration of the bcc and its components. The amount of blood transfused must be adequate to the blood loss, and in case of severe hemorrhage - exceed the BCC deficit by 1.5-2 times; it is necessary to combine the infusion with the infusion of solutions that improve the rheological properties of blood.

Thus, the results of treatment of acute gastrointestinal bleeding can be significantly improved with the strict implementation of a number of scientifically based organizational measures: early hospitalization, early use of infusion therapy and immediate clarification of the cause and localization of the source of bleeding using modern instrumental diagnostic methods, the choice of rational surgical tactics, individualized method and volume surgical intervention, qualified operation and postoperative management. Good results with profuse gastrointestinal tract are obtained when the operation is performed in the first 24 hours from the onset of hemorrhage.

Errors and dangers in the treatment of acute gastrointestinal tract diseases. The prehospital stage of medical care is of significant importance in the treatment outcomes of patients with acute gastrointestinal tract diseases, since in the conditions of the first contact of the doctor with the patients, organizational diagnostic and tactical errors are possible, contributing to the development of dangerous complications and even unfavorable outcomes.

Practical experience shows that a prehospital doctor should not strive to find out the etiology of bleeding at any cost. The volume of emergency care for patients with acute gastrointestinal bleeding at the prehospital stage should be minimal, and the patient must be urgently hospitalized, regardless of his condition and the degree of blood loss. Patients with ongoing bleeding and signs of hemodynamic compromise should be urgently hospitalized, continuing intravenous infusion therapy along the way.

The hospital stage includes the time required to clarify the diagnosis and determine indications for treatment. The first task of the surgical team on duty is urgent assistance medical care, and only then should one begin to diagnose the cause and localization of the source of acute gastrointestinal tract infection.

Diagnostic error often occurs in elderly and senile patients, when cancer is suspected and therefore conservative treatment is carried out for too long (V.L. Bratus, 1972; A.I. Gorbashko, 1974; 1982).

One of typical mistakes hospital is an underestimation of the degree of blood loss and, consequently, insufficient blood transfusion in the preoperative period (A.I. Gorbashko, 1985; 1994). Experience shows that patients with impaired hemodynamics in the preoperative period need to administer at least 500 ml of blood in combination with other plasma-substituting solutions. Only if bleeding continues, while continuing the blood infusion, should emergency surgery be started immediately.

One of the main mistakes is the use of the so-called “active expectant” tactics for profuse GIBs of ulcerative etiology, which often misleads the surgeon and gives him the opportunity to unreasonably refuse emergency surgery only because the bleeding allegedly stopped at the time of examination (A.I. Gorbashko, 1985). A particular danger arises if the patient categorically refuses surgery for profuse GIB. In such cases, a consultation should be urgently convened, involving representatives of the administration.

Endoscopic methods for diagnosing and treating acute gastrointestinal tract diseases can significantly improve immediate results. However, when overestimating their true capabilities, a number of new errors and dangers may arise. Surgeons, sometimes relying too much on the data of this study and when the cause and source of hemorrhage are not identified, often abandon active tactics, continuing conservative treatment (A.I. Gorbashko, 1985).

An attempt to coagulate a large arrozed vessel in a deep ulcerative niche through an endoscope when the patient absolutely needs surgical intervention is considered a tactical mistake. Meanwhile, electrocoagulation of a large artery branch may be unreliable. Electrocoagulation of a vessel in a deep ulcerative niche can only be indicated if the patient has absolute contraindications to surgery and it poses a great risk to his life (V.I. Gorbashko, 1985).

Diagnostic intraoperative errors occur when identifying the source of hemorrhage, which may be due to objective difficulties in its detection or violation of the rules for auditing the abdominal organs.

In order to prevent errors when identifying the source of acute gastrointestinal bleeding, it is necessary to strictly adhere to a certain method of sequential examination of the abdominal organs and, for certain indications, use provocation of acute gastrointestinal bleeding, since when the bleeding has stopped, it is much more difficult to determine the cause and source of hemorrhage (A.M. Gorbashko, 1974).

Tactical intraoperative errors arise when choosing the method and extent of surgical intervention, when the surgeon, having insufficiently assessed the patient’s condition, anemia, age, and the presence of concomitant diseases, seeks to perform gastric resection. IN such a case It is recommended to perform organ-preserving operations - excision or suturing of a bleeding ulcer. It is generally accepted that the use of organ-preserving operations in seriously ill patients can improve the immediate outcomes of treatment of acute gastrointestinal tract diseases of ulcerative etiology (M.I. Kuzin et al., 1980).

One of the technical errors during surgery for acute gastrointestinal tract disease is performing standard mobilization of the stomach, as with planned resection. In this case, it is recommended to begin mobilization of the stomach and duodenum with ligation of the vessels that directly approach the bleeding ulcer. If the ulcer is located on the lesser curvature, it is considered necessary to squeeze it with your fingers, and press the bleeding duodenal ulcer against the posterior wall for the entire duration of mobilization.

Excessive mobilization of the stomach and duodenum is considered a technical error. In such cases, ligation of the superior pancreatic-duodenal artery can cause disruption of the blood supply and failure of the duodenal stump sutures (NSS). The cause of GEA failure may be excessive mobilization of the gastric stump along the greater curvature.

Surgeons can also make a certain mistake when isolating a penetrating ulcer of the duodenum, when they first do not exceed its wall below the ulcerative infiltrate. In this case, the stomach can tear away from the duodenum, the stump of which contracts and descends along with the bottom of the penetrating ulcer deep into the right lateral canal of the abdominal cavity. To avoid this complication, it is recommended to stitch its wall below the ulcer with two sutures before mobilizing the duodenum, creating controlled “holds”.

One of the dangers arises when isolating the duodenum and suturing its stump, especially in patients with an anomaly in the development of the head of the pancreas (“ring-shaped and semi-ring-shaped” structure of the head of the pancreas). When mobilizing and mixing its tissue from the wall of the duodenum into postoperative period Pancreatic necrosis may occur.

Technical errors occur when isolating postbulbar ulcers that penetrate into the head of the pancreas and the hepatoduodenal ligament. In this situation, damage to the CBD, gastroduodenal, and superior pancreatic-duodenal arteries is considered possible, and if an ulcer is left after gastric resection to turn off, perforation is considered possible. In patients with a postbulbar bleeding ulcer and in a compensated state during gastric resection, it is recommended to pierce the bleeding vessel and tamponade the ulcer with a free piece. greater omentum, suturing the edges of the ulcer and ligating it (A.I. Gorbashko, 1985). In this position, organ-preserving surgery is also considered possible, consisting of duodenotomy, suturing of the bleeding vessel, suturing of the ulcer niche with tamponade with its free piece of omentum and SV.

Dangers and difficulties (increased hemorrhage, failure of the sutures (NS) of the lesser curvature) also occur when isolating a highly penetrating cardiac ulcer and an ulcer of the fundus of the stomach with a large inflammatory infiltrate.

Of particular danger are technical errors associated with leaving a bleeding ulcer in the stump of the stomach or duodenum, when resection is performed in a closed manner, as in a planned manner. To prevent these errors, gastric resection for acute gastrointestinal tract diseases of ulcerative etiology should be performed in an “open” way, i.e. Before suturing the stump, it is necessary to examine its SB and check whether there is fresh blood in the lumen.

Difficulties and dangers are encountered when removing an ulcer that penetrates into the head of the pancreas (A.I. Gorbashko, 1985). The use of methods for suturing the duodenal stump using purse-string sutures or complex modifications such as “snail” is considered dangerous, since the infiltrated tissues do not sink well, often the sutures are cut through, which requires additional methods of strengthening them. In order to prevent these complications when suturing a “difficult” duodenal stump, it is recommended (A.I. Gorbashko, 1985) to use interrupted sutures using the method of A.A. Rusanova.

Since there are no methods that absolutely guarantee the reliability of the sutures of the duodenal stump, it is therefore recommended not to neglect other methods of preventing the development of diffuse peritonitis in this complication. For this purpose, in case of a “difficult” duodenal stump, it is recommended to use active decompression of its lumen through a transnasal probe.

It is also considered a mistake to neglect drainage of the right lateral canal of the abdominal cavity with a “difficult” duodenal stump. Although abdominal drainage does not prevent NSC, it contributes to the formation of an external duodenal fistula, which closes on its own.

Errors in the postoperative period are associated with neglect of active decompression of the gastric stump. The accumulation of blood, sputum and mucus in the gastric stump can cause an increase in pressure in its lumen and the duodenal stump, stretching of the gastric stump and impaired circulation of its walls and cause hypoxic circulation, perforation, NSA,

One of the mistakes is insufficient attention to the early removal of decomposing blood from the intestines. To prevent intoxication and paresis in the postoperative period, it is recommended, when hemodynamics are stabilized, to clear the intestines of blood as early as possible using repeated siphon enemas.

Thus, patients with signs of acute gastrointestinal bleeding are subject to emergency hospitalization in a surgical hospital, regardless of the condition, intensity, degree of blood loss and duration of the post-hemorrhagic period. The use of emergency infusion therapy and early diagnosis of the cause and localization of the source of bleeding allows one to avoid tactical and diagnostic errors in the emergency and surgical departments of a hospital.

The surgeon’s active tactics and individualized choice of treatment method make it possible to perform surgical intervention in a timely manner, taking into account the indications and condition of the patient.

Compliance with the basic rules of surgical guidance for acute gastrointestinal tract diseases allows you to avoid a number of intraoperative dangerous mistakes and postoperative complications. Despite the progress achieved, mortality after surgery in conditions of profuse ulcer bleeding remains high - at least 10%. This forces surgeons not to stop there, not to consider surgery a panacea and to look for other ways to help these patients.

The leakage of blood from vessels that are affected by erosion or pathology is a very dangerous phenomenon. Blood flows to the digestive organs. Considering the severity of the situation and the location of the bleeding source, very disappointing symptoms may appear: fainting, tachycardia, melena, vomiting, the color of which resembles coffee grounds, pale skin and dizziness. Diagnostics will help determine the location of internal hemorrhage: colonoscopy, laparotomy, FGDS, enteroscopy and sigmoidoscopy. There are two main methods to stop bleeding: surgical and conservative. If the patient is not provided with timely assistance, this can lead to death.

Currently, there are about 100 different pathologies that can cause gastrointestinal tract. Whenever internal bleeding gastrointestinal tract the patient requires urgent Care professionals.

Hemorrhages are divided into 4 types:

• gastrointestinal diseases;
• blood pathologies;
• portal hypertension;
• vascular damage.

Gastrointestinal bleeding can occur with the following diseases: compression of the vein, cirrhosis, chronic hepatitis, constructive pericarditis.

Bleeding from the gastrointestinal tract, manifested due to vascular damage, is treated as such pathological processes, such as: systemic lupus erythematosus, rheumatism, Ranndu-Osler disease, vitamin C deficiency, periarteritis nodosa, septic endocarditis and scleroderma.

Gastrointestinal bleeding can be a consequence of some blood ailments: chronic and acute leukemia, hemophilia, hemorrhagic diathesis, hypoprothrombinemia.

Situations such as alcohol intoxication, physical stress, chemicals, taking NSAIDs, aspirin and corticosteroids can provoke gastrointestinal bleeding syndrome.

Types of housing and communal services

Before treating hemorrhage, it is important to know the classification of gastrointestinal bleeding. Considering the part of the digestive system that serves as the source, bleeding is distinguished from the upper parts of the gastrointestinal tract (duodenal, esophageal, gastric), as well as from lower sections(colon and small intestine, hemorrhoidal).

For gastrointestinal bleeding, the classification takes into account ulcerative and non-ulcerative nature. There are acute and chronic gastrointestinal tract diseases. Depending on its severity, the condition can be hidden or obvious. Regarding the number of episodes, a distinction is made between recurrent and single GIB.

Considering the severity of blood loss, there are 3 degrees of gastrointestinal tract infection. A mild degree is characterized by a heart rate of 80, systolic blood pressure of at least 110, satisfactory condition and consciousness, dizziness, and normal diuresis. Indicators of moderate acute gastrointestinal bleeding: heart rate - 100 beats per minute, systolic blood pressure - 100-110 millimeters Hg. Art., consciousness and pallor of the skin, cold sweat remain, and diuresis decreases. If such signs occur, it is necessary to call emergency doctors.

Severe gastrointestinal bleeding is manifested as follows: heart rate - more than 100 beats, systolic blood pressure - less than 100, adynamia and lethargy, anuria or oliguria. The composition of the blood changes significantly.

Clinical picture

Signs of internal bleeding may include:

• vomiting, nausea;
• weakness;
• malaise, darkening of the eyes;
• consciousness is confused;
• fainting and dizziness;
• pale skin;
• tachycardia and tinnitus;
• arterial hypotension.

Gastrointestinal tract infection of the upper sections is accompanied by profuse bloody vomiting, which resembles coffee grounds. This can be explained by the fact that hydrochloric acid comes into contact with the blood. Profuse internal hemorrhage is characterized by scarlet or intense red vomit and tarry stools (melena). In bowel movements there are clots and streaks of scarlet blood, which indicates bleeding from the anal canal, rectum or colon.

The clinical picture occurs against the background of symptoms of the main ailment that provoked dangerous complication. Painful sensations in different parts of the gastrointestinal tract, nausea and belching, intoxication, and dysphagia may be observed. Hidden gastrointestinal tract infection is especially dangerous, since it can only be revealed by diagnostics.

The following pathological conditions can be called complications: acute anemia, hemorrhagic shock, renal and multiple organ failure, death.

To avoid such complications, competent and timely treatment tactics will be required. It is possible after a complete and in-depth examination of the patient.

Diagnostic methods

Concerning differential diagnosis gastrointestinal bleeding, then she suggests a complete examination, which begins with determining the medical history, assessing bowel movements and vomit, and performing a digital rectal examination. The color of the skin must be taken into account. The abdominal area is carefully palpated to avoid aggravation of the gastrointestinal tract. It is necessary to review the coagulogram, determine the level of urea and creatine, and a kidney test.

X-ray methods will be useful:

• irrigoscopy;
• celiacography;
• x-ray and angiography.

The most effective and accurate method of diagnosis is endoscopy (FGDS, gastroscopy and colonoscopy, as well as esophagoscopy). These tests will help determine the presence of a surface defect on the mucosa, as well as the source of the gastrointestinal tract.

First aid and therapeutic therapy

If dangerous manifestations are detected, it is important to provide timely the right help. Before the ambulance arrives, you must do the following:

• try to place the victim on his back, elevating his legs, and provide him with rest;
• It is forbidden to eat or drink, as this stimulates the gastrointestinal tract;
• Apply dry ice or a cold object to the suspected source, this will help narrow the blood vessels. It is advisable to do this for twenty minutes with a break of 3 minutes to avoid frostbite;
• Give the patient two or three Dicinone tablets (crushed).

It is strictly forbidden to rinse the stomach or give an enema. In case of loss of consciousness, you must use ammonia, monitor your breathing and pulse.

During gastrointestinal bleeding, treatment involves immediate medical attention. Urgent hospitalization to surgery is indicated, where it will be determined therapeutic tactics. In case of massive blood loss, the patient is given therapy: infusion, blood transfusion, hemostatic.

In a general surgical hospital, patients with gastrointestinal bleeding account for 1/10 of the bed load. Most often, patients are delivered by ambulance; less often, they are transferred from therapy after unsuccessful treatment.

It is very difficult to separate intestinal bleeding from gastric bleeding. The diagnostic process is complicated by common causes, similar clinical signs, close location of sources, anatomical and functional unity of the entire gastrointestinal tract.

Statistical classification

If the stomach is damaged, some of the blood will definitely pass into the intestines and show up in stool tests. Even in the International Classification (ICD-10), the types of such internal bleeding are combined into one group: K92.2 (unspecified gastrointestinal) and melena (black profuse stool) - K92.1.

For some pathology, it is possible to indicate the nature and location of the disease:

• for duodenal ulcer (the initial part of the intestine) - K26;
• at higher localization (gastrojejunal) - K28;
• if the bleeding is directly from the rectum - K62.5.

According to the localization of sources of damage to the lower digestive tract:

• in first place is the duodenum (30% of all cases, considering that 50% occurs in the stomach);
• on the second - the large intestine (rectum and transverse colon) 10%;
• in the third - small intestine 1%.

The left half of the large intestine is the most dangerous location for malignant tumors

What are the types of intestinal bleeding?

There are acute and chronic types. They differ in the speed of development of clinical manifestations and in the main symptoms.

Acute profuse (large volume) blood loss in a matter of minutes or several hours leads the patient to an extremely serious condition. With small portions of blood lost over a long period of time, there is no clear clinical picture, but anemia gradually develops.

If the process is prolonged over a long period of time, it turns into a chronic form of blood loss. The body is unable to compensate for the lack of red blood cells and reacts with the appearance iron deficiency anemia. Treatment of this condition will require a lot of patience and a long period of time.

Causes

Intestinal bleeding is characterized by the same reasons as for the entire digestive tract: ulcerative lesion and non-ulcerative.

To the first group should be added:

• new ulcers at the site of the gastrointestinal connections after surgery to remove part of the stomach (resection);
• nonspecific ulcerative colitis;
• Crohn's disease (multiple slit-like ulcers of the small and large intestines due to inflammation).

Intestinal tumors are most often localized in the descending section of the transverse colon: benign (lipomas, leiomyomas), malignant (sarcoma, carcinoma).

In the rectum there are polypous growths that cause bleeding when traumatized by feces.

The group of non-ulcer diseases should include:

• intestinal diverticula;
• chronic hemorrhoids;
• rectal fissures.

In addition to the reasons listed, bloody stools can be detected in cases of intestinal infection (typhoid fever, dysentery, tuberculosis, syphilis).

Symptoms and features

The main symptom of intestinal bleeding is blood coming out of the anus during bowel movements or on its own. At the beginning of the disease it is not noticed.

You need to remember about the possibility of coloring feces in more dark color when treated with iron, bismuth, or taking activated carbon. Some products can lead to a suspicious manifestation: blueberries, chokeberries, pomegranate, black currants.

In addition, in children it is possible to ingest blood and sputum during nosebleeds, and in adults - during pulmonary bleeding.

Pain syndrome is caused by spasmodic contractions of the intestines

The massiveness of blood loss can be indirectly judged by the general condition of a person:

• pale skin;
• decreased blood pressure;
• dizziness and “darkening” in the eyes.

For colorectal cancer

Chronic anemia develops because bleeding is not severe (often malignancy detected during examination of a patient with anemia). If the tumor is located in the left parts of the large intestine, then the feces are mixed with mucus and blood.

For nonspecific ulcerative colitis

The patient complains about false urges to defecation. The stool is watery and contains blood, pus and mucus. Prolonged course of the disease can contribute to anemia.

For Crohn's disease

The symptoms are similar to colitis, but if the lesion is in part of the large intestine, acute bleeding from deep ulcers is possible.

For hemorrhoids

Blood is released in a stream of scarlet color at the time of defecation or immediately after it, less often on its own during physical stress.

Feces are not mixed with blood. There are other signs of hemorrhoids (itching in the anus, burning, pain). If dilatation of hemorrhoidal veins occurs due to high pressure V portal system(with cirrhosis of the liver), then copious dark blood is released.

For rectal fissure

The character of the stool is similar to hemorrhoids, but severe pain during defecation and after, spasm of the anal sphincter is typical.

Intestinal bleeding in childhood

Bleeding from the lower digestive tract most often occurs in children under three years of age. During the neonatal period, manifestations are possible congenital pathology intestines:

• duplication of the small intestine;
• infarction of part of the large intestine due to volvulus and obstruction;
• ulcerative necrotizing enterocolitis.

The baby has a bloated abdomen. Constant regurgitation, vomiting, green, watery stool with mucus and blood. Bleeding may be massive.

Abdominal pain in a child requires a mandatory examination by a doctor

How to provide first aid?

First aid when identifying signs of intestinal bleeding consists of measures to prevent massive blood loss:

• the patient must remain in bed;
• Place an ice pack or a heating pad with cold water on your stomach;
• If you have hemorrhoidal suppositories in your home medicine cabinet, you can put a suppository in the anus.

If the bleeding is minor, then you should call a doctor from the clinic to your home. If there is a heavy stream of blood or the child is ill, you need to call an ambulance.

Signs of acute anemia require immediate attention. The team’s doctors do not diagnose the location of the affected area. Drugs that increase blood clotting (Dicynon, Vikasol) are administered. The patient is transported on a stretcher to the surgical hospital.

Treatment

Treatment of a patient with signs of intestinal bleeding is carried out in the surgical department. If an infectious nature is suspected - in a boxed ward of the infectious diseases department.

For emergency indications, fibrogastroscopy is performed to exclude stomach disease, and sigmoidoscopy to examine the rectum.

Hemostatic drugs (aminocaproic acid solution, Fibrinogen, Etamsilate) are administered intravenously.

In case of hemodynamic disturbances (low blood pressure, tachycardia) - Reopoliglucin, blood plasma, soda solution.

Question about application surgical treatment When a disintegrating tumor or bleeding polyp is detected, it is resolved routinely after preparing the patient.

If the signs of internal bleeding intensify, then surgeons perform a laparotomy (opening the abdominal cavity), and they have to search for the source on the operating table. Further actions and the scope of surgical intervention correspond to the nature of the detected pathology.

Follow the usual gentle diet for peptic ulcers without spicy and fried foods

How to eat after bleeding

In the hospital, fasting is prescribed for 1 to 3 days. Nutrients are administered intravenously in the form of concentrated glucose and protein preparations.

Then, fat milk is allowed for 2–3 days, raw eggs, fruit jelly. At the end of the week, they switch to pureed porridge, cottage cheese, meat soufflé, soft-boiled eggs, and jelly. Everything is served cold.

Rehabilitation period

After intestinal bleeding, it takes time to restore the integrity of the intestines, healing of ulcers and cracks. Therefore, a strict diet must be followed for at least six months, and any physical activity is prohibited.

After 6 months, the patient should be re-examined by a gastroenterologist and follow his recommendations. Spa treatment in the near future is not recommended. The question of its feasibility should be agreed with a specialist. Remember that even small blood loss from the intestines over a long period of time can lead to blood diseases.

In which blood flows into the lumen of the stomach. In general, the term “gastrointestinal bleeding” is usually 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).

Stomach Bleeding Facts:

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

Features of the structure of the stomach

The human stomach is a hollow organ, a “bag” that receives food from the esophagus, partially digests it, mixes it and sends it further to the duodenum.

Anatomy of the stomach

Sections of the stomach:

• entrance section (cardia)– the transition of the esophagus into the stomach and the area of ​​the stomach immediately adjacent to this place;
• fundus of the stomach– the upper part of the organ, which looks like a vault;
• body of stomach– main part of the organ;
• outlet part (pylorus of the stomach)- the transition of the stomach into the duodenum and the area of ​​the stomach immediately adjacent to this place.

The stomach is located at the top of the abdominal cavity on the left. Its bottom is adjacent to the diaphragm. Nearby are the duodenum and pancreas. On the right are the liver and gall bladder.

The stomach wall consists of three layers:

• 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 muscle tissue the stomach can contract, mix and push food into the intestines. At the junction of the esophagus into the stomach and the stomach into 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.

Normally, an adult's stomach on an empty stomach has a volume of 500 ml. After eating, it usually expands to a volume of 1 liter. The stomach can stretch to a maximum of 4 liters.

Stomach functions

In the stomach, food accumulates, mixes and is partially digested. The main components of gastric juice:

• 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 arteries supplying blood to the stomach pass along its right and left edges (due to the curved shape of the organ, these edges are called the lesser and greater curvature). Numerous small ones branch off from the main arteries.

At the junction of the esophagus and the stomach there is a venous plexus. In some diseases, the veins of which it consists expand and are easily injured. This leads to severe bleeding.

Types of stomach bleeding

Depending on the reason:

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

Depending on the duration of bleeding:

• spicy– develop quickly and require emergency medical care;
• chronic– less intense, lasting for a long time.

Depending on how severe the signs of bleeding are:

• obvious– manifest themselves clearly, all the 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	In approximately 15%-20% of patients, gastric ulcers are complicated by bleeding. Causes of bleeding in gastric ulcers: direct damage to the vessel by gastric juice; development of complications – blocking the lumen of a vessel with a thrombus, causing it to burst.	Main symptoms of a stomach ulcer: pain, which occurs or becomes stronger immediately after eating; vomit, after which the patient feels better; 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 independently or be a complication of peptic ulcer disease. When the tumor begins to disintegrate, bleeding occurs.	Main symptoms of stomach cancer: most often the disease develops in older 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.
Gastric diverticulum	Diverticulum- This is a protrusion in the wall of the stomach. In order to understand what it looks like, you can imagine rubber surgical gloves: each “finger” is a “diverticulum”. This disease is rare. Bleeding occurs as a result of damage to the vessel due to inflammation of the diverticulum wall.	Main symptoms of gastric diverticulum: often the diverticulum is asymptomatic and is detected only during examination; belching, swallowing air while eating; an incomprehensible feeling of discomfort in the abdomen; dull weak pain; Sometimes a diverticulum manifests itself as quite severe pain, pallor, and weight loss.
Diaphragmatic hernia	Diaphragmatic hernia is a disease in which part of the stomach rises through an opening in the diaphragm into the chest cavity. Causes of bleeding with diaphragmatic hernia: damage to the esophageal mucosa gastric juice, which is thrown into it; Ulcer complicating diaphragmatic hernia.	Bleeding with a diaphragmatic hernia develops in approximately 15%-20% of patients. In most cases, it is hidden, that is, not accompanied by any symptoms. But it can also be quite strong.
Stomach polyps	Stomach polyps- these are quite common benign tumors. Bleeding occurs as a result of: ulceration of the polyp under the influence of gastric juice; polyp injuries; circulatory disorders(for example, if a large pedunculated polyp twists or “falls” into the duodenum and is strangulated).	Polyps usually do not show themselves before bleeding begins. If they have enough big sizes, then the passage of food through the stomach is disrupted.
Mallory-Weiss syndrome	Mallory-Weiss syndrome – bleeding that occurs when the mucous membrane ruptures at the junction of the esophagus and the stomach. Causes: prolonged vomiting due to alcohol poisoning, ingestion of large amounts of food; a predisposing factor is a diaphragmatic hernia, a condition in which part of the stomach protrudes through the diaphragmatic opening of the esophagus into the chest cavity.	The 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 (surface defects) appear on the gastric mucosa and there is a risk of bleeding.	Main symptoms: discomfort, pain in the upper abdomen after eating food, especially spicy, sour, smoked, fried, etc.; decreased appetite and weight loss; heartburn, belching; nausea and vomiting; bloating, heaviness in the abdomen; presence of blood in vomit and stool.
Stress ulcer	Stress has a negative impact on many internal organs. A person who is often nervous has a higher likelihood of developing various pathologies. During severe stress in an extreme situation, the adrenal cortex begins to produce hormones (glucocorticoids), which increase the secretion of gastric juice and cause circulatory problems in the organ. This can lead to superficial ulcers and bleeding.	It is often very difficult to identify a stress ulcer, since it is not accompanied by pain or other severe 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.	At the junction of the esophagus and the stomach there is a venous plexus. This is where the branches meet 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 of varicose veins of the esophagus: liver tumors; portal vein thrombosis; chronic lymphocytic leukemia; compression of the portal vein in various diseases.	In the early stages there are no symptoms. The patient does not suspect that he has esophageal varices. Bleeding develops unexpectedly, against the background of a state of complete health. It can be so strong that it quickly leads to death.
Systemic vasculitis: periarteritis nodosa; Henoch-Schönlein purpura.	Systemic vasculitis- this group autoimmune diseases, in which vascular damage occurs. Their walls are affected, resulting in increased bleeding. Some of the systemic vasculitis manifests itself in the form of gastric bleeding.	At systemic vasculitis symptoms of gastric bleeding are combined with symptoms of the underlying disease.
Atherosclerosis, high blood pressure.	With vascular damage and increased blood pressure there is a risk that the wall of one of the vessels will burst during an injury or another pressure surge and bleeding will develop.	Gastric bleeding is preceded by symptoms characteristic of arterial hypertension: headache; dizziness; “tinnitus”, “floaters before the eyes”; weakness, increased fatigue; periodic redness of the face, feeling of heat; sometimes there are no symptoms; when measuring blood pressure using a tonometer, it turns out to be above 140 mm. rt. Art.
Bleeding disorder
Hemophilia	A hereditary disease manifested by a blood clotting disorder 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 is disrupted. bone marrow. The formation of platelets - blood 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 blood clotting disorders and increased bleeding.
Vitamin deficiency K	Vitamin K plays important role during the process of blood clotting. With its deficiency, there is increased bleeding, hemorrhages in various organs, and internal bleeding.
Hypoprothrombinemia	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 associated with various acquired pathological conditions.

Symptoms of stomach bleeding

Symptom/group of symptoms	Description
Common symptoms of internal bleeding– develop with bleeding in any organ.	weakness, lethargy; pallor; cold sweat; decreased blood pressure; frequent weak pulse; dizziness and tinnitus; lethargy, confusion: the patient reacts sluggishly to his surroundings, answers questions with a delay; 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 over a short time. If you don't provide emergency assistance, death may occur. For chronic stomach bleeding the patient may be bothered by slight pallor, weakness and other symptoms for a long time.
Vomiting blood	The appearance of vomit and blood depends on the source and intensity of the bleeding: Gastric bleeding is characterized by vomiting that resembles “coffee grounds.” Vomit takes on this appearance due to the fact that the blood entering the stomach is exposed to hydrochloric acid. If unchanged red blood is present 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 influence of hydrochloric acid. Scarlet blood with foam may indicate pulmonary hemorrhage. Only a specialist doctor can finally establish the source of bleeding, make the correct diagnosis and provide effective assistance!
Blood in stool	Stomach bleeding is characterized by melena – black, tarry stool. 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 there is probably intestinal bleeding rather than gastric bleeding.

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

The severity of stomach bleeding is determined by the amount of blood lost. Depending on the degree of blood loss, there are three degrees of gastric bleeding:

• Mild degree. The patient's condition is satisfactory. He is conscious. Mild dizziness bothers me. 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. Worried about dizziness. The pulse is increased to 100 beats per minute. Blood pressure – 100-110 mm. rt. Art.
• Severe stomach bleeding. The patient is pale, very inhibited, answers questions late, and does not react to the environment. Pulse is more than 100 beats per minute. Blood pressure is below 100 mm. rt. Art.

Only a doctor can adequately assess the patient’s condition after examination and examination. Mild bleeding can turn into severe bleeding at any time!

Diagnosis of gastric bleeding

Which doctor should you contact if you have stomach bleeding?

With chronic gastric bleeding, the patient is often unaware that he has this pathological condition. Patients turn to specialized specialists regarding symptoms of the underlying disease:

• for pain and discomfort in the upper abdomen, nausea, indigestion - see a therapist, gastroenterologist;
• If there is increased bleeding or a large number of bruises appear on the body, see a therapist or hematologist.

The specialist prescribes an examination, during which gastric bleeding is detected.

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

In what cases should you call an ambulance?

With intense acute gastric bleeding, the patient's condition deteriorates very quickly. In such cases, you need to call an ambulance:

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

If, in case of intense acute gastric bleeding, medical assistance is not provided in time, the patient may die from large blood loss!

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

What questions might the doctor ask?

During a conversation and examination of the patient, the doctor faces two tasks: to establish the presence and intensity of gastric bleeding, to make sure that the bleeding comes from the stomach and not from other organs.

Questions you may be asked at your appointment:

• What complaints are bothering you? this moment? When did they arise? How has your condition changed since then?
• Have you had gastrointestinal bleeding in the past? Have you contacted doctors with similar problems?
• Do you have a stomach or duodenal ulcer? If so, 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 operations for diseases of the stomach and abdominal veins? If so, for what reason and when?
• Do you suffer from any liver disease or bleeding disorder?
• How often and in what quantity do you drink alcohol?
• Do you ever have nosebleeds?

How does a doctor evaluate a patient with stomach bleeding?

Typically, the doctor asks the patient to undress to the waist and examines his skin. Then he feels the stomach, doing this carefully so as not to increase the bleeding.

What examination can be prescribed?

Study title	Description	How is it carried out?
Fibrogastroduodenoscopy	An endoscopic examination, during which the doctor examines the mucous membrane of the esophagus, stomach, and duodenum. Most often, it is possible to establish the location and source of bleeding.	The study is carried out on an empty stomach. The patient lies on the couch on his left side. Anesthesia of the mucous membrane is carried out using a spray. A special mouthpiece is placed between the teeth. The doctor inserts a fibrogastroscope into the patient's stomach through the mouth - a flexible tube with a miniature video camera at the end. At this time, the patient should breathe deeply through the nose. Usually the inspection does not take much time.
X-ray of the stomach	To identify the cause of gastric bleeding, X-rays with contrast are performed. The doctor can assess the condition of the organ walls, 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 be able to fill it evenly. The patient drinks a solution of barium sulfate, a substance that does not transmit x-rays. After that they do x-rays in different positions: standing, lying down. The images clearly show the contours of the stomach filled with contrast.
Angiography	X-ray contrast study of blood vessels. Performed when there is a suspicion that gastric bleeding is a consequence of atherosclerosis or other vascular disorders.	A contrast solution is injected into the desired vessel through a special catheter. Then x-rays are taken. The painted vessel is clearly visible on them.
Radioisotope scanning	It is carried out according to indications when the bleeding site cannot be detected by other means. 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 device.	A solution containing labeled red blood cells is injected into the patient's vein, after which images are taken.
Magnetic resonance imaging	It is carried out according to indications when the doctor needs Additional Information. Using MRI, you can obtain slice-by-slice or three-dimensional images of a specific area of ​​the body.	The study is performed in a specialized department using a special installation.
General blood analysis	Deviations that can be detected in a general blood test for gastric bleeding: decrease in the number of erythrocytes (red blood cells) and hemoglobin (anemia associated with blood loss); a decrease in the number of platelets (blood platelets) indicates a decrease in blood clotting.	Blood is taken in the usual way from a finger or from a vein.
Blood clotting study - coagulogram	The study is used in cases where there is a suspicion that gastric bleeding is associated with a blood clotting disorder.	The blood is examined using a special apparatus. A number of indicators are assessed, on the basis of which conclusions are drawn about the state of the coagulation system.

Treatment of stomach bleeding

A patient with gastric bleeding should be immediately hospitalized.

There are two tactics for treating gastric bleeding:

• without surgical intervention(conservative);
• operation.

Only a doctor can make the right decision. He conducts an examination and examination, establishes the cause and location of the bleeding, and 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 the bleeding to subside, but during movement it may increase.
Cold in the epigastric region		The most common method is to use an ice pack wrapped in a cloth.
Gastric lavage with ice water	Under the influence of cold, blood vessels constrict, which helps stop bleeding.	Gastric lavage is carried out using a probe - a tube that is inserted into the stomach through the mouth or nose.
Injection of adrenaline or norepinephrine into the stomach through a tube	Adrenaline and norepinephrine are “stress hormones.” They cause vasospasm and stop bleeding.	A tube 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 drip.
donor 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 intended to combat existing disorders in the body

Endoscopic treatment

Sometimes stomach bleeding can be stopped during endoscopy. To do this, special endoscopic instruments are inserted into the stomach through the mouth.

Endoscopic treatment methods:

• 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 using a laser.
• Stitching threads or metal clips.
• Application of special medical glue.

These methods are used mainly for minor bleeding.

Surgery for stomach bleeding

Surgical treatment of gastric bleeding is necessary in the following cases:

• attempts to stop bleeding without surgery are unsuccessful;
• heavy bleeding and a significant decrease in blood pressure;
• severe disorders in the patient’s body, which can lead to a deterioration of the condition: coronary heart disease, impaired blood flow in the brain;
• repeated bleeding after it has already been stopped.

The most common types of operations for gastric bleeding:

• Suturing the bleeding area.
• Removal of part of the stomach (or the entire organ, depending on the cause of the bleeding).
• Plastic surgery of the junction of the stomach and duodenum.
• Surgery on the vagus nerve, which stimulates the secretion of gastric juice. As a result, the condition of the patient with peptic ulcer improves and the risk of relapse is reduced.
• Endovascular operations. The doctor makes a puncture in groin area, inserts a probe through the femoral artery, reaches the bleeding lesion and closes its lumen.

Stomach surgeries can be performed through an incision or laparoscopically through punctures in the abdominal wall. The attending physician selects the appropriate type of surgical treatment and provides detailed information the patient and his relatives.

Rehabilitation after gastric surgery

Depending on the type of operation, its duration and volume may vary. Therefore, rehabilitation periods may vary.

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

• on the first day the patient is allowed to move his arms and legs;
• breathing exercises usually begin on the second day;
• on the third day the patient can try to get to his feet;
• on the eighth day, if the course is favorable, the sutures are removed;
• on the 14th day they are discharged from the hospital;
• subsequently the patient engages physical therapy, physical activity is prohibited for a month.

Diet in the postoperative period (if the operation was not very difficult and there are no complications):

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

Preventing stomach bleeding

The main measure to prevent gastric bleeding is timely treatment diseases that lead to them (see above - “causes of gastric bleeding”).