Catad_tema Peptic ulcer - articles

Catad_tema Coagulopathies and bleeding - articles

Gastrointestinal bleeding

Published in the magazine:
"Doctor", N2, 2002 Ovchinnikov A., Doctor of Medical Sciences, Professor, MMA named after. I.M.Sechenova

Gastrointestinal bleeding (GIB) is one of the most common reasons emergency hospitalization in surgical hospitals. The therapeutic goal for bleeding from the gastrointestinal tract (GIT) is simple and logical: the patient’s condition must be stabilized, the bleeding stopped and treatment carried out, the goal of which is to prevent subsequent episodes of GI bleeding. To do this, it is necessary to establish the source of bleeding and its location. The most serious mistakes, which can have very serious consequences, include underestimating the severity of the patient’s condition and starting diagnostic and therapeutic procedures without sufficient preparation of the patient. In order to correctly assess the amount of blood loss and the patient’s condition, it is necessary to clearly understand what changes occur in the body with this pathology.

Pathophysiological disorders

Acute blood loss during gastrointestinal bleeding, as with any type of fairly massive bleeding, is accompanied by the development of a discrepancy between the reduced mass of circulating blood and the volume of the vascular bed, which leads to a drop in total peripheral resistance (TPR), a decrease in cardiac stroke volume (SV) and minute volume of blood circulation ( IOC), drop in blood pressure. This is how central hemodynamic disturbances occur. As a result of a drop in blood pressure, a decrease in blood flow speed, an increase in blood viscosity and the formation of red blood cell aggregates in it, microcirculation is disrupted and transcapillary exchange changes. This primarily affects the protein-forming and antitoxic functions of the liver, the production of hemostasis factors - fibrinogen and prothrombin - is disrupted, and the fibrinolytic activity of the blood increases. Microcirculation disorders lead to dysfunction of the kidneys, lungs, and brain.

The body's protective reactions are aimed primarily at restoring central hemodynamics. The adrenal glands respond to hypovolemia and ischemia by releasing catecholamines, causing generalized vasospasm. This reaction eliminates the deficiency in filling the vascular bed and restores OPS and SVR, which contributes to the normalization of blood pressure. The resulting tachycardia increases the IOC. Next, the autohemodilution reaction develops, as a result of which fluid enters the blood from the interstitial depots, which replenishes the deficit in circulating blood volume (CBV) and dilutes stagnant, thickened blood. Central hemodynamics are stabilized, the rheological properties of the blood are restored, microcirculation and transcapillary exchange are normalized.

Determination of the volume of blood loss and the severity of the patient’s condition

The severity of the patient’s condition depends on the amount of blood loss, however, if there is bleeding into the lumen of the stomach or intestines, it is not possible to judge the true amount of blood that has been shed. Therefore, the amount of blood loss is determined indirectly, by the degree of tension in the body’s compensatory and protective reactions, using a number of indicators. The most reliable and reliable of them is the difference in blood volume before and after hemorrhage. The initial BCC is calculated using a nomogram.

Hemoglobin indirectly reflects the amount of blood loss, but is a rather variable value.

Hematocrit the number corresponds quite accurately to blood loss, but not immediately, since in the first hours after bleeding the volumes of both formed elements and blood plasma decrease proportionally. And only after the extravascular fluid begins to penetrate into the bloodstream, restoring the bcc, the hematocrit drops.

Arterial pressure. A loss of 10-15% of blood mass does not cause severe violations hemodynamics, as it can be fully compensated. With partial compensation, postural hypotension is observed. In this case, the pressure is maintained close to normal while the patient is lying down, but it can drop catastrophically when the patient sits down. With more massive blood loss, accompanied by severe hypovolemic disorders, adaptation mechanisms are not able to compensate for hemodynamic disorders. Hypotension occurs in supine position and develops vascular collapse. The patient goes into shock (pallor, turning into a slate-gray color, sweat, exhaustion).

Heart rate. Tachycardia is the first reaction to a decrease in SVR to maintain IOC, but tachycardia itself is not a criterion for the severity of the patient’s condition, as it can be caused by a number of other factors, including psychogenic ones.

Shock index. In 1976, M. Algover and Burri proposed a formula for calculating the so-called shock index (Algover index), which characterizes the severity of blood loss: the ratio of heart rate and systolic blood pressure. In the absence of a BCC deficit, the shock index is 0.5. Increasing it to 1.0 corresponds to a BCC deficit of 30%, and to 1.5-50% corresponds to a BCC deficit.

The given indicators must be assessed in conjunction with the clinical manifestations of blood loss. Based on an assessment of some of the above indicators and the condition of patients, V. Struchkov et al. (1977) developed a classification that distinguishes 4 degrees of severity of blood loss:

I degree- general condition is satisfactory; moderate tachycardia; Blood pressure is not changed; Hb above 100 g/l; BCC deficit - no more than 5% of the due amount;
II degree: general condition - moderate severity, lethargy, dizziness, fainting, pale skin, significant tachycardia, decreased blood pressure to 90 mm Hg; Hb - 80 g/l; BCC deficit - 15% of the required amount;
III degree- general condition is serious; pale skin, cold, sticky sweat; the patient yawns, asks for a drink (thirst); pulse is frequent, threadlike; Blood pressure is reduced to 60 mm Hg; Hb - 50 g/l; BCC deficit - 30% of the required amount;
IV degree- the general condition is extremely severe, bordering on agonal; prolonged loss of consciousness; pulse and blood pressure are not determined; BCC deficit is more than 30% of the required amount.

Patients with II-IV degrees of severity of blood loss require infusion therapy before starting diagnostic and therapeutic procedures.

Infusion therapy

If blood loss is no more than 10% of the blood volume, blood transfusions and blood substitutes are not required. The body is able to fully compensate for this volume of spilled blood on its own. However, one should remember the possibility of re-bleeding, which can quickly destabilize the patient’s condition against the background of compensation stress.

Patients with significant acute gastrointestinal bleeding, especially those in unstable condition, should be admitted to the intensive care unit or intensive care unit. Constant access to a vein is required (catheterization of one of the central veins is desirable). Infusion therapy should be carried out against the background of constant monitoring of cardiac activity, blood pressure, renal function (amount of urine) and additional oxygenation.

To restore central hemodynamics, transfusion of saline solution, Ringer's solution, and basic solution is used. Medium molecular weight polyglucin can be used as a colloidal blood substitute. Restoration of microcirculation is carried out using low-molecular colloidal solutions (reopolyglucin, hemodez, gelatinol). Blood is transfused to improve oxygenation (red blood cells) and clotting (plasma, platelets). Since with active gastrointestinal tract, both are necessary, it is advisable to transfuse whole blood. When the gastrointestinal tract has stopped, when the deficit of the bcc is replenished saline solutions, to restore the oxygen capacity of the blood and relieve a high degree of hemodilution, it is advisable to transfuse red blood cells. Direct blood transfusions are important mainly for hemostasis. If clotting is impaired, which is the case in most patients with cirrhosis, it is advisable to transfuse fresh frozen plasma and platelet mass. The patient should receive fluid resuscitation until his condition is stabilized; in this case, a number of red blood cells is required to ensure normal oxygenation. With ongoing or recurrent gastrointestinal bleeding, infusion therapy is continued until bleeding stops completely and hemodynamic parameters stabilize.

Diagnosis of the causes of bleeding

First of all, it is necessary to establish whether the source of bleeding is in the upper or lower gastrointestinal tract. Bloody vomiting (hemotemesis) indicates the localization of bleeding in the upper sections (above the trigeminal ligament).

The vomit may be fresh, bright red blood, dark blood with clots, or what is called "coffee grounds." Red blood of different shades, as a rule, indicates massive bleeding in the stomach or bleeding from the veins of the esophagus. Pulmonary bleeding should be distinguished from gastric bleeding. Blood from the lungs is more scarlet, foamy, does not clot, and is released when coughing. However, the patient may swallow blood from the lungs or nose. In these cases, typical bloody vomiting and even “coffee grounds” vomiting are possible. Tarry, sticky, foul-smelling stool (meleno), resulting from the reaction of blood with hydrochloric acid, the transition of hemoglobin to hydrochloric acid hematin and the decomposition of blood under the influence of intestinal enzymes, is a sign of bleeding in the upper gastrointestinal tract. However, there may be exceptions. Bleeding from the small intestine and even from the colon can also be accompanied by melena, but if 3 conditions are present: 1) a sufficient amount of altered blood to make the stool black; 2) not too much bleeding; 3) slow intestinal peristalsis to allow enough time for hematin formation. Bloody stools (hematochezia), as a rule, indicate the localization of the source of bleeding in the lower parts of the digestive tract, although with massive bleeding from upper sections blood sometimes does not have time to turn into melena and can be released in a slightly changed form (Table 1).

Table 1. Clinical manifestations bleeding from the gastrointestinal tract

Bleeding pattern	Possible reason
Vomiting of unchanged blood with clots	Rupture of varicose veins of the esophagus; massive bleeding from a stomach ulcer; Mallory-Weiss syndrome
Vomiting "coffee grounds"	Bleeding from a stomach or duodenal ulcer; other causes of stomach bleeding
Tarry stools (melena)	The source of bleeding is most likely in the esophagus, stomach or duodenum; the source of bleeding may be in the small intestine
Dark red blood evenly mixed with stool	The source of bleeding is most likely in the cecum or ascending colon
Streaks or clots of scarlet blood in the stool regular color	The source of bleeding is in the descending or sigmoid colon
Scarlet blood in the form of drops at the end of a bowel movement	Hemorrhoidal bleeding; bleeding from anal fissure

When the question arises about the localization of gastrointestinal tract, it is first recommended to insert a probe into the patient’s stomach. Blood aspirated through a probe confirms the localization of the source of bleeding in the upper gastrointestinal tract. But a negative aspiration result does not always indicate the absence of bleeding in the upper digestive tract. Bleeding from a bulbous ulcer may not be accompanied by the appearance of blood in the stomach. In such cases, the high localization of the source can be judged by other signs: the presence of hyperreactive bowel sounds and an increase in the content of nitrogenous compounds in the blood (primarily creatinine and urea). Nevertheless, the diagnosis of gastrointestinal tract disease is often very difficult, especially in the first hours from the onset of the disease, when the patient is already in serious condition, but there is no bloody vomiting and tarry stools have not yet appeared. If there is no clear idea of ​​the presence and localization of its source, an endoscopic examination is performed.

Upper gastrointestinal bleeding

They account for about 85% of all housing and communal services. In Moscow, according to A. Grinberg et al. (2000), bleeding of ulcerative etiology in 1988-1992. were observed in 10,083 patients, and in 1993-1998. - at 14,700. i.e. their frequency increased 1.5 times. At the same time, the mortality rate of current in our country and abroad is practically no different from that of current 40 years ago; from 10 to 14% of patients die, despite treatment (A. Grinberg et al., 1999; Yu. Pantsyrev and D. Fedorov, 1999). The reason for this is the increase in the proportion of elderly and senile patients from 30 to 50%. Among them, the bulk are elderly patients taking non-steroidal anti-inflammatory drugs (NSAIDs) for joint pathology (E. Lutsevich and I. Belov, 1999). The mortality rate in patients over 60 years of age is several times higher than in young people. It is highest with bleeding from varicose veins of the esophagus - 60% (on average - 40%).

The mortality rate reaches especially high figures during emergency operations at the height of bleeding - it is 3 times higher than the current one during operations performed after it has stopped. Thus, the first task of treating acute gastrointestinal tract bleeding is to stop bleeding and avoid emergency surgery. Its solution can be facilitated by empirical treatment, which does not require an accurate diagnosis, which requires quite invasive manipulations. Empirical treatment begins immediately after the patient’s admission to the intensive care unit against the background of infusion therapy. It becomes especially important when it is impossible to urgently perform an endoscopic examination for various reasons.

Empirical therapy consists of gastric lavage with ice water from the refrigerator and parenteral administration of drugs that reduce acidity. Strongly cooled liquid reduces blood flow in the wall of the stomach, and stopping bleeding, at least temporarily, is achieved in 90% of patients. In addition, lavage helps empty the stomach of blood clots, which greatly facilitates subsequent gastroscopy. Parenteral administration of histamine receptor blockers and inhibitors is justified proton pump, since according to statistics, peptic ulcers are the most common cause of bleeding from the upper gastrointestinal tract. In addition, pepsin, which promotes platelet disaggregation, is inactivated at high gastric pH, which increases blood clotting while reducing gastric acidity. Successfully conducted empirical therapy allows you to gain time and adequately prepare the patient for endoscopic examination and surgery.

Diagnosis of the causes of bleeding from the upper gastrointestinal tract

A well-collected medical history can provide the key to a correct diagnosis even before endoscopic examination. Has the patient had previous episodes of gastrointestinal tract infections? Did he have a previously diagnosed stomach or duodenal ulcer? Does he have any complaints specific to peptic ulcer disease? Has he previously been operated on for peptic ulcers or portal hypertension? Does he have other diseases that could lead to bleeding, such as liver cirrhosis or coagulopathies? Does the patient abuse alcohol or regularly take aspirin or NSAIDs? Does he have nosebleeds? It is advisable to get an answer to these questions if the patient is conscious and sufficiently communicative, for example, is not intoxicated.

Examination of the skin and visible mucous membranes allows us to identify stigmata of liver cirrhosis, hereditary vascular anomalies, signs of capillarotoxicosis, and paraneoplastic manifestations. Palpation of the abdominal cavity may reveal tenderness (peptic ulcer), splenomegaly (liver cirrhosis or splenic vein thrombosis), and gastric swelling. Intraperitoneal bleeding (for example, with a disturbed ectopic pregnancy) is sometimes manifested by signs of acute anemia similar to gastrointestinal bleeding. The presence of symptoms of peritoneal irritation, characteristic of bleeding into the abdominal cavity, can help in the differential diagnosis of these conditions. If auscultation of the abdomen reveals increased peristalsis, there is reason to assume that it is caused by blood entering the intestine from the upper gastrointestinal tract.

The most important information is provided by esophagogastroduodenoscopy (EGD); it allows not only to establish with a high degree of accuracy the location of the source of bleeding and its nature, but also to carry out hemostatic measures, which in a significant number of cases make it possible to stop the bleeding. Radioisotope scanning (labeled 99 Tc colloidal sulfur or albumin) and angiography are very important in certain situations, but most practical significance do not have, since they can extremely rarely be performed for emergency indications.

The main causes of bleeding from the upper gastrointestinal tract and their specific therapy

Ruptured esophageal varices (ERVs)

The cause of GDP is portal hypertension, resulting from intrahepatic (cirrhosis, hepatitis) or extrahepatic blockade. Diagnosing GDP is not difficult; dilated and tortuous veins of a bluish tint, as a rule, are quite clearly visible during esophagoscopy, which, if VVP is suspected, must be carried out very carefully so as not to cause additional trauma to the thinned walls of the veins. Treatment of patients with VVP is the most important factor in reducing mortality in gastrointestinal tract diseases. First aid consists of long-term (1-2 days) vein tamponade with a balloon probe and intravenous administration of a 1% solution of nitroglycerin (to reduce portal pressure) and vasopressin (a pituitary drug). This allows you to temporarily stop bleeding in approximately 60-80% of patients. If this measure is ineffective or there is a threat of recurrent bleeding, you can attempt endoscopic sclerotherapy with intravosal or paravosal (which is safer) administration of sclerosants - 2% solution of thrombovar or varicocid, 1-3% solution of ethoxysclerol (polidocanol), cyanoacrylates (historil, histoacryl, cyanoacrylate kleber), fibrinkleber mixed with iodolipol in a 1:1 ratio. In their absence, use 96% ethyl alcohol.

Endoscopic treatment of VVP is indicated in patients over 60 years of age, who have previously had multiple surgeries, and with severe concomitant pathology. Conditions for relatively safe therapeutic esophagoscopy are stable hemodynamics and the absence of significant liver dysfunction. Complications of sclerotherapy for GDP are not uncommon. These include ulcerations of the esophageal mucosa with bleeding, purulent thrombophlebitis, necrosis of the esophageal mucosa, and perforation of the esophagus. Mortality after emergency sclerotherapy of veins against the background of ongoing bleeding reaches 25%, after planned sclerotherapy it is significantly lower - 3.7%.

A promising method for treating bleeding from the esophagus is endovascular embolization of the esophageal veins. In combination with endoscopic sclerotherapy, it can reduce mortality in emergency cases to 6-7% (A. Scherzinger, 1999).

Shunt operations (portocaval, splenorenal mesocaval and other anastomoses) are performed to divert blood from the esophageal veins from high pressure into systemic veins with low pressure. However, at the height of bleeding they are very risky. After bypass surgery, the incidence of esophageal bleeding decreases, but mortality remains high - patients die not from bleeding, but from liver failure and encephalopathy caused by hyperammonemia. It is recommended to decompress only the esophageal and gastric veins by applying a selective distolic splenorenal shunt.

Rupture of the gastric cardia mucosa (Mallory-Weiss syndrome) observed with severe vomiting. The appearance of fresh blood during repeated vomiting suggests this pathology. The diagnosis is made according to endoscopy. Bleeding can be quite intense, but often stops on its own with rest and hemostatic therapy. If bleeding continues, an attempt at electrocoagulation of bleeding vessels during endoscopy is justified. Occasionally, there are indications for surgery (gastrotomy and suturing of blood vessels in the area of ​​the rupture).

Erosive esophagitis occurs with gastroesophageal reflux disease (GERD), which is very common. Often the underlying cause of the disease is a hernia hiatus diaphragm. Erosion in the cardiac part of the esophagus can sometimes cause bleeding into the lumen of the esophagus and stomach and manifest itself, in addition to the classic symptoms of GERD (belching, heartburn, chest pain), by vomiting mixed with blood.

Duodenal, gastric or marginal (after gastrectomy) ulcers are the cause of bleeding in 40-50% of patients. Ulcers on the posterior wall of the duodenal bulb are especially dangerous, as they can cause massive arterial bleeding as a result of arrosion of the branches of the large gastroduodenal artery passing in this area.

According to the widespread endoscopic classification of ulcerative bleeding according to Forrest, there are:
I. Continued bleeding: A) profuse (stream); B) leakage of blood.
II. Existing bleeding: A) high risk of relapse (a thrombosed vessel is visible); B) low risk of relapse (presence of hematin on the defect).
III. Clinical signs of bleeding (melena) in the absence endoscopic signs bleeding from a detected source.

This classification allows you to determine treatment tactics for bleeding of ulcerative etiology. In case of profuse bleeding (IA), emergency surgery is indicated, since the use of conservative methods leads to loss of time and worsens the prognosis. If blood is leaking from an ulcer (IV), attempts to stop bleeding through an endoscope are justified by monoactive or bipolar electrocoagulation using high-frequency current, photocoagulation with an argon or YAG neodymium laser, by argon-plasma coagulation with ionized gas or injecting the ulcer with ethyl alcohol. Irrigation gives good results. bleeding ulcer through a catheter with a solution of caprofer - a carbonyl complex of ferric chloride and epsilon-aminocaproic acid. Occasionally, special endoclips are applied to the bleeding vessel. When using the entire listed set of endoscopic techniques, according to Yu. Pantsyrev and E. Fedorov (1999), stable hemostosis was achieved in 187 (95%) of 206 patients. In 9 (4.6%) people, hemostasis was ineffective, the patients were urgently operated on. Emergency surgery is also indicated for recurrent bleeding that occurs within the next few hours after preliminary hemostasis.

In case of stopped bleeding with a high risk of relapse (Forrest IIA), emergency surgery is indicated in the next 24 hours, usually in the morning next day. The most justified surgical tactics for a bleeding gastric ulcer is its excision or suturing in combination with pyloroplasty and vagotomy (in the absence of signs of malignancy of the ulcer), and for a duodenal ulcer - economical gastrectomy (antrumectomy) or (in patients with a high degree of surgical risk) - suturing of the ulcer with pyloroplasty and selective vagotomy (Yu. Pantsyrev, 1986, Yu. Pantsyrev and E. Fedorov, 1999).

Recurrent peptic ulcers after gastric resection relatively rarely cause gastrointestinal tract infections. They are usually located at the site of the gastrojejunal anastomosis or near it, and arise, as a rule, due to the incorrect choice of surgical method and technical errors in its implementation (Yu. Pantsyrev, 1986). Bleeding is particularly persistent and intense in recurrent ulcers caused by hypergastrinemia with Zollinger-Ellison syndrome undiagnosed before surgery, if a section of the antrum of the stomach was left during resection. Repeated surgery in patients with a resected stomach is very complicated, so conservative therapy and endoscopic methods of hemostasis are preferred. In general, the choice of treatment tactics is determined by the intensity of bleeding; the principles of treatment do not differ from those in non-operated patients.

Sometimes erosive and ulcerative bleeding occurs as a result of solitary ulcerations described by Dieulafoy. These are small superficial ulcers, at the bottom of which there is quite major artery. Arrosion of the latter leads to profuse, sometimes fatal gastric bleeding. The basis of the disease, as many authors believe, is aneurysms of small arteries of the submucosal layer of the stomach. It is possible that the disease is caused congenital defect vascular development. Not the least role in its pathogenesis is played by the peptic factor, mechanical damage to the mucosa, pulsation of the underlying arteries, hypertension and atherosclerosis. Solitary Dieulafoy's ulcerations (SID) are usually located in the cardial part of the stomach parallel to the lesser curvature, at a distance of 3-4 cm.

The disease usually manifests itself with sudden massive bleeding. Conservative therapy for SID is most often unsuccessful, almost all patients die from blood loss (A. Ponomarev and A. Kurygin, 1987). Surgical treatment consists of suturing the stomach wall to the muscle layer with ligation of the bleeding artery or excision of pathological areas of the gastric wall within healthy tissue. Vascular embolization may be effective.

Acute hemorrhagic gastritis usually associated with taking medications (aspirin, NSAIDs) and alcohol. Hemorrhagic gastritis is often erosive in nature and often develops as stressful state in patients with sepsis, burns, severe concomitant trauma, peritonitis, acute respiratory failure, myocardial infarction, as well as after severe surgical interventions in early postoperative period. Differential diagnosis of acute bleeding gastric ulcers with hemorrhagic gastritis can only be done using endoscopic examination. It is very difficult to stop bleeding in acute hemorrhagic gastritis, since, as a rule, large areas of the gastric mucosa bleed intensely. Preventive and curative is important parenteral use antacids and H-blockers, gastric lavage with ice-cold solutions, irrigation of the mucous membrane during endoscopy with caprofer solution, intravenous administration of hemostatic agents, fibrinolysis and vasopressin inhibitors, transfusion of fresh blood and platelet mass.

The cause of 3 to 20% of all gastrointestinal tracts is disintegrating stomach tumors. In most cases, such bleeding is characterized by moderate blood loss, often stops on its own, and then can resume again. Bloody vomiting and classic melena are not as common as with ulcer bleeding, but the stool may become dark in color. The diagnosis is established or clarified by endoscopy. With advanced cancers, erased, atypical symptoms. In the diagnosis of complicated cases, in addition to endoscopic examination, the role of abdominal radiography is important.

Emergency assistance consists of endoscopic electro- or photocoagulation with a laser, cauterization with a concentrated solution of caprofer. Subsequently, as well as if hemostatic therapy is ineffective, surgical intervention is indicated, the volume of which depends on the location of the tumor and the stage of the cancer process.

Stomach polyps rarely cause acute bleeding. Massive bleeding more often occurs with benign tumors such as leiomyoma, neurofibroma, etc. Moreover, they can be their first manifestation (Yu. Pantsyrev, 1986).

Hemobilia, hematobilia- bleeding from the biliary tract. Arteriobiliary fistulas are formed due to trauma, liver biopsy, liver abscesses, cancer, and hepatic artery aneurysm. Often there is a combination of signs of gastrointestinal tract with hepatic colic and jaundice. With endoscopy, the presence of blood in the duodenum and its discharge from the nipple of Vater are noted. As a therapeutic measure, selective embolization of the hepatic artery may be recommended, and if ineffective, its ligation.

Gastrointestinal endometriosis is quite rare. The diagnosis can be made by repeated gastrointestinal tract problems that occur synchronously with menstruation. The appearance of melena or dark stools or hematochezia is preceded by abdominal pain. An endoscopic examination must be carried out at the height of bleeding, but it is extremely rare to detect a bleeding area of ​​the gastric or intestinal mucosa during endoscopy or colonoscopy. With age, such bleeding decreases and stops during menopause.

Aneurysms of the aorta and branches of the celiac artery When ruptured, they can cause massive, often fatal bleeding. They are usually preceded by small prodromal bleeding - “harbingers”. Duodenal bleeding is described as a result of the occurrence of an aortointestinal fistula due to anastomotic failure after aortic replacement for atherosclerotic lesions and Leriche syndrome.

Bleeding from the lower gastrointestinal tract

In 15% of cases, GIBs occur below the trigeminal ligament, in 1% of cases - in the small intestine, in 14% - in the colon and rectum.

Diagnostics. Important information can give a careful questioning of the patient and a well-collected anamnesis (Table 2). If there is blood in the stool, it is important to find out whether the blood is mixed with the feces (the source is located high) or is released in a relatively unaltered form at the end of the bowel movement, which is more typical for low-lying bleeding tumors and hemorrhoids.

Table 2. Diagnostic value pain syndrome for bleeding from the lower gastrointestinal tract (A. Sheptulin, 2000)

Palpation of the abdominal cavity and digital examination of the anus are mandatory in all patients. Digital rectal examination, according to statistics, allows us to identify up to 30% of all colon tumors, including those complicated by bleeding. The next stage of diagnosis is anoscopy and rectosigmoidoscopy, the effectiveness of which for oncological diseases of the colon is 60%. In the presence of tarry stools, which can be a consequence of both gastroduodenal bleeding and bleeding from the ileum and right parts of the colon, nasogastric aspiration through a probe and endoscopy are recommended to exclude pathology of the stomach and duodenum. Colonoscopy is the most informative method for diagnosing colonic pathology, but with intense bleeding it is quite difficult to perform. If the bleeding stops at least temporarily, then with the help of this procedure a wide variety of pathologies, including vascular ones, can be diagnosed.

Mesenteric arteriography during intestinal bleeding allows you to identify extravasation of contrast and determine the side and approximate localization of the source of bleeding. Angiography is the only method for diagnosing bleeding in the small intestine; it makes it possible to inject vasopressin directly into the bleeding artery. Extravasation is determined only with sufficiently massive bleeding, but even in the absence of its signs, arteriogrophy can detect vascular pathology that is the cause of bleeding. Scintigraphy with erythrocytes labeled with 99 Tc or with platelets labeled with radioactive In is a more sensitive method; the source of bleeding is detected even at a relatively low intensity, but scintigraphy requires a lot of time and therefore can hardly be considered an emergency diagnostic method. Contrasting methods x-ray examination(irrigoscopy and irrigography) are not able to identify the source of bleeding, but can help in diagnosing a tumor, diverticulosis, intussusception and other diseases complicated by bleeding.

The main causes of bleeding from the lower gastrointestinal tract and their specific therapy

One of the most common causes of hematochezia in elderly patients is colonic diverticulosis. The frequency of this pathology increases with age; after 70 years, diverticula are detected during colonoscopy in every 10th patient. The formation of diverticula is promoted sedentary lifestyle life, dysfunction of the colon (tendency to constipation), intestinal dysbiosis, Bleeding, often massive, complicates the course of diverticulosis in 10-30% of cases. It is believed that diverticula are most often localized in the descending and sigmoid colon, but they are also found in the transverse colon and in the right half of the colon. Bleeding with diverticulosis may be preceded by abdominal pain, but often it begins suddenly and is not accompanied by pain. The bleeding may stop on its own and recur after a few hours or days. In almost half of the cases, bleeding occurs once.

Conservative therapy (transfusion of fresh blood, platelets, administration of α-aminocaproic acid, decinone, administration of vasopressin into the mesenteric artery during angiography) is effective in most patients. In some clinics, after angiography, transcatheter embolization is used (A. Sheptulin, 2000). If a source of bleeding is detected during colonoscopy, which is quite rare, you can also count on the effect of local hemostatic measures (electrocoagulation, caprofer irrigation). With ongoing or recurrent bleeding, it is necessary to resort to surgical intervention (resection of the colon, the volume of which is smaller, the more accurate the topical diagnosis is).

At colon polyps Bleeding occasionally occurs in cases of spontaneous separation of the polyp stalk or, much more often, in cases of inflammation and ulceration of its surface.

Massive bleeding from a disintegrating malignant tumor of the colon is very rare. More often, chronic intermittent bleeding is observed in the form of small “spits” of blood, sometimes mixed with mucus or, if the tumor is located high, with a change in the color and consistency of the stool.

Bleeding of moderate or low intensity is possible with nonspecific colitis(non-specific ulcerative colitis and Crohn's disease), intestinal tuberculosis and acute infectious colitis. These diseases are characterized by abdominal pain preceding the appearance of blood, which is usually mixed with mucus. Colonoscopy plays an important role in the diagnosis and differential diagnosis of colitic bleeding, making it possible to identify differences in the endoscopic manifestations of individual diseases. Helps clarify the diagnosis morphological study biopsies of the intestinal wall.

Embolism and thrombosis of mesenteric vessels with oterosclerotic lesions in the elderly, endarteritis and systemic vasculitis in younger patients, embolism from the cavities of the heart (with myocardial infarction, heart defects) or from the aorta (with its atherosclerotic lesion) may be the reasons acute disorders mesenteric circulation, ischemic lesions and hemorrhagic intestinal infarction, manifested by the release of quite large quantity changed blood. Such bleeding is characterized by a pronounced pain syndrome preceding it, nausea, vomiting, and sometimes a collaptoid state, and as the disease progresses, an increase in symptoms of intoxication and peritoneal phenomena.

In case of hemorrhagic infarction of the colon, depending on the stage of the disease, colonoscopy reveals large areas of edematous, cyanotic or blood-soaked mucosa with increased bleeding, and multiple submucosal hemorrhages. Later, superficial bleeding ulcerations appear, areas of necrosis may occur, followed by tissue disintegration and perforation. With high occlusion of the upper mesenteric artery possible infarction and necrosis of the entire small intestine and the right half of the large intestine; in case of thrombosis of the inferior mesenteric artery, due to the presence of powerful vascular collaterals, infarction is usually limited to the sigmoid colon.

In complex diagnostic situations, angiography is very useful - the nature of the blood flow disturbance, the localization and extent of occlusion, and the presence of collaterals are accurately established. If an intestinal infarction is suspected, laparoscopy provides important diagnostic information.

Treatment of patients with intestinal bleeding against the background of acute disorders of the mesenteric circulation is usually surgical. Since blood in the intestinal lumen usually appears at the stage of intestinal infarction, which indicates decompensation of the mesenteric circulation, resection of irreversibly altered sections of the intestine is performed, which is supplemented by intervention on the mesenteric vessels in order to restore blood circulation to the viable remaining sections (V. Savelyev and I. Spiridonov, 1986) .

A fairly rare cause of intestinal bleeding - hemorrhagic angiomatosis thick and small intestine, which manifests itself as angiodysplasia, known as Rendu-Osler-Weber disease (syndrome). Diagnosis is facilitated by modern high-resolution video colonoscopy, which makes it possible to detect even minor changes in the vascular pattern of the mucosa.

Capillary and cavernous hemangiomas and angiodysplasia of the small and large intestine(arteriovenous malformations), according to A. Sheptulin (2000), are the cause of massive intestinal bleeding in 30% of cases. Clinically, the disease is manifested mainly by bleeding from the rectum during bowel movements and regardless of it. With cavernous hemangiomas, massive bleeding is possible, accompanied by collapse. Occasionally, there is pain in the lower abdomen, which intensifies before bleeding. Angiomas of the rectum are characterized by false urges on defecation, a feeling of incomplete emptying, and at times constipation occurs. Differential diagnosis with other causes of hematochezia, especially bleeding nonspecific colitis, intestinal tuberculosis, hemorrhoids, it’s very difficult.

The main role in the diagnosis of colon hemongiomas is played by rectosigmoidoscopy and colonoscopy. An endoscopic examination reveals a bluish-purple color of the intestinal mucosa in a limited area, the absence of typical folding, dilated, tortuous, bulging vessels forming irregular shape plexuses clearly demarcated from unchanged areas of the mucosa. A biopsy of such formations can lead to massive bleeding, which can be very difficult to stop. The main and most radical method of treating intestinal hemangiomas is surgical, although, according to V. Fedorov, therapeutic tactics requires a differential approach. With the development of massive bleeding from low-lying hemangiomas, M. Anichkin et al. (1981) performed embolization and ligation of the superior rectal artery, which stopped the bleeding, albeit temporarily. In case of minor and periodically recurring bleeding that does not affect the general condition of the patient, a wait-and-see approach is acceptable. After bleeding has stopped, small angiomas of the distal parts of the colon can be removed by electroexcision or subjected to sclerotherapy.

The most common cause of rectal bleeding is haemorrhoids. More than 10% of the adult population suffers from hemorrhoids; the release of fresh blood from the rectum is one of its main symptoms. Scarlet blood with hemorrhoids usually becomes noticeable at the end of a bowel movement. The stool retains its normal color. Bleeding may be accompanied by pain and a burning sensation in the anus, which intensifies during and after bowel movements. Often, hemorrhoids fall out when straining. In case of massive hemorrhoidal bleeding, active hemostatic therapy is required. For repeated bleeding, glivenol orally (1 capsule 4 times a day) and suppositories with thrombin or adrenaline are recommended. It is possible to use injections of sclerosing drugs. Radical treatment methods include various types of hemorrhoidectomy. A similar clinical picture is given anal fissure. For differential diagnosis with hemorrhoidal bleeding, as a rule, digital rectal examination and anoscopy are sufficient.

Significant bleeding in childhood may be caused by ulcerations of the mucous membrane Meckel's diverticulum. The clinical picture is very similar to the manifestations acute appendicitis, the diagnosis in most patients is made during appendectomy. In children of the first 2 years of life, the discharge from the anus of a portion of blood with mucus (looking like raspberry jelly) in combination with anxiety and screaming is the main symptom of intussusception of the colon - an acute disease that is very common at this age. For its diagnosis and sometimes treatment, air irrigoscopy is used (dosed injection of air into the colon under the control of an X-ray screen).

Vomiting or bloody stools are definitely dangerous symptoms and always indicate possible stomach bleeding. Doctors use the term GI bleeding - gastrointestinal bleeding. This summarizes all cases of blood loss from digestive system. In the article we will talk about specific symptoms of gastrointestinal tract and their causes.

Danger of bleeding

When an arm or leg is wounded, blood pours out, so it is impossible to miss such bleeding. Internal hemorrhage from the stomach or intestines may remain hidden long time . Its manifestations are not immediately noticeable to a person and even to a doctor.

Therefore, regular examinations, for example, determining the level of hemoglobin in the blood or a stool blood test, are of particular importance.

Blood loss means a decrease in the number of red blood cells - red blood cells - in the blood. Red blood cells contain hemoglobin, a protein that gives them their red color. Hemoglobin plays an important role in the nutrition of the entire body. It carries oxygen to every cell of every human organ. Lack of hemoglobin means shortness of breath.

Hypoxia – lack of oxygen in the body – affects every organ:

• For muscles it means severe weakness and inability to work.
• For the brain– pain and poor memory.
• For heart– pain and rhythm disturbances.

In conditions of blood loss, absolutely all organs suffer, because they all equally do not receive the required amount of oxygen. As bleeding progresses, symptoms become more severe. Depending on the speed of the hemorrhage, the development of a pronounced clinical picture may take several weeks or less than an hour.

All types of blood loss from the digestive system are divided based on the anatomy of the body. This is important in terms of symptoms and causes of hemorrhage.

Doctors distinguish the following types of lesions:

• Esophageal;
• Gastric;
• Intestinal.

Causes of bleeding from the esophagus (table and photos)

Causes	What's happening
Mallory-Weiss syndrome	Rupture of the mucous membrane of the esophagus due to repeated vomiting. The reason is frequent vomiting due to poisoning, for example, alcohol. Bleeding occurs directly from longitudinal ruptures of the mucous membrane.
Bleeding from esophageal varices	Cirrhosis of the liver leads to dilation of the veins through which blood flows from the esophagus. Large, superficial veins can rupture without cause. Heavy bleeding occurs from pathological, enlarged veins.
Tumor	Tumors are always well penetrated with blood vessels for nutrition and rapid growth. For a malignant tumor - esophageal cancer - it is typical to be complicated by bleeding. There is a variant of the tumor - hemangioma, which is completely formed by blood vessels. Such formations bleed profusely and often.
Ulcer	Ulcerative defects in the esophagus can cause small amounts of bleeding if the vessels are not affected. But sometimes the vessel at the bottom of the ulcer is destroyed, ruptured, and large, profuse bleeding occurs.

Symptoms of hemorrhage from the esophagus

The main sign of esophageal bleeding is bloody vomiting. Usually the blood does not have time to be swallowed, so it does not change its color. Based on the severity of bloody vomiting, we can talk about the amount of blood loss. If the bleeding is minor, for example, from an esophageal ulcer, then vomiting does not occur. In this case, only traces of blood can be found in the stool.

Causes of bleeding from the stomach (table and photos)

Causes	What's happening
Peptic ulcer	Under the influence of aggressive factors - stress, high acidity, H. Pylori bacteria - ulcerative defect. A complication is severe bleeding due to arrosive destruction of a vessel near the ulcer. Statistics on gastric bleeding show that this is the most common cause of blood loss.
Ulcers from taking non-steroidal anti-inflammatory drugs	The difference from peptic ulcer disease is the long-term use of non-steroidal painkillers - indomethacin, diclofenac. Under their influence, multiple acute ulcers of large size are formed on the surface of the stomach. They usually do not cause pain, unlike peptic ulcers. Often the first symptom is stomach bleeding.
Tumors and polyps	Tumor formations or polyps on the gastric mucosa can bleed easily, as they are well supplied with blood vessels.
Hemorrhagic gastritis	Inflammation of the gastric mucosa, in which red blood cells leak out of the vessels. Hemorrhages appear in the stomach - hemorrhages on the mucous membrane. Severe bleeding with gastritis is rare; blood is usually found in the stool. The pain is usually severe.

Symptoms of stomach bleeding

The main sign of gastric bleeding is dark vomit. Doctors call this the term "coffee ground vomiting."

Scarlet blood, entering the stomach, mixes with gastric juice. Hydrochloric acid oxidizes hemoglobin, giving the blood a dark, deep brown color. This is the difference between gastric vomiting and esophageal vomiting, which is why this symptom is called pathognomonic. This means it is characteristic only of a specific pathology - gastric bleeding.

If the source of bleeding in the stomach is minor, then vomiting does not occur. Blood particles pass through the entire internal tract. A small amount of blood can only be detected through a stool test.

Causes of bleeding from the intestines (table and photos)

Causes	What's happening
Acute ulcers	Ulcerative defects inside the intestines form less frequently than in the stomach. The duodenum is usually affected, but ulcers of other parts may occur. The mucous membrane ulcerates under the influence of toxic drugs and stress.
Tumors and polyps of the colon	Tumor formations extremely rarely occur in the small intestine; usually these are the terminal sections of the intestine. Tumors of the sigmoid colon, rectum, or polyposis in any part of the large intestine are common. A good vascular supply makes bleeding from the tumor possible at any time.
Nonspecific inflammatory bowel diseases (Crohn's disease, ulcerative colitis)	Autoimmune inflammation in such colitis is associated with an attack of one’s own immunity. The depth of inflammation and prevalence depend on the severity of the disease. Complications of colitis are manifested by bleeding from the affected areas of the intestine.
Infectious colitis, for example, dysentery	Bacterial enterocolitis can cause hemorrhages in the intestines. The most dangerous are Shigella and enterohemorrhagic Escherichia. When an infection develops, red blood cells leak from the vessels and enter the intestinal cavity, causing blood to appear in the stool.
Haemorrhoids	One of the most common causes of red blood in the stool is bleeding from hemorrhoids. This is an expansion of the veins of the rectum, associated with many reasons: chronic constipation, flatulence, pregnancy. Such dilated sections of veins have very thin walls, so they can be easily damaged, for example, during defecation.

Symptoms of intestinal hemorrhage

The manifestation of intestinal bleeding is the detection of blood in the stool. Depending on the volume of blood lost and the level of pathology, stool may have a different appearance.

With massive blood loss from the upper intestines, the blood is digested in its cavity. As a result, the stool takes on a deep black color. Doctors call this the term "melena". Typically, stool is quite liquid, which is due to the large volume of blood.

With major bleeding from the large intestine, the blood does not have time to be digested. It mixes with feces. The stool is stained cherry red with blood.

Special symptoms appear if the source of hemorrhage directly in the rectum is a polyp or hemorrhoids. In this case, the blood is in small clots on top of the feces, without mixing with them. This will indicate hemorrhage from the most terminal parts of the intestine.

Separately, it is worth mentioning hemorrhagic colitis due to dysentery. Only it is characterized by symptoms that are not similar to other bleeding. Due to the large amount of mucus in the stool and the entry of red blood cells into the intestinal lumen, the stool takes on the appearance of “raspberry jelly.”

Minor bleeding from the large or small intestine cannot be visually noticed. In this case, the tactics are the same as for minor blood loss from the esophagus or stomach. Traces of blood are detected in a laboratory stool test.

Common symptoms of gastrointestinal bleeding

In addition to specific signs of blood loss, specific to each part of the gastrointestinal tract, there are other criteria for bleeding. These are common symptoms associated with blood loss and anemia. Their cause is hypoxia and lack of blood volume.

Signs that are absolutely the same for any type of hemorrhage:

• Weakness;
• Dizziness;
• Flashing before the eyes of “flies” and “black dots”;
• Loss of consciousness;
• Rapid pulse and low blood pressure;
• Pale skin;
• Cold sweat;
• Thirst and dry mouth;
• Decreased urine output.

Diagnostics

Diagnostic methods for suspected gastrointestinal bleeding are divided into:

• Laboratory;
• Instrumental.

Laboratory methods are necessary if the question arises of how to determine the degree of blood loss and tactics for replenishing blood volume. They are universal for any hemorrhage. Instrumental methods vary depending on the clinic. For some pathologies instrumental methods diagnostics become therapeutic, since with their help it is possible to eliminate the source of bleeding.

Research method	When to use	What can show
General blood analysis	For any hemorrhage	decrease in red blood cells;
		decrease in hemoglobin;
		decrease in color index
Blood chemistry	For any hemorrhage	decreased clotting rates;
		increased bleeding rates;
		liver failure
Fecal occult blood test	If occult bleeding is suspected	Does not differentiate the source of bleeding, only confirms the fact of its presence
Fibrogastroduodenoscopy	If esophageal or gastric bleeding is suspected	The source of hemorrhage is visually detected in the wall of the esophagus or stomach.
Sigmoidoscopy	If you suspect bleeding from the rectum	Detection of polyp, rectal tumor, inflammatory changes
Colonoscopy	If you suspect intestinal bleeding	Detection of polyp, colon tumor, inflammatory changes in the mucosa

First aid and treatment

Bleeding from the gastrointestinal tract can be severe. Losing more than 30% of the body's total blood can be fatal.

Therefore, if you suspect hemorrhage, you should try to provide the maximum possible assistance:

• Apply an ice pack to your stomach;
• Do not give food or medicine;
• Take to the emergency department as soon as possible.

Inpatient treatment is carried out in the surgical department or in the ward intensive care if bleeding has reached critical levels.

The source of hemorrhage can be eliminated:

• Conservatively– rinsing with ice water and drugs that improve clotting;
• Endoscopically– cauterization or suturing during fibrogastroduodenoscopy;
• Open intervention– if it was not possible to stop the bleeding using the previous two methods.

For hemorrhages associated with nonspecific inflammatory bowel diseases, strong anti-inflammatory therapy is used. The drugs reduce the aggressiveness of one’s own immunity, reducing the activity of inflammation.

Medicines can be used separately or in combination:

• Anti-inflammatory– sulfasalazine;
• Cytostatics– methotrexate;
• Glucocorticosteroids– prednisolone;
• Monoclonal antibody preparations– infliximab.

Hemorrhoidal bleeding can be treated conservatively with the help of drugs that improve coagulation. But with constantly repeating episodes, elective surgery. It consists of eliminating hemorrhoids.

Small interventions are also possible:

• Sclerotherapy;
• Applying latex rings.
• Regardless of the source of bleeding, the victim will require infusion therapy:
• Saline solutions - Ringer's, physiological solution;
• Colloids – Gelofundin, Venofundin;
• Erythrocyte mass.

The indication for red blood cell transfusion is a rapid decrease in hemoglobin below 70 g/l. In this case, it will be impossible to restore lost hemoglobin without transfusion. Therefore, red blood cell preparations that match the antigens with a person’s own blood group are used.

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 a blood vessel or small capillaries in any of its areas. 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, 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 significant force may also have the form of vomiting with unchanged blood, since the blood does not have time to coagulate.

Gastrointestinal bleeding from the small intestine and colon can manifest itself either as coffee-ground vomiting or as melena, bloody diarrhea that has a tarry 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 (large intestine, rectum, anus), it appears 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 when laboratory research feces and gastric juice. Hidden bleeding from the upper 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 manifests itself only as general signs of 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 fresh air access 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 assistance for gastrointestinal bleeding depends primarily on the severity of the bleeding and its nature, as well as on the condition of the patient. 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 with surgical or conservative means.

In case of significant bleeding, if it is not possible to stop the blood loss, they 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 is vital important systems body;
• Treatment of the underlying disease that led to bleeding.

Video from YouTube on the topic of the article:

Gastrointestinal bleeding is the leakage of blood into the cavity of the stomach and intestines, followed by its release only with feces or with feces and vomiting. It is not an independent disease, but a complication of many – more than a hundred – different pathologies.

Gastrointestinal bleeding (GIB) is a dangerous symptom, indicating that it is urgent to find the cause of the bleeding and eliminate it. Even if a very small amount of blood is released (and there are even situations where the blood is not visible without special tests), this may be the result of a very small, but rapidly growing and extremely malignant tumor.

Note! Gastrointestinal bleeding and internal bleeding are not the same thing. In both cases, the source of bleeding may be the stomach or various departments intestines, but with gastrointestinal bleeding, blood is released into the cavity of the intestinal tube, and with internal bleeding - into the abdominal cavity. Gastrointestinal bleeding can in some cases be treated conservatively, while internal bleeding (after injury, blunt trauma, etc.) can only be treated surgically.

What happens when you lose more than 300 ml of blood

Massive bleeding from the gastrointestinal tract causes the following changes in the body:

Causes of gastrointestinal condition

There are so many causes of acute gastrointestinal bleeding that they are divided into two classifications. One of the classifications designates the type of causes, the second - the causes depending on the location in the gastrointestinal “tube”.

So, depending on the type of reasons, gastrointestinal tract can be caused by:

1. Inflammatory, erosive and ulcerative formations of the gastrointestinal tract, as a result of which the vessels feeding one or another structure are “corroded”. Not all of these pathologies occur due to poor diet or Helicobacter pylori infection. Erosive-ulcerative lesions occur with any serious illness (this is called stress ulcers). They are caused by burns from strong alcoholic drinks, acids and alkalis, drunk by mistake or intentionally. Erosion and ulcers also often occur as a result of taking painkillers and glucocorticoid hormones.
2. Tumors of the gastrointestinal tract of any degree of malignancy.
3. Wounds and injuries of the gastrointestinal tract.
4. Blood clotting diseases.
5. Increased pressure in the vessels of the gastrointestinal tract. This mainly happens only with portal hypertension syndrome caused by cirrhosis, blood clots in the portal vein or compression from the outside.

Depending on the location, bleeding from the upper sections (up to the end of the duodenum) and bleeding from the lower sections (starting from the small intestine) of the gastrointestinal tract are distinguished. The upper sections suffer more often: they account for about 90% of gastrointestinal tract infections, while the lower sections, accordingly, account for a little more than 10% of cases.

If we consider the frequency of damage to individual organs, then bleeding from the stomach is every second gastrointestinal tract, bleeding from the duodenum occurs in every third case. The colon and rectum are every 10th bleeding, the esophagus is every twentieth. Small intestine in adults it rarely bleeds - in 1% of cases.

The causes of gastrointestinal tract from the upper gastrointestinal tract are:

• erosive esophagitis, whose main cause is ingestion of acids or alkalis;
• erosive and hemorrhagic gastritis, including those caused by taking painkillers;
• peptic ulcer of the gastric or duodenal localization;
• increased pressure in the veins of the esophagus (portal hypertension syndrome). It develops with cirrhosis of the liver, blood clots in the hepatic or other veins communicating with the portal vein, compression of the portal vein at the level of the heart - with constrictive pericarditis or at any other level - with tumors and scars of nearby tissues;
• penetrating wounds chest or upper abdomen;
• Mallory-Weiss syndrome;
• stomach polyps;
• injuries to the esophagus or stomach caused by foreign bodies or hard (metal) medical equipment during examination;
• bleeding from diverticula (“pockets”) and tumors of the esophagus, stomach or duodenum;
• hiatal hernia;
• aorto-intestinal fistulas;
• injuries of the biliary tract (mainly during operations and manipulations), in which blood along with bile enters the duodenum.

The causes of gastrointestinal bleeding from the lower sections are:

• blunt abdominal trauma;
• abdominal wounds;
• tumors;
• thrombosis of mesenteric vessels;
• infection with worms;
• increased pressure in the veins of the rectum, which is caused by portal hypertension, which has the same reasons as in the case of the esophagus;
• nonspecific ulcerative colitis;
• Crohn's disease;
• anal fissures;
• haemorrhoids;
• diverticula;
• infectious colitis;
• intestinal tuberculosis.

The causes of gastrointestinal bleeding, which can cause bleeding from any part of the gastrointestinal tract, are vascular damage due to:

• systemic lupus erythematosus;
• vitamin C deficiency;
• periarteritis nodosa;
• atherosclerosis;
• Rendu-Osler disease;
• rheumatism;
• congenital malformations, telangiectasias and other vascular malformations,

• coagulation disorders (eg, hemophilia);
• decreased platelet levels or abnormalities in their structure (thrombocytopathy)

In addition to acute bleeding, there are gastrointestinal bleeding chronic. This means that in specific localization there are damaged vessels of small caliber, from which small, non- life threatening, blood volumes. The main causes of chronic bleeding are stomach and duodenal ulcers, polyps and tumors.

How to recognize gastrointestinal bleeding

The first signs of bleeding are weakness, which increases at different rates (depending on the rate of blood loss), dizziness, sweating, and a feeling of rapid heartbeat. With severe blood loss, a person becomes inadequate, and then gradually falls asleep, turning pale. If blood is lost quickly, a person experiences a strong feeling of fear, turns pale, and loses consciousness.

These symptoms are typical for any acute bleeding with a loss of more than 300 ml of blood, as well as for any conditions that can result in shock (intoxication, taking antibiotics against the background of significant bacterial infection, taking an allergen product or medication).

It is about the gastrointestinal tract that you should think about based on the existing symptoms:

• cirrhosis or thrombosis of the hepatic veins. This yellow dry skin, weight loss in the arms and legs with an enlarged abdomen, in which fluid accumulates, redness of the palms and feet, bleeding;
• clotting diseases. This is bleeding when brushing teeth, bleeding from injection sites, and so on;
• gastritis, duodenitis and peptic ulcer. These are pain in the upper abdomen immediately after eating (typical of stomach lesions) or 2-4 hours after it (typical of duodenal lesions), nausea, belching;
• infectious bowel disease. These are fever, nausea, vomiting, chills, weakness. In this case, a person may remember that he ate something “dangerous”: raw water, belyash at the bus station, three-day salad with mayonnaise, cake or pastry with cream. It must be said that infectious gastroenterocolitis will not cause profuse gastrointestinal tract, unless it is dysentery, in which (but not at the very beginning of the disease) ulcers form in the lower intestines.

Most tumors, diverticula or polyps of the gastrointestinal tract have no manifestations. Therefore, if gastrointestinal bleeding develops acutely, against the background full health(or you can only remember alternating constipation and diarrhea, unexplained weight loss), you need to think about this.

Why don’t we immediately describe the appearance of blood, since gastrointestinal tract infections are necessarily accompanied by it? Yes, indeed, blood has a laxative effect; it will not remain in the lumen of the gastrointestinal tract and will not be absorbed back. It will not stagnate, unless the gastrointestinal tract coincides with acute intestinal obstruction (for example, blockage of the intestine by a tumor), which can coincide extremely rarely

But in order for the blood to “appear” outside, time must pass until it covers the distance from the damaged vessel to the rectum or to the mouth. You can immediately describe the appearance of blood only when bleeding from the sigmoid or rectum. Then the first symptoms will not be weakness and dizziness, but defecation, when stool scarlet blood was found (most often it is hemorrhoids or anal fissure, so defecation will be painful)

Further symptoms of gastrointestinal bleeding vary depending on which section of the vessel is damaged.

So, if the source of bleeding is in the upper parts of the stomach, and the volume of blood lost exceeds 500 ml, then there will be vomiting of blood:

• scarlet blood - if the source is an artery in the esophagus;
• similar to coffee grounds (brown) - when the source is in the stomach or duodenum, and the blood could mix with gastric juice and oxidize;
• dark (venous) blood - if the source is the dilated vein of the esophagus.

In addition, with any amount of blood loss from the upper part, the stool will also be stained with blood: it will take on a darker color. The more blood is lost, the blacker and more liquid the stool will be. The greater the amount of bleeding, the sooner this stool will appear.

Gastrointestinal bleeding from the upper gastrointestinal tract must be distinguished from conditions when blood entered from the respiratory tract. You need to remember: blood from the respiratory tract will be released with a cough; it contains a lot of foam. The stool practically does not darken.

There are also conditions where the source of bleeding was in the mouth, nose or upper respiratory tract, the blood was swallowed, after which vomiting was observed. Then the victim needs to remember whether there was an injury to the nose, lips or teeth, whether a foreign body was swallowed, or whether there was a frequent cough.

For bleeding from the small and large intestines, vomiting blood is not typical. They are characterized only by darkening and thinning of the stool. If bleeding:

• from the rectum or anal sphincter - scarlet blood will appear on the surface of the stool;
• from the cecum or ascending colon - stool can be either dark or look like brown stool mixed with dark red blood;
• from the descending colon, sigmoid or rectum - stool of normal color, streaks or blood clots are visible in it.

Severity of gastrointestinal tract infections

To know how to provide assistance with gastrointestinal bleeding in a particular case, a classification has been developed that takes into account several indicators, their changes are divided into 4 degrees. To determine, you need to know your pulse, blood pressure, and with the help of blood tests, determine hemoglobin and (the percentage of the liquid part of the blood and its cells), according to which the circulating blood deficiency (CBD) is calculated:

• The number of heartbeats is within 100 per minute, blood pressure is normal, hemoglobin is more than 100 g/l, DCV is 5% of normal. The person is conscious, scared, but adequate;
• The number of heartbeats is 100-120 per minute, the “upper” pressure is 90 mm Hg, hemoglobin is 100-80 g/l, DCV is 15%. The person is conscious, but lethargic, pale, and dizzy. The skin is pale.
• Pulse is more often than 120 per minute, difficult to palpate. “Upper” pressure 60 mm Hg. Consciousness is confused, the patient constantly asks for a drink. The skin is pale and covered in cold sweat.
• The pulse is not palpable, the pressure is not determined or is palpated once within 20-30 mm Hg. DCC 30% or more.

Bleeding in children

Bleeding in children is very serious reason to contact a medical facility. It will not go away on its own, even if the child vomits blood, and after that behaves normally, plays and asks for food. Before applying, remember if he could have eaten chocolate, hematogen or foods that are colored red (beets, cakes with red dye). Also rule out injuries in the mouth and nose (they are visible to the naked eye).

There are quite a few causes of gastrointestinal tract problems in children. When looking for a diagnosis, doctors first of all pay attention to the age of the child: there are diseases that are most typical for a particular age period:

Age	Diseases
2-5 days of life	Hemorrhagic disease of newborns - vitamin K deficiency. Characterized by dark, profuse stools 3-4 times a day
Up to 28 days of life	Ulcers of the stomach (more often), duodenal ulcers (less often), ulcerative necrotizing colitis of newborns
From 14 days to 1 year of life	Duodenal ulcers (more often), stomach ulcers (less often)
1.5-4 months	Intussusception
1-3 years	Juvenile intestinal polyps, Meckel's diverticulum, Dieulafoy's disease, familial colon polyposis (in 5% of untreated children it transforms into cancer by age 5)
Over 3 years old	Esophageal varices
5-10 years	Portal hypertension syndrome, ulcerative colitis
10-15 years	Peutz-Jeghers syndrome, when many small polyps are found in the intestines. In this case, the skin, lips, eyelids have a characteristic feature - multiple brown spots

At any age of a child, starting from the neonatal period, the following may occur:

• gastritis: the cause may be a serious illness, hypoxia (for example, in newborns);
• esophagitis. Most often it occurs in children with shortened esophagus, achalasia cardia, hiatal hernia;
• doubling of the stomach;
• duplication of the small intestine;
• Mallory-Weiss syndrome;
• hiatal hernia;
• eosinophilic gastroenteropathy;
• vascular malformations of the gastrointestinal tract: hemangiomas and vascular malformations.

Diagnostics and urgent Care Children are treated on the same principle as adults.

First aid

The algorithm for gastrointestinal bleeding is as follows:

1. Call an ambulance.
2. Lay the patient down, raise his legs, returning the maximum possible amount of blood from the depot in the veins into the bloodstream.
3. Provide fresh air flow.
4. Put cold on your stomach. Be sure to put it on your clothes to avoid frostbite. Keep it on for 15-20 minutes, remove it for 10 minutes, then put it back on.
5. As for medications, you can give only 50 ml of aminocaproic acid solution and/or 1-2 tsp. calcium chloride.
6. Do not give anything to drink or eat: this may further increase bleeding.
7. To go to the toilet - use a bedpan, a diaper or some kind of container so that he doesn’t have to get up. At the same time, you should not be allowed to push.

What are they doing in the hospital

From the moment of admission, the patient is given assistance: colloidal solutions of blood substitutes (gelatin or starch solutions) are infused; after determining the blood type, blood and plasma are transfused (if necessary). This is explained by the fact that if surgery is necessary, go to the operating room, even in emergency, you need to take only a prepared patient. Such a patient has a better chance of survival.

Hemostatic drugs (“Tranexam”, “Tugina”, “Vikasol”, “Etamzilat”) are necessarily injected into a vein, and “Aminocaproic acid” is given by mouth. When found erosive and ulcerative lesions Acid-reducing drugs (Contraloc, Kvamatel or Ranitidine) are also injected into the vein.

All this time he is examined in the emergency department or intensive care unit (the second option is if the patient was brought in in very serious condition, with grade 3-4 bleeding):

• take a general blood test from your finger or look only at “red blood” (red blood cells and hemoglobin);
• blood is taken from a vein for hematocrit, determining the percentage of the liquid part of the blood and its formed elements, and blood for a coagulogram (the state of the coagulation system;

These indicators are used to judge the degree of gastrointestinal tract disease and develop tactics for further action;

• perform FEGDS - examination of the stomach and duodenum using fiber optic technology to determine the source of bleeding. If such a source is found in the esophagus, stomach or duodenum, they try to cauterize it directly during the procedure. If this is successful, no surgical intervention is undertaken;
• if necessary, and if the patient’s condition allows, angiography can be performed if FEGDS is uninformative.

Next, they look at the results of the examination, prepare the patient for surgery as much as possible and perform it using one of the methods: either open surgery, or introducing a fragment blocking the vessel using the intravascular method, or clipping (applying clips) under the control of an endoscope or laparoscope.

With portal hypertension syndrome, they try to stop bleeding conservative method: placement of a special Blackmore probe and intensive drug hemostatic therapy. If this does not help, shunt operations are performed - they direct blood from veins with high pressure to veins with lower pressure.

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 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.
• 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 fairly 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 Negative influence 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. It is the junction of branches of the portal vein (which collects blood from the intestines) and the superior vena cava (which collects blood from the upper half of the body). When the pressure in these veins increases, they expand, are easily injured, and bleeding occurs. Causes varicose veins veins of the esophagus: liver tumors; portal vein thrombosis; chronic lymphocytic leukemia; compression of the portal vein in various diseases.	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.	With systemic vasculitis, the symptoms of gastric bleeding are combined with the symptoms of the underlying disease.
Atherosclerosis, high blood pressure.	If blood vessels are damaged and blood pressure increases, there is a risk that the wall of one of the vessels will burst during an injury or another surge in pressure 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 an important role in the blood clotting process. 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
General symptoms 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 strong acute bleeding The patient's condition deteriorates very quickly. All symptoms increase over a short time. If emergency assistance is not provided, death may occur. With chronic gastric bleeding, the patient may experience 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 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. Finally establish the source of bleeding, make the correct diagnosis and provide effective assistance Only a specialist doctor can!
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.
• Moderate severity. 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. Bleeding mild degree It can turn serious at any moment!

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 and perform 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 this, X-rays are taken 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. It is performed when there is a suspicion that gastric bleeding is a consequence of atherosclerosis or other vascular disorders.	Through special catheter A contrast solution is injected into the desired vessel. 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	Carried out according to indications when for staging correct diagnosis 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;
• severe 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 they have 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 patient's condition improves peptic ulcer, 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 chooses the appropriate type 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 of the diseases that lead to it (see above - “causes of gastric bleeding”).