GASTROINTESTINAL BLEEDING — the bleeding from bodies of digestive tract which is characterized by a clinical syndrome which can include a hematemesis, a tar-like chair and symptoms of acute blood loss
. - to. to. were known in an extreme antiquity. The first message on the bleeding stomach ulcer was made by A. Littre in 1704
Distinguish acute and hron, bleedings; explicit, shown a hematemesis and a tar-like chair, and hidden which decide only on the help of the analysis of contents went. - kish. a path on impurity of blood; single and recurrent.
Depending on degree of blood loss and depth patol, changes in an organism. - to. to. divide on severity.
Easy degree — the quantity of erythrocytes are higher 3 500 000, the level of hemoglobin is more than 10 g %, the gematokritny number is higher than 30%, pulse rate to 80 beats/min, systolic the ABP is higher than 110 mm of mercury.; deficit of the volume of the circulating blood (VCB) to 20%.
Average degree — the quantity of erythrocytes 2 500 000 — 3 500 000, level of hemoglobin is 8 — 10 g of %, gematokritny number 25 — 30%, pulse rate of 80 — 100 beats/min, systolic the ABP of 100 — 110 mm of mercury., deficit of OTsK from 20 to 30%.
Heavy degree — the quantity of erythrocytes less than 2 500 000, level of hemoglobin is lower than 8 g of %, the gematokritny number is lower than 25%, pulse rate is higher than 100 beats/min, systolic the ABP is lower than 100 mm of mercury., deficit of OTsK of 30% and more. The heavy bleeding which is followed by massive blood loss call profuse.
Reasons. - to. to. are diverse. The bleeding point can be localized in any body went. - kish. path. The most widespread diseases which course becomes complicated. - to. to. — acute and hron, stomach ulcer and a duodenum, hemorrhagic gastritis, Mallori's syndrome — Weiss, nonspecific ulcer colitis, diverticulums went. - kish. a path, hemorrhoids, specific diseases of a stomach and intestines (tuberculosis, syphilis, an actinomycosis), benign and malignant tumors went. - kish. a path, a varicosity of a gullet and stomach at portal hypertensia, an idiopathic hypertensia, hemobilias (see), infectious diseases, general diseases of blood, acute fibrinolysis, etc. Hard proceeding allergic reactions, bruises, burns of a stomach and intestines are also followed. - to. to.
At children. - to. to. it is, as a rule, caused by hemorrhagic diathesis of newborns, paraezofagealny hernia, an erosion of a mucous membrane of a diverticulum of a small bowel (see. Mekkelya diverticulum ). They can develop owing to inborn arteriovenous shunts, an inborn hemorrhagic angiomatosis — a disease of Randyu — Oslera. Angiomatous changes at this disease can be localized in thin and direct guts. Can be the cause of bleeding at children progressing polyposes of intestines with regeneration that is the cornerstone of Peytts's syndrome — Egersa, an abdominal form of a hemorrhagic vasculitis — Shenleyn's disease — Genokh, a Werlhof's disease — Verlgof's disease. At children 5 years the same as at adults are aged more senior, bleedings from acute stomach ulcers and a duodenum can take place and at hemorrhagic gastritis; they have stressful character and arise against the background of acute respiratory diseases or hormonal therapy.
== Pathological physiology ==. - to. to. are followed by blood loss of various degree and cause considerable patofiziol, and patomorfol, changes in an organism which weight depends on rate of bleeding and volume of blood loss. At deficit of OTsK (30% and more) the ABP, the central venous pressure, speed of a blood-groove decreases, tachycardia accrues, there is a hypoxia of a myocardium and brain. Changes of a liver develop funkts, and morfol. The amount of protein of plasma, albumine decreases and relatively the number of globulinovy fractions increases. Prothrombin activity of a blood plasma and amount of fibrinogen, content of calcium, chlorides, potassium and sodium of blood decreases. Decrease in catecholamines of blood demonstrates oppression of activity of sympathoadrenal system. The specified shifts and sudden falling of OTsK, development of shock cause disturbance of microcirculation in a liver, heart, kidneys and lead to disturbance of their functions. In aggravation of weight of bleeding intoxication as a result of absorption of decomposition products of the blood which streamed in intestines has essential value.
The clinical picture is various. At easy degrees of bleeding only dizziness, weakness, insignificant pallor can be observed; at massive bleedings — a collapse, sharp falling of cordial activity and sudden death. At gastric and duodenal bleeding emetic masses reminds a coffee thick more often (see. Hematemesis ). Vomiting can be single and repeated. Melena (see) it is characteristic of bleedings from upper parts went. - kish. path. The dark red blood which is evenly mixed with excrements takes place at bleeding from a small bowel. Not changed scarlet blood not mixed with excrements is more characteristic of bleeding from lower parts of a large intestine (tsvetn. fig. 2).
Symptoms of blood loss (weakness, dizziness, heartbeat, perspiration, disturbances of consciousness, decrease in the ABP etc.) are defined by degree and duration of bleeding (see. Blood loss ). At children even insignificant. - to. to. are followed by accurately expressed symptoms of blood loss.
the Diagnosis is based on data of the anamnesis, symptoms of blood loss and results of a research by means of additional methods of a research. At the same time existence of bleeding, its weight, the reason and localization of a bleeding point is established. Define quantity of erythrocytes, hemoglobin, OTsK, level of crude protein, protein fractions, carry out the analysis a calla on the occult blood and emetic masses on blood.
Besides, the tracer technique with marked radioactive chrome can be used ( 51 Cr) erythrocytes. The method is based that the erythrocytes entered into a blood channel, marked radioactive chrome, normal practically do not get to a gleam went. - kish. path. Having got at bleeding to a gleam went. - kish. a path, radioactive chrome reabsorbirutsya in small degree and is emitted with a stake. Finding in Calais of a certain amount of radioactive chrome proves existence of bleeding. By quantity 51 Cr in 1 ml of blood and to quantity it in Calais calculate the size of blood loss.
Indications to use of this method are diagnosis hidden. - to. to., assessment of size of blood loss at hidden and explicit. - to. to. in dynamics, establishment of constant or periodic nature of bleeding at suspicion of cancer of bodies went. - kish. a path, at anemias of not clear etiology when it is required to exclude hron, posthemorrhagic anemia as a result of existence of a bleeding point in the digestive channel.
Special training of the patient is not required. From a vein of inspected take 20 ml of blood in a geparinizirovanny centrifugal test tube. Add 200 — 300 mkkyur of drug of radioactive chrome and leave at the room temperature for 30 min. Centrifuge 15 min. at 1000 rpm. Suck away plasma, erythrocytes wash from not included in them twice 51 Cr fivefold volume fiziol, solution under the same conditions of centrifuging. The remained suspension of marked erythrocytes is intravenously entered to the patient and from the next day collected all allocated at it kcal (an indispensable condition of collecting a calla — an exception of hit in it of urine and menstrual blood). About 1 time in 3 days (for this term concentration 51 Cr in erythrocytes significantly does not change) take 10 ml of blood from a vein. Radioactivity of blood and a calla measure.
Calculation of amount of blood in the studied portion a calla is made on a formula: Kr = the Joint stock company/acre, where Kr - amount of blood in ml, Joint stock company — activity of a portion a calla, the Acre — activity of 1 ml of blood.
Single introduction of marked 51 Cr of erythrocytes allows to study to the loudspeaker Zh. - to. to. within several weeks. The concealed hemorrhage can be considered established in the presence in daily Calais quantities 51 Cr equivalent to more than 3 ml of blood.
Errors of a method can be connected with hit in kcal of urine, menstrual blood, inaccuracy of measurements. For an exception of mistakes in a wedge, the treatment should consider that the method is so sensitive that can reveal small bleeding from an oral cavity during the toothbrushing, as a result of statement of an enema, etc. The method of studying of blood loss with radioactive iron is less exact ( 59 Fe). The method can be applied at explicit gastric bleedings, but it is a little suitable for their emergency diagnosis. In these cases it can be useful to definition of OTsK by means of marked erythrocytes or albumine. Contraindications for use of tracer techniques — children's age and pregnancy.
The greatest difficulties for diagnosis. - to. to. represents definition of a bleeding point. For this purpose additional methods of a research serve: introduction to a stomach of the probe (see. Sounding of a stomach ), aspiration of contents with its research on impurity of blood. Detection of blood during the sounding of a stomach testifies to bleeding from upper parts went. - kish. path.
Emergency rentgenol, the research (roentgenoscopy of a stomach, an irrigoskopiya) in most cases allows to reveal a bleeding point. It is sometimes complicated because of accumulation of blood in a stomach or a large intestine. Therefore negative data rentgenol, researches at. - to. to. not finally exclude existence of a bleeding point in a stomach, a duodenal or large intestine.
In such cases crucial importance in establishment of a bleeding point is gained by data of an endoscopic research (see. Gastroscopy , Duodenoskopiya , Intestinoskopiya , Kolonoskopiya , Rektoromanoskopiya ). It allows to define the nature of the disease complicated by bleeding, rate of bleeding. The endoscopic research is shown to each patient with. - to. to. during the first hours after hospitalization, irrespective of these previous researches.
In extremely hard diagnostic cases at profuse. - to. to. diagnostic is acquitted laparotomy (see).
Sharply arising. - to. to. demand acute management. The patient shall be hospitalized in a surgical hospital where provide it rest, cold on a stomach and take measures for elimination of shock and a stop of bleeding. In the first 24 — 48 hours appoint a Meulengracht's diet (see. Clinical nutrition ), further — a table 1a with gradation to a table 1. Carry out correction of water and electrolytic balance, blood-substituting and styptic therapy, appoint vitamins, cardiovascular means.
At a gastromenia a number of authors recommends a gastric lavage solution of silver nitrate (1: 400) via the dvukhprosvetny probe. However this method was not widely adopted.
The amount of the transfused blood, proteinaceous drugs, liquid and electrolytes decides on the help of assessment of number of erythrocytes, level of hemoglobin, OTsK and its components, acid-base equilibrium, ionic composition of blood, the central venous pressure. At children, especially early age, blood loss shall be filled in the shortest possible time. Further treatment. - to. to. both at adults, and at children depends on character of a basic disease „At the most part of patients with ulcer bleeding it is possible to stop it by means of conservative actions.
About positive takes at gastric bleedings of a local artificial hypothermia (see. Hypothermia artificial, local ) B. A. Petrov (1967), Vangensten (O. reported H. Wangensteen, 1968). However the subsequent experience showed that efficiency of an artificial local hypothermia of a stomach at. - to. to. it is insignificant.
Thanks to improvement of the endoscopic equipment carrying out is possible to lay down. manipulations at. - to. to.: aim irrigation of the place of bleeding hemostatics (solution of calcium chloride, aminocaproic to - that high concentration, Ambenum, Haemophobinum, etc.); injections to the area of the center of bleeding of hemostatics (inhibitors of a fibrinolysis, proteases); introduction of sclerosing means to expanded veins of a gullet and stomach; applications of aerosol film-forming drugs on the bleeding site of a mucous membrane (lifuzol); diathermocoagulations of a bleeding point; electroscission of a polyp; influence by cold on a bleeding point; use of beams of optical quantum generators (lasers).
Methods to lay down. endoscopies are more often effective at bleedings from superficial damages of a mucous membrane went. - kish. path. Efficiency is lower than them at heavy hemorrhages, but at a number of seriously ill patients, especially advanced age with high risk of operation, to lay down.; endoscopy can be saving. At the same time the rational method and rate of hemotransfusion which shall be chosen individually is of great importance (a constant drop transfusion, a transfusion through the catheter which is carried out to a punktirovanny subclavial vein). Efficiency of conservative treatment is estimated on an all-wedge. to signs, on indicators of erythrocytes, hemoglobin, OTsK, the central venous pressure. However at massive blood loss (level of hemoglobin within 7 g of % and below) transfusion of 2 000 — 2 500 ml of blood does not provide rise in level of hemoglobin, a stable hemodynamics and recovery of OTsK.
If bleeding is not stopped by conservative actions, an urgent operative measure on condition of the authentic diagnosis is shown (e.g., ulcers, a resectable tumor, Mallori's syndrome — Weiss, etc.). The issue of an operative measure is resolved during the first, as much as possible second day from the beginning of bleeding.
At. - to. to. an ulcer origin several types of operations are applied: a resection of a stomach with removal of the bleeding ulcer; an economical resection of a stomach (antrectomy) with vagisection; vagisection with underrunning of an ulcer and a pyloroplasty; an obshivaniye of the main arteries of a stomach at contraindications to a resection of a stomach because of weight of a condition of the patient.
If during operation the surgeon does not find an ulcer at palpation of a stomach and duodenum, then for their audit the longitudinal gastroduodenotomiya is shown.
At profuse. - to. to. and a serious general condition of the patient with the only attempt of rescue of the patient at authentically established diagnosis of the bleeding stomach ulcer or a duodenum the emergency operative measure is, a cut it has to be combined with simultaneous massive hemotransfusions and holding resuscitation actions. Sometimes in such cases the positive effect is brought by so-called palliative operations — wedge-shaped excision of stomach ulcer, underrunning of blood vessels around an ulcer.
The serious condition of the patient owing to a helcomenia of a duodenum, especially in the presence of associated diseases, and at persons of advanced and senile age, the is higher risk of a resection of a stomach. The encouraging results are received at use of operation of underrunning for them of the bleeding ulcer, pyloroplasty (see) and trunk vagisections (see). This intervention has perspective value at the heaviest contingent of patients.
In case of efficiency of resuscitation actions, but at the proceeding helcomenia of a stomach and duodenum at young patients the most radical intervention — s antrectomy with vagisection. This operation reliably stops bleeding, cures of an ulcer and shortcomings of a high resection of a stomach of the remote period are to a lesser extent inherent in it (e.g., a dumping syndrome, etc.).
At hemorrhagic or erosive gastritis the resection of a stomach does not provide a stop of bleeding from the remained its part. More effective intervention is trunk subphrenic vagisection and a pyloroplasty. Vagisection causes reduction of inflow of blood to a stomach and its redistribution between a mucous membrane and a submucosa.
At persistent bleedings from varicose expanded veins of a gullet and the cardia make bandaging of veins of a gullet or Tanner's operation (see. Portal hypertensia ).
At children at height of profuse bleedings carry out intensive haemo static care, in a cut the important place is taken by direct hemotransfusions, reception of vitamins. At hemorrhagic diathesis also administration of Vikasolum is important. In the absence of effect of conservative treatment an operative measure is carried out, indications to Krom at children are defined strictly individually. At a peptic ulcer of a stomach and duodenum apply an economical resection of a stomach or excision of an ulcer, combining this operation with a pyloroplasty and vagisection.
Bibliography: Bratus V. D. Acute gastric bleedings, Kiev, 1972, bibliogr.; Gorbashko A. I. Acute gastrointestinal bleedings, l., 1974, bibliogr.; Mosquitoes B. D., Kushunin V. V. and Teryaev V. G. Sindr Mallori — Weiss, Surgery, No. 11, page 127, 1974, bibliogr.; Kossyura M. B. Stomach diseases at children, M., 1968, bibliogr.; Mazurin A. V. A Werlhof's disease (Verlgof's disease) at children, M., 1971, bibliogr.; Mistakes and difficulties in diagnosis of casuistic cases in surgery, under the editorship of V. A. Zhmur, page 66, M., 1972, bibliogr.; Patsiora M. D., Tsatsanidik. N and Eramishan-ts of e in A. K. Bleedings from varicose veins of a gullet and a stomach, M., 1971, bibliogr.; Pugachev A. G., etc. Portal hypertensia at children, M., 1971, bibliogr.; B. S rose trees. Gastric bleedings and their surgical treatment, M., 1960, bibliogr.; The guide to an urgent surgery of abdominal organs, under the editorship of V. S. Savelyev, M., 1976; Salm of M. M An. Urgent X-ray inspection in clinic of acute gastroduodenal bleedings, M., 1963, bibliogr.; V. I. pods, etc. Gastrointestinal bleedings and fibroendoskopiya, M., 1977, bibliogr.; Jones P. F. Emergency abdominal! surgery in infancy, childhood and adult life, Oxford, 1974, bibliogr.; M a with k b at M. of J. The surgical treatment of portal hypertension bleeding esophageal varices and ascites, Springfield, 1960; Urgent endoscopy of digestive and abdominal diseases, ed. by Z. Maratka a. J. Setka, Basel — N. Y., 1972.
V. A. Ageychev, G. A. Pokrovsky; A. T. Pulatov (ped.), And. 3. Tsfasman (I am glad.).