Catad_tema Peptic ulcer - articles

Catad_tema Coagulopathies and bleeding - articles

Gastrointestinal bleeding

Gastrointestinal bleeding (GIB) is one of the most common causes emergency hospitalization to 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 up. With more massive blood loss, accompanied by severe hypovolemic disorders, adaptation mechanisms are not able to compensate for hemodynamic disorders. Hypotension occurs in a supine position and vascular collapse develops. 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, pallor of the 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. In case of stopped gastrointestinal tract, when the deficit of bcc is replenished with saline solutions, it is advisable to transfuse red blood cells to restore the oxygen capacity of the blood and relieve a high degree of hemodilution. 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 must receive infusion therapy until his condition stabilizes; 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 so-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 of gastrointestinal bleeding

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 negative result aspiration 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). However, the diagnosis of gastrointestinal tract infections is often very difficult, especially in the first hours after the onset of the disease, when the patient is already in in serious condition, but there is no bloody vomiting and no tarry stools have appeared yet. 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 an increase in the proportion of elderly and old age 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 is admitted 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 proton pump inhibitors is justified, 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

The key to correct diagnosis Even before endoscopic examination, a well-collected medical history can help. 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 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 abdominal cavity may detect tenderness (peptic ulcer), splenomegaly (liver cirrhosis or splenic vein thrombosis), stomach tumor. Intraperitoneal bleeding (for example, with impaired ectopic pregnancy) sometimes manifests itself with signs of acute anemia similar to gastrointestinal tract. 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 intestines from the upper gastrointestinal tract.

The most important information is provided by esophagogastroduodenoscopy (EGD); it allows not only high degree accurately determine the location of the source of bleeding and its nature, but also 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 they do not have much practical significance, 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 reason for GDP is portal hypertension, arising as a result of 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 GDP is the most important factor reducing mortality in gastrointestinal tract infections. First aid consists of long-term (1-2 days) tamponade of veins 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 in case of emergency up 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 operations, the frequency 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 when 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 are especially dangerous on back wall duodenal bulbs, as they can cause massive arterial bleeding as a result of arrosion of the branches of the large gastroduodenal artery passing in this zone.

According to widespread endoscopic classification ulcerative bleeding according to Forrest, are distinguished:
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 of endoscopic signs of 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 the bleeding through an endoscope by monoactive or bipolar electrocoagulation using current are justified high frequency, photocoagulation with an argon or YAG-neodymium laser, by argon-plasma coagulation with ionized gas or puncture of an ulcer ethyl alcohol Good results are obtained by irrigating a 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.

When bleeding has stopped high risk relapse (IIA according to Forrest), emergency surgery is indicated in the next 24 hours, usually in the morning of the next day. The most justified surgical tactics for a bleeding gastric ulcer - 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 hemostasis. 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 a rather large 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 by a congenital malformation of blood vessels. 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 a stressful condition in patients with sepsis, burns, severe concomitant trauma, peritonitis, acute respiratory failure, myocardial infarction, as well as after severe surgical interventions in the 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. The preventive and therapeutic parenteral use of antacids and H-blockers, gastric lavage with ice-cold solutions, irrigation of the mucous membrane with caprofer solution during endoscopy, intravenous administration of hemostatic agents, fibrinolysis and vasopressin inhibitors, transfusion of fresh blood and platelet mass are important.

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 ulcerative bleeding, but the stool may become dark color. The diagnosis is established or clarified by endoscopy. With advanced cancers, erased, atypical symptoms are possible. 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 is more common with such benign tumors, such as leiomyoma, neurofibroma, etc. Moreover, they may 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 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)

Abdominal palpation and digital examination anus mandatory for 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, which are effective in oncological diseases colon is 60%. If you have tarry stools, which can be a consequence of both gastroduodenal bleeding and bleeding from 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. Contrast X-ray examination methods (irrigoscopy and irrigography) are not able to identify the source of bleeding, but can help in the diagnosis of tumors, 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 by a sedentary lifestyle, 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 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(nonspecific 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. In the diagnosis and differential diagnosis of colitic bleeding important role Colonoscopy plays a role in identifying differences in endoscopic manifestations individual diseases. Helps clarify the diagnosis morphological study biopsies of the intestinal wall.

Embolism and thrombosis of mesenteric vessels with atherosclerotic 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 lesions) can be the causes acute disorders mesenteric circulation, ischemic lesions and hemorrhagic intestinal infarction, manifested by the release of a fairly large amount of altered blood. Such bleeding is characterized by a pronounced pain syndrome preceding it, nausea, vomiting, 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 superior mesenteric artery, infarction and necrosis of the entire small intestine and the right half of the colon are possible; 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 precisely 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 video colonoscopy with high resolution, making 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 a false urge to defecate, 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 an irregular plexus, 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, treatment tactics require 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. By radical method treatments are different kinds 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. Clinical picture is very similar to the manifestations of acute appendicitis; the diagnosis in most patients is established 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 stool - definitely dangerous symptoms, which always indicate probable gastric bleeding. Doctors use the term GI bleeding - gastrointestinal bleeding. This summarizes all cases of blood loss from the 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 for a 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 this 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)

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)

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, dense 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)

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 in this case The tactics are the same as for minor blood loss from the esophagus or stomach. Traces of blood are found in laboratory analysis feces

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. In some pathologies, instrumental diagnostic methods become therapeutic, since with their help it is possible to eliminate the source of bleeding.

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 surgical department or in the intensive care ward 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 diseases intestines, 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.

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

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

Statistical classification

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

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

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

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

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

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

What are the types of intestinal bleeding?

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

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

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

Causes

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

To the first group should be added:

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

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

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

The group of non-ulcer diseases should include:

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

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

Symptoms and features

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

It is necessary to remember about the possibility of stool becoming darker in color when treated with iron, bismuth, or taking activated carbon. Some products can lead to a suspicious manifestation: blueberries, chokeberries, pomegranate, black currants.

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

Pain syndrome is caused by spasmodic contractions of the intestines

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

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

For colorectal cancer

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

For nonspecific ulcerative colitis

The patient complains of a false urge to defecate. The stool is watery and contains blood, pus and mucus. Prolonged course of the disease can contribute to anemia.

For Crohn's disease

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

For hemorrhoids

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

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

For rectal fissure

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

Intestinal bleeding in childhood

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

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

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

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

How to provide first aid?

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

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

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

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

Treatment

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

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

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

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

The issue of using surgical treatment when a disintegrating tumor or bleeding polyp is identified is resolved routinely after preparing the patient.

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

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

How to eat after bleeding

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

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

Rehabilitation period

After intestinal bleeding, it takes time to restore the integrity of the intestines, healing of ulcers and cracks. That's why strict diet must be observed for at least six months; any physical activity is prohibited.

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

When stomach bleeding occurs, symptoms may include varying degrees severity depending on the underlying disease and the severity of its course. This phenomenon is considered a serious complication of a number of diseases that requires taking urgent measures. Large blood losses can be life-threatening, and therefore knowledge of first aid techniques will help to avoid tragic consequences. It is important to strictly observe prohibitions on the use of a number of products, because it is not proper nutrition often provokes pathology.

The essence of the problem

Gastrointestinal bleeding is the effusion of blood into the lumen of the intestines or stomach. This phenomenon is not considered an independent disease, but usually expresses pathognomonic signs of different origins. It has been established that bleeding into the stomach can occur with the development of more than 100 various diseases, and therefore a problem often arises in terms of making a diagnosis.

In order to understand the mechanism of intestinal bleeding, you need to become familiar with the anatomy of the organ. The human stomach is a kind of hollow “bag” into which food enters from the esophagus, where it is partially processed, mixed and sent to the duodenum. The organ consists of several sections:

• entrance section, or cardia;
• gastric fundus (in the form of a vault);
• body;
• (transition of the stomach into the duodenum).

The gastric wall has a three-layer structure:

• mucous membrane;
• muscle layer;
• outer shell of connective tissue.

The volume of the stomach in adults is usually 0.5 liters and expands to 1 liter when eating.

The blood supply to the stomach is provided by arteries passing along the edges - on the right and left. Numerous small branches branch off from the large ones. In the area of ​​the cardia there is a venous plexus. Bleeding is possible if any of the listed vessels are damaged. The most common source of intestinal bleeding can be the venous plexus, since for a number of reasons the veins dilate, which increases the risk of damage.

Types of pathology

Depending on the etiological mechanism, there are 2 main types of gastric bleeding: ulcerative (occurring from a stomach ulcer) and non-ulcerative. According to the nature of the pathology, acute and chronic form. In the first case, internal bleeding develops very quickly with intense blood loss, which requires urgent medical measures. The chronic clinic is characterized by a long course with small constant leaks of blood into the gastric lumen.

Taking into account the severity of the phenomenon, 2 types are distinguished: obvious and hidden bleeding. In the first option, all signs of gastric bleeding are intense and easily detected. A latent course is characteristic of a chronic process, while the definition of the disease is hampered by the absence of pronounced symptoms, and the presence of pathology, as a rule, is indicated only indirect signs, in particular the pallor of a person. According to the severity of the manifestation, the following degrees are distinguished: mild, moderate and severe.

The clinical picture of intestinal bleeding also depends on the location of the source of hemorrhage. The following main options are distinguished:

1. Bleeding in the upper part of the gastrointestinal tract: esophageal, gastric, duodenal.
2. Bleeding in the lower sections: small, large and rectal.

Etiology of the phenomenon

Most often, the causes of gastric bleeding are associated with the development of peptic ulcers in the organ itself or the duodenum. They are recorded in almost every fifth sick person with this pathology. In this case, direct damage occurs blood vessels gastric juice or complications develop in the form of blood clot formation, leading to rupture of the vessel.

The problem under consideration can also be caused by reasons not related to peptic ulcer:

• erosion of the gastric mucosa;
• ulcers caused by injuries, burns, surgical intervention(so-called stress ulcers);
• ulcers caused by a long course of treatment using potent drugs;
• Mallory-Weiss syndrome, i.e. damage to the mucous membrane due to intense vomiting;
• ulcerative colitis;
• tumor formations, polyps;
• Gastric diverticulum, caused by a protrusion of the stomach wall;
• diaphragmatic hernia associated with protrusion of part of the stomach into the abdominal cavity.

Causes due to disruption of the structure of blood vessels are also recorded:

• the formation of atherosclerotic plaques in the vascular walls;
• vascular aneurysms;
• venous expansion in portal hypertension due to liver dysfunction;
• connective tissue diseases: rheumatism, lupus erythematosus;
• systemic vasculitis: periarteritis nodosa, Henoch-Schönlein purpura.

Sometimes the cause of bleeding is a bleeding disorder. The main pathologies of this type include thrombocytopenia and hemophilia. In addition, blood loss can be caused by mechanical trauma when a solid body enters the stomach, as well as infectious lesions- salmonellosis, dysentery, etc.

Symptomatic manifestations

There are several groups of signs of bleeding in the stomach. For any internal bleeding V human body General symptoms develop:

• pale skin;
• general weakness and apathy;
• cold sweating;
• arterial hypotension;
• the appearance of a rapid but weakened pulse;
• dizziness;
• noise in ears;
• confusion and lethargy.

With intense blood loss, a person may lose consciousness.

Pathognomonic signs of the phenomenon under consideration include vomiting and defecation with blood. Bleeding can be determined by the characteristic appearance of the vomit: it resembles “coffee grounds.” In this case, blood is released that was affected by acid in the stomach. At the same time, in case of bleeding from the esophagus or severe damage to the gastric arteries, scarlet, unchanged blood may be released in the vomit. Blood impurities in the stool give it the appearance of a tarry substance.

The severity of a sick person’s condition with gastric bleeding is assessed according to 3 degrees:

1. A mild degree is determined when the patient’s general condition is satisfactory. Slight dizziness is possible, pulse is up to 76–80 beats per minute, pressure is not lower than 112 mm Hg.
2. The average degree is established in the presence of pronounced pallor of the skin with cold sweating. The pulse may increase to 95–98 beats, and the pressure may drop to 98–100 mmHg.
3. Severe degree requires assistance emergency assistance. It is characterized by such a sign as obvious inhibition. The pulse exceeds 102 beats, and the pressure drops below 98 mm Hg.

If treatment is not carried out or carried out incorrectly, the pathology progresses quickly.

Providing emergency assistance

With the development of acute gastric bleeding, symptoms increase very quickly. If you don't start timely treatment, then the consequences can become very serious. At sharp deterioration human condition, severe weakness and pallor, clouding of consciousness, the appearance of vomiting in the form of " coffee grounds“It is necessary to urgently call an ambulance.

Before doctors arrive, first aid for gastric bleeding is provided. How to stop blood loss in an emergency? Complete rest and ice compress are provided. The patient is placed in supine position with slightly raised legs. Ice is placed in the abdominal area. At difficult circumstances An intramuscular injection of calcium gluconate and Vikasol is performed. It is possible to use Dicynon tablets.

Principles of pathology treatment

Treatment of gastric bleeding is aimed at combating the underlying disease and eliminating the symptom itself and its consequences. It can be carried out conservatively or operational methods depending on the type of pathology and the severity of its course.

Treatment is based on the following principles:

1. With mild damage. A strict diet is provided for gastric bleeding, an injection of Vikasol is prescribed, calcium-based drugs are taken, as well as vitamins.
2. With moderate severity. Treatment includes endoscopy with chemical or mechanical impact to the source of bleeding. Blood transfusion is possible.
3. In case of severe pathology. Emergency services are provided resuscitation measures and usually surgery. Treatment is carried out in a hospital setting.

Conservative therapy is aimed at stopping bleeding. To achieve this, the following measures are taken:

1. Gastric lavage with a cold solution. It is carried out using a tube inserted through the mouth or nose.
2. Administration of drugs to induce vascular spasms: Adrenaline, Norepinephrine.
3. Intravenous injection (drip) of hemostatic agents.
4. Transfusion using donated blood or blood substitutes.

Endoscopic methods are carried out using special instruments. The most commonly used methods are:

• injecting the ulcer with adrenaline;
• electrocoagulation of destroyed small vessels;
• laser exposure;
• suturing the damaged area with threads or special clips;
• use of special glue.

An important element of treatment is proper nutrition. Diet after stomach bleeding should be strictly maintained. What can you consume after taking it? emergency measures and eliminating the acute course? On the first day you should not eat or drink at all. The next day you can start consuming liquid (100–150 ml). Meals over the next 3–4 days include the gradual introduction of broths, pureed soups, fermented milk products, and liquefied porridges. You can eat normally, but within the limits of a gentle diet, only 9–10 days after the bleeding has stopped. Subsequent meals are carried out in accordance with table No. 1 with a transition to less rigid diets. The meal schedule is set frequently (7–8 times a day), but in measured portions.

Bleeding in the stomach is considered a very dangerous manifestation of certain diseases. If such a pathology is detected, measures must be taken urgently.