- this is the outflow of blood from damaged vessels of the stomach into the lumen of the organ. Depending on the intensity, it can manifest itself as weakness, dizziness, anemia, coffee grounds vomiting, and black stools. It is possible to suspect gastric bleeding on the basis of anamnesis and clinical tests, but it is possible to make an accurate diagnosis only after performing esophagogastroduodenoscopy. Treatment for minor hemorrhages is conservative (hemostatics, transfusion of fresh frozen plasma, etc.), for profuse hemorrhages - only surgical (endoscopic coagulation, clipping, extended surgery).
General information
Gastric bleeding is a dangerous complication of many diseases not only of the gastrointestinal tract, but also of the blood coagulation system and other body systems. The frequency of pathology in the world is approximately 170 cases per 100 thousand of the adult population. Previously, it was believed that the main cause of the development of gastric hemorrhage is peptic ulcer.
However, despite the development of new successful treatments for this disease, the frequency of bleeding from this part of the gastrointestinal tract has remained unchanged over the past twenty years. This is associated with a large selection of various drugs, their uncontrolled intake, which is why drug erosion and ulceration of the gastric mucosa came to the fore among the causes of gastrointestinal bleeding. Mortality ranges from 4% to 26%; this complication is the leading cause of emergency hospitalization.
Causes
For many years, peptic ulcer of the stomach and duodenum remained the main causal factor in the development of gastric bleeding. In recent years, the incidence of peptic ulcer has significantly decreased, but the continuing high stress tension in society, low medical literacy of the population, uncontrolled intake of non-steroidal anti-inflammatory drugs have led to an unexpected increase in the frequency of gastric bleeding by almost three times.
Today, the main causes of pathology are non-ulcerative lesions of the gastric mucosa: drug erosion, stress lesions, Mallory-Weiss syndrome. Chronic renal failure can lead to the formation of bleeding ulcers. Other causes include ischemia of the gastric mucosa against the background of cardiovascular diseases, cirrhosis of the liver, malignant neoplasms (as well as their accompanying chemotherapy), chemical and physical burns of the gastric mucosa. Traumatic brain injury, shock, significant general hypothermia, sepsis, severe psycho-emotional stress, myocardial infarction, hyperparathyroidism, terminal oncopathology can provoke the development of bleeding from the gastrointestinal tract.
Mortality risk factors are the patient's age over 60; low blood pressure, severe bradycardia or tachycardia (a combination of hypotension with tachycardia is especially dangerous); chronic insufficiency of the function of the heart, liver, kidneys, lungs; disturbances of consciousness; long-term prior treatment with anticoagulants and antiplatelet agents. It has been proven that in patients who have not completed a course of anti-Helicobacter therapy, the risk of rebleeding over the next 2 years is almost 100%.
Classification
Gastric bleeding can be acute or chronic. Acute hemorrhage is usually profuse, quickly leads to a deterioration in the patient's condition, and requires the immediate initiation of intensive care. Chronic bleeding is not abundant, causes gradual anemia, and may not manifest itself in any way, except for moderate weakness and fatigue.
Pathology can be hidden and obvious. Latent bleeding does not have a pronounced clinic, the patient may not be aware of it for a long time. A fecal occult blood test can confirm the presence of this condition. Explicit bleeding is usually manifested by hematemesis, chalky, symptoms of severe anemia. According to the severity of blood loss, hemorrhage is classified as mild, moderate and severe.
Symptoms of stomach bleeding
The clinic largely depends on the intensity and duration of hemorrhage. Short-term non-intensive bleeding can only be manifested by dizziness when changing body position, flashing flies before the eyes, and weakness. With blood loss of moderate intensity, blood accumulates in the cavity of the stomach, partially enters the duodenum. Under the influence of gastric juice, hemoglobin is oxidized, turning into hematin.
When the accumulated blood reaches a certain volume, vomiting of bloody contents occurs, the color of which, due to the admixture of hematin, resembles “coffee grounds”. If the bleeding is intense, the stomach cavity fills up very quickly and hemoglobin does not have time to oxidize. In this case, the vomit will contain a large amount of scarlet blood. The blood that has entered the duodenum, passing through the entire digestive tract, also undergoes changes, staining the stool black.
In addition to vomiting "coffee grounds" and melena, chronic bleeding is manifested by weakness, increased fatigue, decreased performance, pallor of the skin and mucous membranes. Acute bleeding involves the rapid onset of these symptoms, the patient complains of flies before the eyes, cold sticky sweat. With significant blood loss, disturbances of consciousness (up to coma) can be noted, hemorrhagic shock develops. With profuse bleeding or untimely treatment of the patient for medical care, a fatal outcome is possible.
Diagnostics
If the patient has one of the predisposing diseases, the gastroenterologist may suspect gastric bleeding if there are complaints of weakness, fatigue, pallor. First of all, clinical tests are prescribed: a detailed blood test with the determination of the level of Hb and platelets, a stool test for occult blood, a coagulogram. These tests can reveal a significant decrease in hemoglobin levels, disorders of the blood coagulation system.
However, the main diagnostic method is gastroscopy - an endoscopic examination of the gastric mucosa. Consultation with an endoscopist with endoscopy will allow you to detect varicose veins of the esophagus and upper stomach, which could serve as a source of bleeding. In addition, it is possible to detect erosion and gastric ulcers, ruptures of the mucous membrane (with Mallory-Weiss syndrome). To identify diseases that can lead to gastric bleeding, ultrasound of the abdominal organs and other auxiliary diagnostic methods are used.
Treatment of stomach bleeding
Treatment of moderate hemorrhage that does not cause significant deterioration of the patient's condition can be carried out on an outpatient basis or in the department of gastroenterology. To stop bleeding conservatively, hemostatic drugs are prescribed, and iron preparations are used to correct posthemorrhagic anemia. In the event of acute profuse hemorrhage, mandatory hospitalization with the use of surgical hemostasis is required.
Upon admission to the department, the patient is provided with complete rest, reliable venous access, intensive replenishment of the volume of circulating blood with crystalloid, colloid solutions and blood products (fresh frozen plasma, cryoprecipitate, erythrocyte mass) begins. An ice pack is placed on the stomach area. After relative stabilization of the condition, an emergency stop of gastroduodenal bleeding is carried out by clipping or ligation of bleeding vessels during gastroduodenoscopy, stitching of a bleeding stomach ulcer. If the cause of bleeding is a stomach ulcer, it is excised, and in some cases, a stomach resection (2/3 of the organ is removed and an anastomosis is created between the stomach stump and the intestines).
After the implementation of instrumental hemostasis, antisecretory and symptomatic therapy is prescribed, aimed at preventing the occurrence of recurrent gastric bleeding. The patient should be informed that untimely recognized gastric bleeding can lead to the development of severe anemia, hemorrhagic shock, acute renal failure, and subsequently to multiple organ failure and death. That is why it is so important to follow all the recommendations of a gastroenterologist, to conduct a full course of antisecretory therapy.
It was noted that in the group of patients of young and middle age, the use of endoscopic hemostasis in combination with antisecretory therapy leads to the best results, the frequency of relapses in these age groups is minimal. However, in elderly patients, the effectiveness of this technique is not so high, and fairly frequent cases of repeated bleeding in aged patients lead to an increase in mortality from this complication up to 50%.
Forecast and prevention
The outcome depends on the severity of hemorrhage, the timeliness of diagnosis and treatment. In chronic low-intensity bleeding, the prognosis is relatively favorable; timely treatment of the underlying disease significantly improves the patient's quality of life and reduces the risk of fatal complications. Profuse bleeding has a very poor prognosis. This is due to the difficulties of diagnosis, the late start of adequate therapy. Acute profuse hemorrhages often end in death.
Prevention is the prevention of diseases that can cause the development of this complication. It is necessary to visit a therapist annually for early detection of peptic ulcer, other diseases of the gastrointestinal tract, and the blood system. Patients with gastric ulcer are advised to undergo timely courses of anti-Helicobacter and antisecretory therapy.
Gastrointestinal bleeding syndrome complicates the course of many diseases of the digestive tract and can cause death. All bleeding is divided primarily into bleeding from the upper, lower gastrointestinal tract (GIT) and bleeding of unknown etiology. Most often, this syndrome complicates diseases of the upper gastrointestinal tract (above the ligament of Treitz). Thus, in the United States, the annual number of hospitalizations for bleeding from this section of the gastrointestinal tract ranges from 36 to 102 patients per 100,000 population. The gastrointestinal tract is found twice as often in men. Bleeding from the lower gastrointestinal tract as a whole is much less common. It should be noted that due to the widespread introduction of endoscopic research methods, the proportion of bleeding of unknown etiology has decreased from 20-25% to 1-3%, and according to other authors, to 5-10%. Among the causes of bleeding from the upper gastrointestinal tract, erosive and ulcerative lesions of the stomach and duodenum (DUC) are in the first place, and destructive processes in the duodenum lead to hemorrhagic complications twice as often. The mortality rate for upper GI bleeding ranges from 3.5-7% in the US to 14% in the UK, and the mortality rate for lower GI bleeding is 3.6%.
There are hidden, as a rule, chronic, gastrointestinal bleeding and obvious (massive) hemorrhages.
In acute bleeding, the degree of blood loss can be different.
In the case of massive blood loss, the volume of circulating blood decreases, there is a discrepancy with its vascular bed, a decrease in blood pressure, an increase in heart rate, a decrease in minute volume of blood circulation, which causes an increase in total peripheral vascular resistance due to compensatory, generalized vasospasm. This compensatory mechanism is short-term, and with continued blood loss in the body, irreversible hypoxic phenomena may occur. First of all, liver function suffers, in which foci of necrosis may occur.
In the development of any bleeding, two periods are distinguished: latent, from the moment blood enters the digestive tract, and generalized, manifested by such obvious signs of blood loss as tinnitus, dizziness, weakness, cold sweat, palpitations, drop in blood pressure, fainting. The duration of the first period depends on the rate and volume of bleeding and ranges from several minutes to a day.
Bleeding from the upper GI tract
The main causes of bleeding from the upper gastrointestinal tract are presented in Table 1.
Table 1. Causes of bleeding from the upper gastrointestinal tract.
| Cause of bleeding (diagnosis) | Percent |
| duodenal ulcer | 22,3 |
| Erosive duodenitis | 5,0 |
| Esophagitis | 5,3 |
| Gastritis, including hemorrhagic and erosive | 20,4 |
| stomach ulcer | 21,3 |
| Varicose veins (esophagus and stomach) with portal hypertension | 10,3 |
| Mallory-Weiss syndrome | 5,2 |
| Malignant tumors of the esophagus and stomach | 2,9 |
Rare causes, including:
|
Total 7.3 |
It was found that 44% of all hospitalizations for bleeding from the upper gastrointestinal tract occur in patients over 60 years of age, and mortality rates in older people are also significantly higher. However, it should be noted that approximately 80% of upper GI bleeding episodes resolve spontaneously or require non-massive therapy.
An analysis of the causes of deaths in upper gastrointestinal bleeding shows that higher mortality rates (from 50 to 70%) are associated with cases of recurrent bleeding from varicose veins of the esophagus and stomach. In general, it is recurrent bleeding that is most dangerous in prognostic terms. Risk factors for rebleeding include endoscopically detectable signs of the threat of rebleeding (jet ongoing bleeding, blood leakage, thrombosed vessel and visible non-bleeding vessel). These visual signs most often accompany erosive and ulcerative lesions of the gastrointestinal tract. It is believed that these signs of bleeding are more important for gastric ulcers than for duodenal ulcers.
Among other signs that can cause or affect the outcome of bleeding, factors such as the size of the ulcer (giant ulcers), comorbidities (renal failure, cirrhosis of the liver, acute coronary insufficiency, chronic circulatory failure, neoplastic, endocrine, systemic diseases) should be noted .
In general, in the first place for the causes of bleeding (see table 1) is erosive and ulcerative lesions of the stomach and duodenum. And this is despite the undoubted progress in the treatment of peptic ulcer, achieved in recent years. Apparently, there are several reasons, and the main ones are asymptomatic ulcers and uncontrolled use of non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin, alcohol, and a combination of these factors. So, it is the intake of NSAIDs in patients with peptic ulcer that can give an erased picture of the disease, on the one hand, and fatal bleeding, on the other. Of no small importance in the etiology of gastrointestinal bleeding of its recurrence in patients with peptic ulcer is the infection of patients Helicobacter pylori(HP), especially in cases of incomplete HP eradication, as well as acid-peptic factor.
A clear period of upper GI bleeding usually begins with vomiting of blood (bright red blood, dark clots, or "coffee-ground" vomit) or melena (black, tarry, smearing stools with a specific, fetid odor), but should be noted that with massive bleeding from the upper gastrointestinal tract, abundant scarlet blood may also appear in the feces.
At the same time, the patient has anxiety or lethargy, pallor, decreased blood pressure, tachycardia, and in some cases, patients with severe blood loss may also have bradycardia associated with vagal influence. A critical hemodynamic situation occurs when blood is lost at the level of 40% of the total volume of circulating blood. During this period, the presence of bleeding as a syndrome is beyond doubt, but it is much more difficult to determine its specific source.
The main method for diagnosing bleeding from the upper gastrointestinal tract is endoscopic visualization of the bleeding site during endoscopy; other methods (nasogastric tube, the level of residual nitrogen in the blood) are auxiliary. As a rule, endoscopic diagnosis of ulcerative bleeding, especially gastric localization, is not difficult. The situation is different with gastropathies, as sources of hemorrhagic complications. Endoscopically, gastropathy is determined by the presence of a large number of submucosal hemorrhages, erythema and erosions. Erosion is a defect in the mucous membrane that does not extend to its muscular plate. In fact, most endoscopists define erosion as an area of hemorrhage or shallow defects in the mucosa with a core of necrosis no more than 3–5 mm in diameter. Gastropathy is often induced by taking NSAIDs, alcohol and occurs as a result of stressful influences.
Bleeding from dilated veins of the esophagus and stomach is more often observed from large nodes or common varicose veins. Assessing the situation, endoscopists often focus on the color of the nodes. The red and blue color of one node is considered a risk factor for bleeding. A white spot on a varicose vein may be a fibrin plug and be considered a diagnostic factor for previous bleeding, but does not indicate the possibility of rebleeding. Isolated gastric varices in the fundus may be the result of thrombosis of the splenic vein, which is detected by angiography. Varicose veins in the duodenum rarely bleed.
In Mallory-Weiss syndrome, the source of bleeding is a mucosal tear near the gastroesophageal junction, caused by intense vomiting that accompanies prolapse of the stomach lining. Patients with this syndrome are associated with chronic alcohol use and portal hypertension.
Management of patients with bleeding from the upper gastrointestinal tract, often associated with erosive and ulcerative lesions of the stomach and duodenum, is carried out in three stages.
- Urgent measures aimed at identifying the source of bleeding, stopping it and correcting hemodynamic and metabolic disorders.
- Treatment aimed at restoring the integrity of the affected organ, taking into account the etiology and pathogenesis of the underlying disease.
- Prevention of recurrent bleeding, including rational therapy of the underlying disease.
At the first stage, the complex of necessary measures includes: ensuring the patency of the respiratory tract (position on the side, the introduction of a nasogastric tube), as well as intravenous access, determining the blood type, Rh factor and biological compatibility. In addition, a blood test for hemoglobin and hematocrit is taken from the patient, the number of formed elements, the state of the blood coagulation system, the levels of urea, electrolytes, and glucose are determined; perform liver function tests; monitor arterial blood gases. With significant blood loss, it is necessary to restore the BCC (transfusion of saline, and if there are signs of sodium retention in the body, a 5% dextrose solution). If there are signs of a fall in BCC, a transfusion should be performed within an hour: 500 ml - 1 liter of a colloidal solution, followed by hemotransfusion of erythromass or whole blood (with a large amount of blood loss, the second is preferable). During fluid therapy, care must be taken to ensure that the urine output is above 30 ml/h and to beware of volume overload. At the same time, measures should be taken to stop bleeding. If endoscopy is impossible for some reason, you can try to stop the bleeding by therapeutic methods: gastric lavage with ice water and the introduction of antisecretory agents that, in addition to affecting secretion, have the ability to reduce blood flow in the mucous membrane. The use of blockers of acid production is especially indicated for erosive and ulcerative bleeding. According to recent data, the use of H2-histamine receptor blockers and proton pump inhibitors (PPIs) can reduce the likelihood of surgery and death by 20% and 30%, respectively. Particularly effective are modern PPIs, characterized by rapid action. Usually, patients are given 40 mg of omeprazole (Losek) or 50 mg of ranitidine (Zantac and others) intravenously. The use of famotidine (quamatel at a dose of 20 mg two to four times a day, depending on the degree of blood loss and the severity of endoscopic changes, also gives a good effect. Simultaneously with acid production blockers, it is advisable to prescribe cytoprotective agents: sucralfate (venter), preferably in the form of an emulsion according to 2.0 g every 4 hours, bismuth preparations (de-nol, ventrisol, etc.).
Diagnostic and therapeutic endoscopy (argon plasma coagulation, electrocoagulation, laser photocoagulation, diathermocoagulation, clipping, chemical coagulation with dehydration, etc.) significantly improves the results of therapy for bleeding from the upper gastrointestinal tract. According to available data, with bleeding caused by erosion, a good effect (80-90%) is given by intra-arterial infusion of vasopressin during angiography and catheterization, the effect is less pronounced after intravenous infusion of vasopressin. With ulcerative bleeding, the effect of vasopressin is hardly noticeable, possibly due to the larger caliber of bleeding vessels. Otherwise, the treatment of bleeding in gastropathy does not differ from that described above.
With regard to bleeding from dilated veins of the esophagus and stomach, here the drug of choice is a synthetic analogue of somatostatin (octreotide), which has now replaced vasopressin. Octreotide (sandostatin) is administered at a dose of 25–50 mcg/h as a continuous infusion over five days. The combined use of metoclopramide and intravenous infusions of nitroglycerin also has an effect. The main forms of treatment for this type of bleeding are urgent sclerotherapy or ligation.
Bleeding in duodenitis almost always stops spontaneously, and therefore therapeutic endoscopy is rarely required, and angiodysplasia is treated mainly with laser endoscopic coagulation therapy.
It should be noted that for the full therapy of a patient with bleeding from the upper gastrointestinal tract, it is not enough to stop the bleeding and stabilize the patient's condition; it is necessary to prescribe a rational treatment for the underlying disease that caused blood loss. So, for the treatment of erosive and ulcerative processes associated with HP, it is quite obvious that it is necessary to prescribe a full-fledged eradication therapy, taking into account not only the resistance of HP to metronidazole, but also polyresistance to other antibacterial agents. Based on the results of our studies, we can talk about a weekly triple therapy with colloidal bismuth subcitrate (240 mg twice a day), tetracycline (750 mg twice a day) and furazolidone (200 mg twice a day). Weekly or, if metronidazole resistant, 14-day quadruple therapy is possible: omeprazole (20 mg twice a day), colloidal bismuth subcitrate (240 mg twice a day), tetracycline (500 mg four times a day) and metronidazole (500 mg twice a day). HP eradication with this treatment reaches 85.7-92%.
To prevent bleeding caused by the use of NSAIDs in association with HP, patients who continue to take anti-inflammatory drugs according to indications should undergo such eradication therapy with the mandatory inclusion of PPIs (losek, pariet) 20 mg twice a day in the regimen, with a further transfer to maintenance course of PPI at half daily dose. Misoprostol (200 micrograms four times a day) may be taken. Misoprostol is also effective in preventing stress erosions, although it causes diarrhea in some patients.
Bleeding from the lower GI tract
The most common causes of bleeding from the lower gastrointestinal tract according to A. A. Sheptulin (2000) are:
- angiodysplasia of the small and large intestine;
- intestinal diverticulosis (including Meckel's diverticulum);
- tumors and polyps of the colon;
- tumors of the small intestine;
- chronic inflammatory bowel disease;
- infectious colitis;
- intestinal tuberculosis;
- hemorrhoids and anal fissures;
- foreign bodies and intestinal injuries;
- aorto-intestinal fistulas;
- helminthiases.
The mean age of patients with bleeding from the lower GI tract is higher than that of patients with bleeding from the upper GI tract. In the past few decades, mortality rates from acute bleeding from the lower gastrointestinal tract have slightly decreased, which is associated primarily with the improvement in the diagnosis of bleeding due to the use of colonoscopy and angiography, which allow choosing the optimal algorithm for surgical or angiographic treatment.
As with upper GI bleeding, 80% of all episodes of lower GI bleeding stop spontaneously, and 25% of patients who stop bleeding experience relapses. Unlike upper GI bleeding, most lower GI bleeding is occult or minor, intermittent, and does not require hospitalization.
Of all the above causes of bleeding from the lower gastrointestinal tract, the most common (30%) are hemorrhages from cavernous hemangiomas and angiodysplasias of the mucous membrane of the small and large intestine (arteriovenous malformations of types I, II and III). In second place is diverticulosis (17%), and in 5-10% of cases in patients with bleeding from the lower gastrointestinal tract, the cause of bleeding cannot be established.
In diverticulosis, a bleeding diverticulum is more commonly found in the left side of the colon. More often, bleeding occurs with concomitant diverticulitis and trauma to the blood vessels. The degree of blood loss can be dangerous for the elderly.
Tumor processes rarely give acute bleeding, they mainly cause chronic, latent blood loss and iron deficiency. Occult bleeding also accompanies ulcerative colitis and Crohn's disease more often, since with this pathology, large vessels, as a rule, are not damaged.
Bleeding with hemorrhoids is often mild, but in some cases there may be massive blood loss, requiring urgent surgical measures.
Diverticular bleeding often manifests as acute, painless, and manifests as bright red, unaltered blood (hematochezia) in the stool, although melena may also occur if the source of bleeding is located in the small intestine. Moreover, the lighter the blood, the more distal is the focus of bleeding. A similar picture is often observed in angiodysplasia. The differential diagnosis in these cases is usually based on colonoscopy or angiography. In neoplastic processes, the bleeding clinic, as a rule, is represented by weak, intermittent bleeding and stools with a positive reaction to occult blood. With internal hemorrhoids, pain is most often absent, and bleeding can be in the form of a trickle of scarlet blood, or it can be manifested by the presence of blood on toilet paper or around the stool, but not mixed with feces, which retains its normal color. In general, when there is evidence of bleeding, the intestinal contents retain their normal color, this indicates a low location of the source of bleeding (in the rectosigmoid sector). Bleeding with hemorrhoids is often noted when straining or when passing hard feces. A similar picture is also typical for patients with bleeding from anal fissures, but in this case it is often accompanied by a sharp pain syndrome. In addition, the same symptoms may accompany rectal polyps and rectal carcinoma. In this regard, patients with these symptoms must necessarily undergo anoscopy and sigmoidoscopy.
Bleeding, the source of which is Meckel's diverticulum, is more often observed in childhood. This is a painless bleeding that may present with chalky or bright red blood, classically described as "currant jelly" stools. Here, too, everything depends on the level of location of the diverticulum. The diagnosis is made on the basis of radioisotope studies, which, however, often give both false negative and false positive results.
Inflammatory bowel disease is characterized by pain, which usually precedes bleeding. The blood in these patients usually mixes with the stool, which changes its color, since the source of bleeding is more often located above the rectosigmoid colon. At the same time, other signs of the disease were found, such as diarrhea, tenesmus, etc. Infectious colitis caused by pathogenic intestinal flora can also often be represented by bloody diarrhea, but in this case, significant blood loss is rarely observed. The diagnosis in this case is based on sigmoidoscopy with biopsy and stool culture.
If the bowel lesion is ischemic in nature, there is colicky pain in the abdominal cavity, often on the left, followed later (within a day) by bloody diarrhea. For this type of bleeding, minimal blood loss is characteristic, massive bleeding is less common. Diagnosis is usually made by x-ray and colonoscopy with biopsy.
Of great importance in the diagnosis of bleeding from the lower gastrointestinal tract are the information obtained during the collection of anamnesis and objective examination of the patient. A significant role is played by aggravated heredity, past and existing chronic pathology (oncological diseases in the patient and relatives, including familial colon polyposis, hepatitis, cirrhosis of the liver, urogenital pathology), as well as living and working conditions, contact with animals, etc.
Examination of the patient often allows us to draw a number of conclusions, for example, the presence of multiple telangiectasias on the skin and mucous membranes suggests that they are also present in the intestinal wall. In addition, it is important to consider the symptoms of existing posthemorrhagic iron deficiency anemia, abdominal pain, diarrhea, anorexia, weight loss, or the presence of palpable masses in the abdominal cavity. Colonoscopy is invaluable in the diagnosis of bleeding from the lower gastrointestinal tract, and in cases of progressive blood loss, patients are shown angiography.
However, despite the fact that at present there is a rich arsenal of technical means, one should not forget about simple, but quite informative research methods available in any conditions - digital rectal examination, which can answer many questions, especially in pathology rectum. It is no coincidence that this procedure is in the first place in the list of diagnostic measures for bleeding from the lower gastrointestinal tract. In addition to the above measures (anoscopy, sigmoidoscopy, colonoscopy with biopsy, angiography), one should not forget about the need to study feces for occult blood with benzidine (after careful preparation of the patient). In some cases, radioisotope studies, computed tomography and MRI diagnostics help in making the correct diagnosis.
In 80% of cases, acute bleeding from the lower gastrointestinal tract stops on its own or during therapeutic measures aimed at treating the underlying disease. The most effective therapy for diverticular and angiodysplastic bleeding are: selective catheterization with intra-arterial administration of vasopressin; transcatheter embolization of intestinal arteries; endoscopic electro- and laser coagulation; sclerotherapy. With hemorrhoids, methods such as local (in candles) vasoconstrictive therapy can be used; a 10% solution of calcium chloride is prescribed orally (one tablespoon four to five times a day). With massive bleeding, rectal tamponade can be used. With repeated bleeding, surgical treatment is indicated. With internal hemorrhoids, in some cases, sclerosing therapy with varicocid, ethoxyscleron and other agents is prescribed. Great importance in the prevention of hemorrhoidal rebleeding is given to the treatment of chronic obstipation syndrome in these patients.
Given the fact that bleeding from the lower gastrointestinal tract is much more often latent and is accompanied by chronic iron deficiency anemia, it is necessary in each case to diagnose occult blood loss and their timely therapeutic correction. The presence in most patients with chronic blood loss of combined pathology of the gastrointestinal tract (chronic atrophic gastritis, intestinal dysbacteriosis), malnutrition with vitamin deficiency, and in some cases alcohol abuse, creates the need for complex therapy, which is preferable to be carried out with the help of combined drugs. In this case, the drug of choice is Ferro-Folgamma (which contains 100 mg of anhydrous iron sulfate or 37 mg of iron, folic acid (5 mg), cyanocobalamin (10 μg) and ascorbic acid (100 mg). A successful combination of these ingredients in one dosage form creates conditions for the most effective absorption of iron and correction of pathological processes.In addition, the presence of rapeseed oil as a carrier in the preparation protects the gastric mucosa from the irritating effect of iron, which is of great importance in case of its concomitant damage.
Doses and duration of treatment are selected individually according to laboratory and clinical parameters. Usually the drug is prescribed 1 capsule two to three times a day.
In any case, the therapy of patients with gastrointestinal bleeding should be comprehensive and take into account the individual characteristics of patients and comorbidities.
For literature inquiries, please contact the editor
I. V. Maev, doctor of medical sciences, professor
A. A. Samsonov, Doctor of Medical Sciences
G. A. Busarova, Candidate of Medical Sciences
N. R. Agapova
MGMSU, Moscow
From this article you will learn: what is intestinal bleeding. Causes and treatment.
Article publication date: 05/22/2017
Article last updated: 05/29/2019
Intestinal bleeding is the release of blood into the lumen of the small or large intestine. Blood is secreted from the damaged intestinal wall and sooner or later leaves the body naturally during bowel movements. Moreover, the nature of the blood in the stool will be very different depending on either the location or the "height" of the site of damage to the mucosa. The higher up in the gastrointestinal tract the discharge of blood began, the more altered blood will be in the stool. It is by the unusual appearance and color of the feces that the patient may suspect something is wrong with the intestines.
Intestinal bleeding is just a symptom or manifestation of a disease, some of which are deadly. That is why the slightest suspicion of the release of blood from the intestines should be the reason for going to the doctor. The primary link in the diagnosis most often becomes a general practitioner who, as necessary, refers the patient to a surgeon, proctologist, gastroenterologist or oncologist.
The prognosis of the disease depends entirely on the massiveness of bleeding, as well as the immediate cause of this condition. In some cases, the disease can pass without a trace, and sometimes it threatens the life of the patient. Approximately 60-70% of gastrointestinal bleeding is caused by gastric and duodenal ulcers - without immediate help, such conditions can take the patient's life in a matter of hours.
Causes of intestinal bleeding
The main reasons for the flow of blood from the intestines:
- Peptic ulcer of the stomach and duodenum is the most common cause of the appearance of altered blood in the stool.
- Diseases of the rectum: anal fissure, hemorrhoids.
- Injuries to the intestine: the rectum can be injured by a fall or by a foreign object. The rest of the gastrointestinal tract can be damaged by foreign objects accidentally or deliberately swallowed by the patient: needles, hairpins, blades, and so on.
- A special group of inflammatory bowel diseases: Crohn's disease, ulcerative colitis, celiac disease and others.
- Infectious bowel diseases caused by a special group of intestinal microbes: dysentery, shigellosis, typhoid fever.
- Oncological bowel diseases: bowel cancer of various localization.
The formation of polyps (abnormal growths of tissue) can also cause intestinal bleeding. Symptoms of intestinal bleeding
With massive bleeding, the picture of the disease is so bright that the diagnosis of this condition is not difficult. The situation is worse with the diagnosis of rare and minor bleeding.
Let's list what are the symptoms of intestinal bleeding.
Direct detection of blood in the stool
Doctors call this blood fresh because its appearance has not changed. Fresh blood usually covers the surface of the feces or is passed along with the stool. This symptom is typical for diseases of the lowermost parts of the large intestine of the rectum. Hemorrhoids, anal fissure, rectal cancer and inflammation of the rectum - proctitis - are very often accompanied by the appearance of fresh blood in the stool.
Blood streaks in stools
The blood retains its appearance, but it is already mixed with feces or has the appearance of streaks. This symptom is also characteristic of diseases of the large intestine, however, more "high" sections of the colon are affected: the caecum and sigmoid colon.
The cause may be colon cancer and a special group of inflammatory diseases of the colon - colitis, including Crohn's disease or ulcerative colitis (UC). Also, blood in the stool can occur against the background of some infectious diseases - dysentery and shigellosis.
Changes in color, odor and consistency of stools
The feces acquire a liquid or mushy consistency, black color, a “varnished” surface and a very characteristic fetid odor. Doctors call such stools tarry stools or melena. Such a chair occurs due to the fact that the enzyme systems of the stomach and intestines “digest” the blood, releasing iron from it, which determines the very black, like tar, color. This is one of the most characteristic symptoms of gastric or small intestine bleeding that accompanies peptic ulcer of the stomach and duodenum, as well as malignant neoplasms of these sections of the gastrointestinal tract.
There is a small nuance - melena can accompany not only gastrointestinal bleeding, but also outflow of blood from the oral cavity, esophagus, nasopharynx and upper respiratory tract. In this case, the patient simply swallows blood, which goes through all the same enzymatic reactions in the stomach and intestines.
The second caveat is that the feces can become dark when taking certain foods and medications: raw meat, activated charcoal, bismuth and iron preparations. This feature is described in the "Side Effects" section of each of the drugs, but it still scares patients. In fact, such fecal masses are fundamentally different from true melena, primarily in the absence of smell and varnished sheen.
Stomach ache
Abdominal pain often accompanies the initial period of the condition. The pain syndrome has its own characteristics depending on the underlying cause and localization of bleeding:
- with bleeding ulcers of the duodenum, the pain is very strong and sharp;
- with oncological diseases of the intestine - dull and inconsistent;
- with nonspecific ulcerative colitis - migratory, cramping;
- with dysentery - accompanying the urge to defecate.
Weight loss
Weight loss is also a very characteristic symptom that accompanies intestinal bleeding. This is due to the constant loss of iron and nutrients from the blood, as well as disruption of the damaged intestine. Destruction of the intestinal mucosa interferes with the absorption of nutrients from food.
anemic conditions
Anemia or anemia - a decrease in the level of red blood cells, red blood cells and hemoglobin. Due to blood loss, the body does not have time to restore iron stores and synthesize new hemoglobin and red blood cells. With a massive outflow of blood, anemia occurs acutely and leads to a violation in all organs and tissues. With periodic loss of small amounts of blood, anemia develops slowly. Such latent anemias also harm human health, reduce its performance and resistance to other diseases.
Anemia can be diagnosed by a general blood test, and suggested by indirect signs: pale skin and mucous membranes, weakness, drowsiness, dizziness, dry skin and hair, brittle nails, shortness of breath and palpitations - tachycardia.
indigestion
Digestive disorders are not direct signs of intestinal bleeding, but quite often they are accompanied. It can be diarrhea, constipation, bloating, increased gas formation, nausea and vomiting.
Fever
An increase in temperature is characteristic of some diseases that accompany intestinal bleeding: dysentery, shigellosis, UC, Crohn's disease and other inflammatory bowel diseases.
paraneoplastic syndrome
In case of bowel cancer, a special symptom complex can develop - paraneoplastic syndrome, that is, a list of symptoms that accompanies any malignant process: weakness, dizziness, lack or perversion of appetite, sleep and memory disturbances, skin itching and vague rashes, specific changes in the picture of a blood test.
Diagnostic measures for intestinal bleeding
It is very important to recognize this condition in time, because even small blood losses significantly impair the patient's performance and quality of life. We list the mandatory minimum research for intestinal bleeding.
Endoscopic diagnostics
Colonoscopy - alone or in combination with fibrogastroscopy - is an examination of the inner surface of the gastrointestinal tract using an endoscope. An endoscope is a long, thin, flexible tube equipped with a fiber optic system and connected to a monitor screen. The tube may be inserted through the mouth or through the anus of the patient. During endoscopy, you can not only identify the source of bleeding, but also “burn” this place or put metal brackets on it with special nozzles, as well as take a suspicious bleeding area of the mucosa for biopsy and subsequent examination under a microscope.
Colonoscopy X-ray methods
X-ray examination of the intestine is carried out with the passage of barium. This rather old research method has been partially superseded by endoscopy. However, X-ray remains informative, especially in cases where endoscopy is not possible for technical and physiological reasons.
The method consists in the fact that the patient receives a solution of barium salt in the form of a drink or an enema. The barium solution is clearly visible on x-rays. It tightly fills the intestinal lumen, repeating its internal relief. Thus, you can see the characteristic changes in the mucosa of the digestive tract and suggest the cause of bleeding.
microscopic examination
Histological or microscopic examination of the obtained fragments of the mucosa. With the help of a biopsy, malignant tumors, as well as various inflammatory bowel diseases, can be confirmed or refuted. Histology is the gold standard for diagnosing Crohn's disease and ulcerative colitis.
Rectoscopy
This is an examination of the rectum using the finger method or a special rectal speculum. This is a quick and easy way to detect abnormal hemorrhoidal veins, fissures, and rectal tumors.
A rectoscope is an instrument used by a doctor to examine the rectum. Laboratory diagnostics
- Blood test to monitor the level of hemoglobin, red blood cells and platelets. The first two indicators provide information about the nature and massiveness of blood loss, and the level of platelets will indicate the patient's individual problems with blood clotting.
- Analysis of feces for various indicators: the microbial composition in intestinal infections, the remains of undigested fibers, as well as the analysis of feces for occult blood. The latter analysis is extremely important for diagnosing rare and minor bleeding, when those small amounts of blood lost do not change the appearance of the stool in any way. Such an analysis is performed for clinical symptoms of intestinal bleeding and for any obscure anemia.
- Special blood tests for antibodies to various infectious and non-specific bowel diseases.
Treatment of intestinal bleeding
The speed, duration and aggressiveness of therapy directly depend on the massiveness of bleeding, as well as on its root cause.
- A massive outflow of blood from any part of the intestine, threatening the life of the patient, is subject to immediate surgical treatment. First of all, they try to stop the blood by endoscopic methods: by cauterization or by applying brackets or clips to a bleeding vessel. If such a gentle treatment is impossible or ineffective, doctors go for an open operation. This type of surgery is an emergency.
- Replenishment of blood volume by transfusion of donor blood components or blood-substituting solutions. Such actions are absolutely necessary to stabilize the patient's condition after massive bleeding.
- Planned surgical treatment involves a certain amount of surgical intervention in the preliminary preparation of the patient. Such planned operations include surgical treatment of hemorrhoids, removal of intestinal polyps or tumors, plastic surgery of gastric or duodenal ulcers.
- Drug stopping of bleeding with hemostatic or hemostatic drugs: tranexam, etamsylate, aminocaproic acid, calcium gluconate and others. This treatment is used only for minor bleeding.
- Treatment of the immediate cause of bleeding: this includes a strict diet and anti-ulcer therapy, specific treatment for ulcerative colitis, antibiotic therapy for intestinal infections. In these cases, the cure or at least stabilization of the cause of bleeding completely eliminates blood loss.
- Taking iron supplements to restore hemoglobin levels and treat anemia is indicated for all patients after intestinal bleeding.
Hemostatic drug Tranexam Prognosis for the disease
The prognosis for correct and timely treatment of intestinal bleeding is favorable.
The highest mortality rate and severe health consequences are intestinal bleeding from gastric and duodenal ulcers.
Also, the prognosis for the life of a patient with bleeding from a decaying cancerous tumor of the intestine is extremely unfavorable. Such cancer is often neglected and is not subject to radical cure.
Mortality in gastrointestinal bleeding (GI) is 7-15%, therefore, it is advisable to hospitalize patients with moderate and severe bleeding in the ICU, where they can be further examined and treated. Responsibility for the patient must be shared. To the patient immediately call a surgeon and endoscopist, if necessary - other specialists. In a serious and extremely serious condition of the patient, it makes sense to convene a consultation.
Bleeding stops spontaneously in about 80% of cases. Continued bleeding requires it to be stopped endoscopically as soon as possible. If this is not possible, then resort to active surgical tactics. In some cases, endovascular intervention or conservative treatment is performed.
The main tasks assigned to the anesthesiologist-resuscitator in the treatment of patients with GIB:
- Carrying out the prevention of recurrence of bleeding after it has stopped;
- Restoration of systemic hemodynamics and other indicators of homeostasis. Naturally, the amount of assistance provided can vary widely: from resuscitation to simple dynamic monitoring of the patient;
- Providing assistance during endoscopic intervention or surgical intervention (if necessary);
- Timely detection of recurrent bleeding;
- In relatively rare cases - conservative treatment of bleeding.
Sequence of care
If the patient received anticoagulants prior to bleeding, they should be discontinued in most cases. Assess the severity of the condition and the estimated amount of blood loss based on clinical signs. Vomiting blood, loose stools with blood, melena, changes in hemodynamic parameters - these signs indicate ongoing bleeding. Arterial hypotension in the supine position indicates a large blood loss (more than 20% of the BCC). Orthostatic hypotension (a decrease in systolic blood pressure above 10 mm Hg and an increase in heart rate over 20 bpm when moving to a vertical position) indicates moderate blood loss (10-20% of the BCC);
In the most severe cases, tracheal intubation and mechanical ventilation may be required before endoscopic intervention. Perform venous access with a peripheral catheter of sufficient diameter (G14-18), in severe cases, install a second peripheral catheter or catheterize the central vein.
Take a sufficient volume of blood (usually at least 20 ml) to determine the group and Rh factor, combine blood and conduct laboratory tests: complete blood count, prothrombin and activated partial thromboplastin time, biochemical parameters.
Infusion therapy
Start infusion therapy with the introduction of balanced salt solutions.
Important! If there are signs of ongoing bleeding or unstable hemostasis is achieved, blood pressure should be maintained at the minimum acceptable level (SBP 80-100 mm Hg), i.e. infusion therapy should not be too aggressive. Blood transfusions are carried out if adequate infusion therapy fails to stabilize the patient's hemodynamics (BP, heart rate). Consider the need for blood transfusion:
With a decrease in hemoglobin levels below 70 g / l. with stopped bleeding;
With continued bleeding, when hemoglobin is below 90-110 g / l.
With massive blood loss (more than 50-100% of the BCC), transfusion treatment is carried out in accordance with the principles of "Hemostatic resuscitation". It is believed that each dose of red blood cells (250-300 ml) increases the level of hemoglobin by 10 g/l. Fresh frozen plasma is prescribed for clinically significant coagulopathy, including drug-induced coagulopathy (for example, the patient is receiving warfarin). And in case of massive blood loss (>50% of BCC). If reliable hemostasis is achieved, there is no need to administer FFP even with significant blood loss (more than 30% of BCC). Dextrans (polyglucin, rheopolyglucin), solutions (HES) can increase bleeding, and their use is not recommended.
Antisecretory therapy
Optimal conditions for the implementation of vascular-platelet and hemocoagulation components of hemostasis are created at pH > 4.0. Proton pump inhibitors and H2-histamine receptor blockers are used as antisecretory drugs.
Attention! It is not advisable to simultaneously prescribe H2-histamine receptor blockers and proton pump inhibitors.
Drugs of both groups suppress the production of hydrochloric acid in the stomach and thereby create conditions for stable hemostasis of the bleeding vessel. But proton pump inhibitors show more stable results in reducing gastric acidity and are much more effective in reducing the risk of rebleeding. The antisecretory effect of proton pump inhibitors is dose-dependent. Therefore, the use of high doses of drugs is currently recommended, so the regimens indicated below are not a mistake by the author.
Patients are given an IV infusion of one of the following proton pump inhibitors:
- (Losek) IV 80 mg as a loading dose, followed by 8 mg/hour.
- (Controloc) 80 mg IV as a loading dose, followed by 8 mg/hour.
- (Nexium) IV 80 mg as a loading dose, followed by 8 mg/hour.
The loading dose of the drug is administered in about half an hour. Intravenous administration of the drug is continued for 48-72 hours, using, depending on the possibilities, a bolus or continuous route of administration. In the following days, they switch to oral administration of the drug at a daily dose of 40 mg (for all of the proton pump inhibitors listed in this paragraph). The approximate duration of the course is 4 weeks.
Attention. The introduction of proton pump inhibitors should be started before endoscopic intervention, as this reduces the likelihood of rebleeding.
In the absence of proton pump inhibitors, or their intolerance by patients, intravenous H2-histamine receptor blockers are prescribed:
- Ranitidine 50 mg IV every 6 hours or 50 mg IV followed by 6.25 mg/hour IV. Three days later, inside 150-300 mg 2-3 times a day;
- Famotidine IV drip 20 mg every 12 hours. Inside for the purpose of treatment, 10-20 mg 2 times / day or 40 mg 1 time / day are used.
Preparation for gastroscopy
After relative stabilization of the patient's condition (SBP more than 80-90 mmHg), an endoscopic examination is required, and if possible, determine the source and stop bleeding.
To facilitate gastroscopy against the background of ongoing bleeding, the following technique allows. 20 minutes before the intervention, the patient is given intravenous erythromycin by rapid infusion (250-300 mg of erythromycin is dissolved in 50 ml of 0.9% sodium chloride solution and administered over 5 minutes). Erythromycin promotes rapid evacuation of blood into the intestines, and thus facilitates finding the source of bleeding. With relatively stable hemodynamics, for the same purposes, intravenous administration of 10 mg of metoclopramide is used.
In patients with valvular heart disease, antibiotic prophylaxis is recommended before gastroscopy. Sometimes, to remove blood clots from the stomach (to facilitate endoscopic examination), a large diameter gastric tube (24 Fr or more) is required. Gastric lavage is recommended to be carried out with water at room temperature. After the end of the procedure, the probe is removed.
The use of a gastric tube for the purpose of diagnosis and control of bleeding (if endoscopic examination is possible), in most cases, is considered inappropriate.
Further tactics
Depends on the results of the endoscopic examination. Below we consider the most common options.
Bleeding from the upper GI tract
Peptic ulcer of the stomach, duodenum, erosive lesions
Bleeding classification (based on the Forrest classification)
I. Continued bleeding:
a) massive (jet arterial bleeding from a large vessel)
b) moderate (bleeding blood from a venous or small arterial vessel quickly fills the source after washing it off and flows down the intestinal wall in a wide stream; jet arterial bleeding from a small vessel, the jet nature of which periodically stops);
c) weak (capillary) - a slight leakage of blood from a source that can be covered by a clot.
II. Past bleeding:
a) the presence in the source of bleeding of a thrombosed vessel, covered with a loose clot, with a large amount of altered blood with clots or contents such as "coffee grounds";
b) a visible vessel with a brown or gray clot, while the vessel may protrude above the bottom level, a moderate amount of content such as "coffee grounds".
c) the presence of small point thrombosed brown capillaries that do not protrude above the bottom level, traces of contents such as "coffee grounds" on the walls of the organ.
Currently, combined (thermocoagulation + application, injections + endoclipping, etc.), which has become the de facto standard, endohemostasis provides an effective stop of bleeding in 80-90% of cases. But far from all institutions where patients with ulcerative bleeding are admitted, there are the necessary specialists.
Attention. With continued bleeding, its endoscopic stop is indicated, if it is ineffective, stop the bleeding by surgery.
If surgical hemostasis is not possible
Quite often there are situations when it is not possible to perform both endoscopic and surgical hemostasis. Or they are contraindicated. We recommend the following amount of therapy:
Prescribe proton pump inhibitors. And in their absence - blockers of H2-histamine receptors.
In the treatment of erosive and ulcerative bleeding, especially with a slow release of blood (type Forrest Ib), a good effect is the use of sandostatin () - 100 mcg IV bolus, then 25 mcg / h until the bleeding stops, and preferably within two days .
With continued bleeding, one of the following fibrinolysis inhibitors is simultaneously prescribed for 1-3 days (depending on the control endoscopy data):
- aminocaproic acid 100-200 ml of 5% intravenous solution for 1 hour, then 1-2 g / h until bleeding stops;
- tranexamic acid - 1000 mg (10-15 mg / kg) per 200 ml of 0.9% sodium chloride 2-3 times a day;
- (Kontrykal, Gordox, Trasilol) in comparison with the previous drugs, has less nephrotoxicity, lower risk of venous thrombosis. Because of the risk of allergic reactions (0.3%), 10,000 IU IV is administered initially. For the same reasons, the drug is now rarely used to treat bleeding. In the absence of a reaction, 500,000 - 2,000,000 IU are injected intravenously in 15-30 minutes, then infusion at a rate of 200,000 - 500,000 IU / h until bleeding stops;
Recombinant activated human coagulation factor VIIa (rFVIIa) (Novo-Seven) at a dose of 80-160 mg/kg IV is prescribed if other therapy is ineffective. Significantly increases the risk of thrombosis and embolism. In case of significant coagulopathy, before its administration, the deficiency of coagulation factors should be replenished by transfusion of fresh frozen plasma in a volume of at least 15 ml / kg / body weight. The drug is quite effective even with severe bleeding. But, due to the high cost, its widespread use is impossible.
Attention. Etamsylate (dicynone), often prescribed in patients with bleeding, is in fact completely ineffective. Actually, the drug does not have any hemostatic effect at all. It is intended for the treatment of capillaropathy as an adjuvant.
With erosive lesions, mucosal ruptures (Mallory-Weiss syndrome) and (or) the ineffectiveness of the above therapy, they are used intravenously as a bolus at a dose of 2 mg, and then intravenously at 1 mg every 4-6 hours until bleeding stops. Vasopressin is just as effective, but has more complications. Vasopressin is administered using a drug dispenser into a central vein according to the following scheme: 0.3 IU / min for half an hour, followed by an increase of 0.3 IU / min every 30 minutes until bleeding stops, complications develop, or the maximum dose is reached - 0.9 IU/min. As soon as the bleeding has stopped, the rate of drug administration begins to decrease.
Perhaps the development of complications of therapy with vasopressin and terlipressin - ischemia and myocardial infarction, ventricular arrhythmias, cardiac arrest, ischemia and infarction of the intestine, skin necrosis. This type of treatment should be used with extreme caution in peripheral vascular disease, coronary heart disease. Vasopressin is administered against the background of cardiac monitoring. The infusion is reduced or stopped if angina pectoris, arrhythmias, or abdominal pain occur. Simultaneous intravenous administration of nitroglycerin reduces the risk of side effects and improves treatment outcomes. Nitroglycerin is prescribed if systolic blood pressure exceeds 100 mm Hg. Art. The usual dose is 10 micrograms / min IV with an increase of 10 micrograms / min every 10-15 minutes (but not more than 400 micrograms / min) until systolic blood pressure drops to 100 mm Hg. Art.
The bleeding has stopped. Further therapy
Continue the introduction of the above antisecretory drugs. The probability of rebleeding after endoscopic or medical arrest is about 20%. For timely diagnosis, dynamic monitoring of the patient is carried out (hourly blood pressure, heart rate, hemoglobin 2 times a day, repeated endoscopic examination every other day). Hunger is not indicated (unless surgical or endoscopic intervention is planned), usually 1 or 1a table is prescribed;
The introduction of a nasogastric tube to control bleeding, as mentioned above, is not indicated. But it is installed if the patient is not able to eat on his own and needs enteral nutrition. Prophylactic administration of antifibrinolytics is not indicated (aminocaproic and tranexamic acid, aprotinin).
It is believed that 70-80% of duodenal and gastric ulcers are infected with Helicobacter pylori. Eradication should be carried out in all patients who have this infection. That allows you to accelerate the healing of the ulcer and reduces the frequency of recurrence of bleeding. A common and fairly effective regimen is omeprazole 20 mg twice daily + clarithromycin 500 mg twice daily + amoxicillin 1000 mg twice daily. The duration of the course is ten days.
Bleeding from varicose veins of the esophagus or stomach due to portal hypertension
Lethality reaches 40%. In our country, endoscopic hemorrhage arrest (sclerotherapy, endoscopic knot ligation, etc.), surgical and endovascular interventions are relatively rare. More often, drug treatment, tamponade of varicose veins with a balloon probe, and operations are used. Note that the use of factor VIIa (rFVIIa) proved to be ineffective in these patients. The safest and most effective method of conservative therapy is considered to be intravenous administration of sandostatin (octreotide) - 100 mcg IV bolus, then 25-50 mcg/h for 2-5 days.
If therapy fails, terlipressin is prescribed intravenously at 2 mg, then 1-2 mg every 4-6 hours until bleeding stops, but not more than 72 hours. Technique: Perform local anesthesia of the nasopharynx with an aerosol of lidocaine. Before insertion, the probe is checked by inflating both balloons, lubricated with a conductive gel for ECG electrodes or glycerin (sometimes simply moistened with water), the balloons are folded around the probe and, in this form, are passed through the nasal passage (usually the right one) into the stomach. Sometimes the introduction of the probe through the nose is not possible and it is placed through the mouth. Then, 200-300 ml of water is injected into the distal (spherical) balloon, the entire probe is pulled up until resistance to movement appears, and carefully fixed in this position. After that, air is pumped into the esophageal balloon with a sphygmomanometer to a pressure of 40 mm Hg. Art. (unless the probe manufacturer recommends other air and water injection volumes or cylinder pressures).
Through the lumen of the probe, gastric contents are aspirated, i.e., dynamic control over the effectiveness of hemostasis is carried out, and feeding is carried out. It is necessary to control the pressure in the esophageal cuff every 2-3 hours. After the bleeding stops, the pressure in the balloon should be reduced gradually. The probe with the deflated balloon is left in place for 1-1.5 hours, so that when bleeding resumes, tamponade can be repeated. If there is no bleeding, the probe is removed. Ulceration and necrosis of the mucosa can occur quite quickly, so the duration of the probe in the esophagus should not exceed 24 hours, but sometimes this period has to be increased.
Patients are prescribed cefotaxime 1-2 g IV three times a day, or ciprofloxacin 400 mg IV 2 times a day - for the purpose of prevention. Liver failure is being treated. To prevent hepatic encephalopathy, give oral lactulose 30-50 ml every 4 hours.
Prevention of bleeding from varicose veins of the esophagus or stomach
The appointment of a non-selective beta-blocker (but not other beta-blockers) reduces the pressure gradient in the hepatic veins and reduces the likelihood of rebleeding. In this case, it is the effects of beta-2-blockade that are important, due to which there is a narrowing of the splanchnotic vessels, which leads to a decrease in blood flow and pressure in the varicose vessels of the esophagus and stomach.
An individual maximum tolerated dose is selected, which reduces the resting heart rate by approximately 25% of the initial level, but not lower than 50-55 beats per minute. The approximate starting dose is 1 mg / kg / day, divided into 3-4 doses.
Bleeding from the lower GI tract
The main causes of bleeding from the lower gastrointestinal tract are angiodysplasia, diverticulosis, inflammatory bowel disease, neoplasms, ischemic and infectious colitis, and diseases of the anorectal region. They are clinically manifested by bloody stools - the flow of scarlet or maroon blood from the rectum.
Diagnostic problems
Endoscopic diagnostics very often turns out to be ineffective, it is rarely possible to find the source of bleeding, and even more so, to stop the bleeding. However, this largely depends on the qualifications of the endoscopist. Angiography is used if the cause of bleeding cannot be determined after a colonoscopy. During surgery, it is also difficult to establish the source of bleeding. Sometimes there are multiple sources of bleeding (for example, inflammatory bowel disease).
Attention. Before surgery, FGS should be performed in order to exclude bleeding from the upper gastrointestinal tract.
Emergency surgery against the background of ongoing bleeding is accompanied by high mortality (~ 25%). Therefore persistent conservative treatment should be the main method of treatment of these patients.
Treatment:
- It is necessary to achieve stabilization of the state at the time of diagnostic measures.
- The scope of the survey is determined by the diagnostic capabilities of the health facility;
- Based on the results obtained, try to establish the cause of bleeding. Then the treatment will be targeted;
- If the exact cause of bleeding is unclear, measures are taken to maintain systemic hemodynamics, using hemostatics.
Emergency surgery is indicated:
- with continued bleeding and the development of hypovolemic shock, despite ongoing intensive therapy;
- with ongoing bleeding that requires a transfusion of 6 or more doses of blood per day;
- if it was not possible to establish the cause of bleeding after performing a colonoscopy, scintigraphy or arteriography;
- when establishing an accurate diagnosis of the disease (with colonoscopy or arteriography), the best treatment for which is surgery.
There are a lot of reasons why gastrointestinal bleeding can occur, they can complicate several hundred diseases. With this pathology, blood is poured directly into the lumen of the gastrointestinal tract. Do not confuse with abdominal bleeding, when, with damage to the organs of the digestive system, blood flows into the abdominal cavity.
Causes
Esophageal varices are a common cause of gastrointestinal bleeding.Depending on the source, bleeding from the upper and lower gastrointestinal tract is isolated, such a division is necessary, since the symptoms of the pathology, methods of diagnosis and treatment can differ significantly.
Bleeding from the upper GI tract:
- and (up to 70% of requests);
- esophagitis (inflammation of the esophagus, including as a result of burns);
- Mallory-Weiss syndrome (superficial damage to the mucous membrane of the esophagus as a result of repeated severe vomiting, coughing, overeating, sometimes even hiccups);
- , and the duodenum.
There are also many other causes that are quite rare.
Bleeding from the lower GI tract:
- tumors and polyps;
- infectious colitis,;
- damage to the intestinal walls by foreign bodies;
- complications of infectious diseases (typhoid fever, cholera, etc.);
- and etc.
In the practice of a surgeon, bleeding from the lower part of the gastrointestinal tract is somewhat less common than from the upper part. One of the causes of bleeding from any source, including the organs of the digestive system, may be blood diseases, in which its coagulability decreases.
Symptoms of gastrointestinal bleeding
The signs of this pathology are very diverse, it is often not possible to reliably establish the source of bleeding from them, this requires additional instrumental diagnostics.
Common signs of blood loss
The first non-specific symptoms may be:
- growing weakness;
- dizziness;
- fainting;
- blanching of the skin and mucous membranes;
- strong thirst;
- the appearance of cold sticky sweat;
- increased heart rate;
In severe cases, shock may develop.
If the bleeding is small, then the symptoms will increase slowly, if it is strong, then its external signs will appear pretty soon. If a person is known to suffer from any chronic gastrointestinal disease, if such complaints appear, you should immediately consult a doctor.
Vomit
After some time, which depends on the intensity of bleeding, the patient may vomit. Its color resembles the color of coffee grounds (this color of vomit is the result of a chemical reaction of blood components with gastric juice and hydrochloric acid). The appearance of vomiting "coffee grounds" indicates that the bleeding has been going on for several hours, and the stomach already contains about 150-200 ml of blood.
Vomiting with an admixture of scarlet unchanged blood may indicate bleeding from the veins of the esophagus, and a combination of “coffee grounds” and “fresh” blood is possible, since part of it drains into the stomach, and part goes up. Or it can be profuse bleeding from the stomach or duodenum, when the blood does not have time to mix with the contents of the stomach and comes out unchanged. Such a patient must be urgently delivered to the hospital, otherwise he may die.
Change of stool
The color and consistency of the stool also depends on the intensity and duration of the onset of bleeding. The appearance of changes in the stool indicates that the bleeding has been going on for at least several hours. With little bleeding, the color of the feces can change only the next day, or it may even remain the same, and the presence of blood in the feces can only be detected with the help (Gregersen's reaction).
With such bleeding, darkening of the feces can be observed, it can become black, but remain dense. Abundant blood loss is accompanied by the appearance of a black, tarry stool, called melena.
The appearance of red blood in unchanged stool in the absence of vomiting and general signs of blood loss in most cases indicates bleeding from hemorrhoids or anal fissure. This condition of the patient's life is not threatened, but, of course, it requires treatment.
The patient, along with general nonspecific symptoms, may have vomiting and changes in the stool, only one of these signs may appear.
First aid for gastrointestinal bleeding
When symptoms of gastrointestinal bleeding appear, the patient should be hospitalized in a hospital in a short time. When symptoms of this formidable complication appear, it is necessary to deliver the patient to the hospital as soon as possible. If this is not possible, you need to call an ambulance, be sure to inform the dispatcher that the person may be bleeding.
Before the arrival of the ambulance, the patient must be laid on a flat surface and lift his legs. Any physical activity is excluded.
Ice should be placed on the area of the alleged bleeding (through a towel or several layers of tissue), this will help slow down blood loss due to vasoconstriction.
Many patients suffering from chronic diseases of the gastrointestinal tract, which can suddenly become complicated by bleeding, are warned by the doctor about the need to keep some hemostatic drugs in the home medicine cabinet. The most common are aminocaproic acid and 10% calcium chloride solution. If such drugs are at hand, then you can give the patient to drink 30-50 ml of aminocaproic acid or one or two ampoules of calcium chloride.
Prevention
The described pathology never occurs on its own - it is always a complication of a disease, less often an injury. All patients suffering from chronic diseases of the digestive system (and in most cases this is a peptic ulcer) should regularly undergo preventive examinations with a doctor, take tests as prescribed and perform endoscopic studies.
In the presence of such diseases, it is imperative to constantly follow the diet recommended by the doctor, since in many cases the cause of the exacerbation of the disease and the occurrence of complications is precisely the error in nutrition and alcohol consumption.
Which doctor to contact
If symptoms of gastrointestinal bleeding appear, the immediate help of a surgeon is needed. After it stops, treatment by a gastroenterologist, proctologist, oncologist is necessary. In some cases, a consultation with a hematologist is required.