Acute gastrointestinal bleeding. Treatment. Stomach bleeding

Is bleeding. This life-threatening condition can cause death. Approximately every fifth patient is admitted to the emergency department with this diagnosis. These are mainly older patients, more than a man with a history of illness upper sections Gastrointestinal tract (esophagus, stomach and duodenum). Lower floors gastrointestinal tract usually do not cause such massive blood loss and rarely require emergency hospitalization.

There are several types of gastrointestinal bleeding depending on the speed and severity of blood loss, the location of the source, and the severity of symptoms. In some cases, the form of bleeding can be determined by clinical picture, and also when using additional methods research – endoscopy, ultrasound.

Currently, due to the widespread implementation of endoscopic methods diagnosis, identifying the source of bleeding in the gastrointestinal tract is not difficult, which significantly increases the effectiveness of treatment and improves the prognosis for the patient.

There are the following types of bleeding from the gastrointestinal tract:

1. Acute and chronic. The first occurs suddenly, and the amount of blood loss can be different - a massive loss of blood in a few hours can lead to a sad outcome, a small one - manifests itself gradually. Chronic bleeding leads to the development of iron deficiency anemia.
2. Explicit (external) and hidden (internal). The latter is more often chronic.
3. Bleeding from the upper levels of the gastrointestinal tract (before the ligament of Treitz, which supports the duodenum) and from the lower (after the duodenum).
4. By severity - mild, moderate and severe (depending on the volume and rate of blood loss, dysfunction of vital organs).

Etiology and pathogenesis

The causes of gastrointestinal bleeding can be various diseases and lesions of the digestive system, portal hypertension, vascular damage and hematopoietic diseases. The most common reasons are the following:

The pathogenesis of gastrointestinal bleeding is most often associated with a violation of the integrity of the vascular wall (erosions, ulcers, ruptures, sclerosis, embolism, thrombosis, rupture of an aneurysm or pathological dilated nodes, increased permeability of small capillaries).

The second mechanism is changes in the hemostatic system (impaired blood clotting abilities). A combination of these two mechanisms in the same patient is possible.

Symptoms and diagnostic methods

There are two main periods in the clinical development of any bleeding:

• hidden (latent) period - begins from the moment blood enters the gastrointestinal tract until the appearance of external signs;
• generalized period - when all the symptoms of blood loss become obvious (noise in the head, severe weakness and pallor, thirst, cold sweat, tachycardia, drop in blood pressure, fainting).

The duration of the first period depends on the rate and volume of blood loss and ranges from several minutes to 24 hours. With slow and light bleeding general symptoms may be scanty - slight pallor of the skin and mucous membranes, fatigue, slight tachyarrhythmia against the background of normal blood pressure. This is due to the fact that the body manages to turn on all compensatory mechanisms to compensate for blood loss.

It should be remembered that internal bleeding can manifest itself only as general symptoms, while the blood does not flow out, but into one of the cavities of the human body, which poses a serious threat to the patient’s life if the diagnosis is not timely.

All other types of gastrointestinal bleeding have symptoms of external release of blood through the mouth or rectum:

1. Bloody vomiting - if unchanged blood comes out, then the source is in the esophagus or stomach (with a large intensity of blood loss, there is no time for a reaction to occur with hydrochloric acid). If blood accumulates in the stomach cavity for some time to the amount of one glass, then vomiting will occur like coffee grounds. If bloody vomiting repeats within two hours, you should think about ongoing bleeding, but if vomiting resumes after 4 or more hours, this is repeated bleeding.
2. Stool with blood - scarlet blood on top of the stool indicates that the source of blood loss is the lower part of the large intestine (hemorrhoids, rectal fissure). Dark blood mixed with feces and clots of mucus are characteristic of colon and rectal cancer. Dark, tar-like stools (melena) indicate bleeding in the upper level of the gastrointestinal tract (ulcer, stomach cancer).

There is no vomiting, feces do not change color, and general symptoms are mild - this happens if the volume of blood lost per day does not exceed 100 ml, in which case a fecal occult blood test comes to the rescue. This analysis is carried out in all patients with chronic cancer, especially with a hereditary burden of oncology.

The main instrumental method for diagnosing gastrointestinal pathology is endoscopy.

If the symptoms indicate bleeding from the upper gastrointestinal tract, then the most informative study will be EGDS (esophagogastroduodenoscopy); if the lower sections are affected, sigmoidoscopy and colonoscopy are performed. These methods allow you to stop minor bleeding during the study. Additional information is provided by ultrasound, MRI and x-ray methods.

When analyzing the patient’s symptoms, it is necessary to take into account the possibility of black stool appearing during treatment with iron supplements, when consuming activated carbon, blueberries, prunes, cherries. An admixture of blood in the vomit may occur when it is swallowed during nosebleeds or pulmonary bleeding. On the contrary, hemoptysis (coughing up blood) can occur when blood flows from the esophagus and pharynx into the trachea and lower respiratory tract.

Help

Gastrointestinal bleeding is a life-threatening condition that requires immediate first aid to a patient at home, at work or at play.

Even suspicion of existing bleeding is a reason to call an ambulance and hospitalize the patient in the nearest surgical hospital.

First aid is as follows:

• the patient must be laid down, legs raised slightly above head level;
• moving is allowed only on a stretcher;
• do not give food and water until the ambulance arrives;
• put ice or a bottle of cold water at the site of the suspected source of bleeding, remove for 3 minutes every 15 minutes;
• in the hospital, an examination is carried out, the source of bleeding is identified and eliminated (administration of hemostatic agents), replenishment of the volume of lost fluid and circulating blood, treatment of anemia and concomitant pathologies;
• surgical intervention is performed if there is no effect from medicinal methods stop bleeding.

Failure to timely seek qualified medical help or attempt self-treatment can lead to serious consequences for the health and life of the patient - the development of hemorrhagic shock, anemia, acute multiple organ failure, and death. For prevention, it is necessary to regularly undergo examination by specialists (gastroenterologist, proctologist), treat existing diseases, follow all recommendations on diet and the right image life.

- this is the outflow of blood from eroded or damaged by a pathological process of blood vessels into the lumen digestive organs. Depending on the degree of blood loss and the location of the source of bleeding, vomiting of the color of “coffee grounds”, tarry stools (melena), weakness, tachycardia, dizziness, pallor, cold sweat, and fainting may occur. The source is established taking into account the data of FGDS, enteroscopy, colonoscopy, sigmoidoscopy, and diagnostic laparotomy. Stopping bleeding can be done conservatively or surgically.

General information

Gastrointestinal bleeding is the most a common complication a wide range of acute or chronic diseases of the digestive system, posing a potential threat to the patient’s life. The source of bleeding can be any part of the gastrointestinal tract - the esophagus, stomach, small and colon. In terms of frequency of occurrence in abdominal surgery, gastrointestinal bleeding ranks fifth after acute appendicitis, cholecystitis, pancreatitis and strangulated hernia.

Causes

To date, more than a hundred diseases have been described that may be accompanied by gastrointestinal bleeding. All hemorrhages can be divided into 4 groups: bleeding due to damage to the gastrointestinal tract, portal hypertension, vascular damage and blood diseases.

Bleeding that occurs with lesions of the gastrointestinal tract can be caused by gastric ulcer or peptic ulcer 12p. intestines, esophagitis, neoplasms, diverticula, hiatal hernia, Crohn's disease, ulcerative colitis, hemorrhoids, anal fissure, helminthiasis, trauma, foreign bodies, etc. Bleeding due to portal hypertension usually occurs with chronic hepatitis and liver cirrhosis, thrombosis of the hepatic veins or portal vein system, constrictive pericarditis, compression of the portal vein by tumors or scars.

Bleeding developing as a result of vascular damage can be etiologically and pathogenetically associated with varicose veins of the esophagus and stomach, periarteritis nodosa, systemic lupus erythematosus, scleroderma, rheumatism, septic endocarditis, vitamin C deficiency, atherosclerosis, Randu-Osler disease, thrombosis of mesenteric vessels and etc.

Bleeding often occurs in diseases of the blood system: hemophilia, acute and chronic leukemia, hemorrhagic diathesis, vitamin deficiency K, hypoprothrombinemia, etc. Factors that directly provoke pathology may include taking aspirin, NSAIDs, corticosteroids, alcohol intoxication, vomiting, contact with chemicals, physical tension, stress, etc.

Pathogenesis

The mechanism of gastrointestinal bleeding may be due to a violation of the integrity of blood vessels (with their erosion, rupture of walls, sclerotic changes, embolism, thrombosis, rupture of aneurysms or varicose nodes, increased permeability and fragility of capillaries) or changes in the hemostatic system (with thrombocytopathy and thrombocytopenia, disorders of the blood coagulation system). Often, both the vascular and hemostasiological components are involved in the mechanism of bleeding development.

Classification

Depending on the part of the digestive tract that is the source of hemorrhage, bleeding is distinguished from the upper parts (esophageal, gastric, duodenal) and lower parts of the gastrointestinal tract (small intestinal, colonic, hemorrhoidal). The flow of blood from the upper parts of the digestive tract is 80-90%, from the lower - 10-20% of cases. In accordance with the etiopathogenetic mechanism, ulcerative and non-ulcerative gastrointestinal hemorrhages are distinguished.

Based on duration, acute and chronic bleeding; by severity clinical signs– obvious and hidden; by the number of episodes – one-time and recurrent. There are three degrees of bleeding based on the severity of blood loss. Mild degree characterized by heart rate - 80 per minute, systolic blood pressure - not lower than 110 mm Hg. Art., satisfactory condition, preservation of consciousness, slight dizziness, normal diuresis. Blood parameters: Er - above 3.5x1012/l, Hb - above 100 g/l, Ht - more than 30%; BCC deficit – no more than 20%.

With moderate bleeding, heart rate is 100 beats per minute, systolic pressure is from 110 to 100 mm Hg. Art., consciousness is preserved, the skin is pale, covered with cold sweat, diuresis is moderately reduced. In the blood, a decrease in the amount of Er is determined to 2.5x1012/l, Hb - to 100-80 g/l, Ht - to 30-25%. The BCC deficit is 20-30%. A severe degree should be considered when the heart rate is more than 100 beats. per minute weak filling and tension, systolic blood pressure less than 100 mm Hg. Art., lethargy of the patient, adynamia, severe pallor, oliguria or anuria. The number of red blood cells in the blood is less than 2.5x1012/l, the Hb level is below 80 g/l, Ht is less than 25% with a BCC deficiency of 30% and above. Bleeding with massive blood loss is called profuse.

Symptoms

The clinical picture of gastrointestinal bleeding manifests itself with symptoms of blood loss, depending on the intensity of hemorrhage. The condition is accompanied by weakness, dizziness, poor skin, sweating, tinnitus, tachycardia, arterial hypotension, confusion, and sometimes fainting. When the upper gastrointestinal tract is affected, bloody vomiting (hematomesis) appears, having the appearance of “coffee grounds,” which is explained by contact of blood with hydrochloric acid. With profuse gastrointestinal bleeding, the vomit is scarlet or dark red in color.

To others characteristic feature Acute hemorrhages from the gastrointestinal tract are caused by tarry stools (melena). The presence of clots or streaks of scarlet blood in the stool indicates bleeding from the colon, rectum or anal canal. Symptoms of hemorrhage are combined with signs of the underlying disease. In this case, pain in various parts of the gastrointestinal tract, ascites, symptoms of intoxication, nausea, dysphagia, belching, etc. may be observed. Hidden bleeding can only be identified based on laboratory signs- anemia and a positive fecal reaction to occult blood.

Diagnostics

The patient is examined by an abdominal surgeon and begins with a thorough history, assessment of the nature of vomit and bowel movements, and a digital rectal examination. Pay attention to color skin: the presence of telangiectasia, petechiae and hematomas on the skin may indicate hemorrhagic diathesis; yellowness of the skin indicates problems in the hepatobiliary system or varicose veins of the esophagus. Palpation of the abdomen is carried out carefully to avoid increased gastrointestinal bleeding.

Laboratory indicators include counting of red blood cells, hemoglobin, hematocrit number, platelets; coagulogram study, determination of creatinine, urea, liver tests. Depending on the suspected source of hemorrhage, various radiological methods can be used in diagnosis: radiography of the esophagus, radiography of the stomach, irrigoscopy, angiography of mesenteric vessels, celiacography. The fastest and precise method examination of the gastrointestinal tract is endoscopy (esophagoscopy, gastroscopy, colonoscopy), which makes it possible to detect even superficial defects of the mucous membrane and the direct source of gastrointestinal bleeding.

To confirm bleeding and identify its exact location, radioisotope research(scintigraphy of the gastrointestinal tract with labeled red blood cells, dynamic scintigraphy of the esophagus and stomach, static scintigraphy of the intestine, etc.), MSCT of the abdominal organs. The pathology must be differentiated from pulmonary and nasopharyngeal bleeding, for which X-ray and endoscopic examination of the bronchi and nasopharynx is used.

Treatment of gastrointestinal bleeding

Patients are subject to immediate hospitalization in the surgical department. After clarifying the location, causes and intensity of bleeding, treatment tactics are determined. In case of massive blood loss, blood transfusion, infusion and hemostatic therapy are carried out. Conservative tactics are justified in the case of hemorrhage that develops due to impaired hemostasis; the presence of severe intercurrent diseases (heart failure, heart defects, etc.), inoperable cancer processes, severe leukemia.

When bleeding from varicose veins of the esophagus can be stopped endoscopically by ligating or sclerosing the altered vessels. According to indications, they resort to endoscopic control of gastroduodenal bleeding, colonoscopy with electrocoagulation or puncture of bleeding vessels. In some cases, surgical stopping of gastrointestinal bleeding is required.

So, in case of a stomach ulcer, the bleeding defect is sutured or an economical gastric resection is performed. For duodenal ulcers complicated by bleeding, suturing of the ulcer is supplemented with truncal vagotomy and pyloroplasty or anthrumectomy. If the bleeding is caused by nonspecific ulcerative colitis, a subtotal resection of the colon is performed with the imposition of an ileo- and sigmostoma.

Prognosis and prevention

The prognosis for gastrointestinal bleeding depends on the causes, degree of blood loss and general somatic background (patient’s age, concomitant diseases). The risk of an unfavorable outcome is always extremely high. Prevention is the prevention and timely treatment of diseases that can cause hemorrhage.

What symptoms can you use to identify internal bleeding in the intestines?

Every tenth patient in the surgical department is admitted with a diagnosis of intestinal bleeding. In most cases, patients are delivered in a state close to hemorrhagic shock. Despite the development of medicine, the number of deaths does not decrease. Why such internal bleeding in the intestines is dangerous, the symptoms and principles of treatment will be discussed in this article.

Intestinal bleeding or hemorrhage is hemorrhage in the lower parts of the digestive system. At risk are children and people with poor nutrition and those leading an inactive lifestyle. Hemorrhage can be caused by gastrointestinal pathologies, vascular disorders, intestinal infections and mechanical damage.
The human intestine is about 12 meters long, bleeding can occur in any part:

● 70% of cases occur in the large intestine;
● 20% of expirations occur in ileum;
● 10% of intestinal bleeding occurs in small intestine and duodenum.

There are 2 types of hemorrhages in the intestines:
● acute – sudden intense blood loss causes sharp deterioration conditions;
● chronic – intestinal damage is minor, but gradually leads to the development of anemia.

Internal bleeding of the intestine is not an independent pathology, but a manifestation of other diseases of the gastrointestinal tract and vascular system.

Causes of bleeding

Hemorrhages occur when the integrity of the mucous membrane and blood vessels is damaged. Damage may occur if it gets into digestive tract foreign object and long-term constipation. IN in rare cases effusion begins after surgery or instrumental research intestines.
Much more often, bleeding is one of the manifestations of other diseases:

• hemorrhoids;
• colitis;
• intestinal ischemia;
• diverticulosis;
• polyps;
• Crohn's disease;
• anal fissure;
• malignant tumors.

In 10 cases out of 100, it is not possible to determine the cause of such bleeding.

Clinical picture

Differentiating intestinal hemorrhage can be problematic due to anatomical and physiological characteristics. Blood mixes with secretions, so the violation for a long time goes unnoticed.
Signs of intestinal hemorrhage depend on the location of the damage and the intensity of the effusion.

General signs

If the mucous membrane is damaged, symptoms characteristic of all internal bleeding are observed:

• fast fatiguability;
• weakness;
• paleness of blood;
• dry mouth;
• lowering blood pressure;
• development of tachycardia;
• constant thirst.

Specific signs

If the integrity of the gastrointestinal tract is violated, a specific symptom is the appearance of blood in the stool and a change in its color. It can be present in feces or mixed with them. The shade depends on the location of the microtrauma:

• if the upper sections are damaged, it becomes almost black.
• with changes in the large intestine and rectum, a person notices blood in the form of drops on toilet paper or red streaks in the discharge.

Changes in stool color are associated with hemoglobin oxidation. They can be caused by dietary habits and certain medications.
Bleeding when pathological changes in the gastrointestinal tract is supplemented by other unpleasant signs:
1. With inflammation of the mucous membrane (colitis, Crohn's disease), abdominal pain appears, prolonged diarrhea with mucus and pus.
2. During intestinal infections, the main symptoms are added heat and muscle pain.
3. With intestinal tuberculosis, in addition to periodic hemorrhages, rapid weight loss, severe weakness and frequent diarrhea are observed.
4. Malignant neoplasms appear severe pain, loss of appetite, gradual development of anemia.

The intensity of bleeding affects the time it takes for symptoms to develop. At minor damage It may take several weeks or months before a person notices a change in their condition.
Severe injuries cause rapid changes in condition: the victim turns pale, loses consciousness, and the heart rate slows down.

Diagnostics

It is not easy to establish the fact of hemorrhage only by external signs. Gastroenterologists and proctologists use several methods:

• general analysis blood;
• examination of stool for the presence of occult blood;
• colonoscopy;
• gastroscopy;
• X-ray examination with contrast agents;
• tissue biopsy.

Laboratory methods determine the fact of hemorrhage: the number of red blood cells in the blood decreases, and traces of blood are found in the stool.
Instrumental and radiation diagnostics are used to determine the location of the damage and its degree. Using a gastroscope, the duodenum and stomach are examined; colonoscopy allows you to examine the surface of the large intestine.

X-ray examination is prescribed if there are contraindications to instrumental methods, for example, with exacerbation of hemorrhoids. Tissue puncture (biopsy) is performed if malignant changes are suspected.

Help with intestinal bleeding

How to treat intestinal bleeding depends on its form. Severe internal effusions require immediate action and urgent transportation to the surgical department. Delay may result in death.
The primary goal is to stop bleeding. At home, this will require several steps:

• lay the victim down;
• place ice or a heating pad with cold water on your stomach;
• avoid stimulation of peristalsis (do not give drink).

In the hospital, the victim is given drugs that increase blood clotting and compensate for its loss. Only after this they begin to determine the location of the damage and eliminate it.
Minor hemorrhages disappear after the cause is relieved.
In 75% of cases, the cause of hemorrhage can be eliminated minimally invasively through endoscopic examination.

If internal bleeding occurs in the intestines, treatment is carried out under the supervision of a doctor after a thorough examination. To prevent the development of complications after eliminating the cause, it is necessary to follow the doctor’s recommendations and undergo preventive examinations.

Bleeding from the gastrointestinal tract is a dangerous phenomenon that develops with ulcerative, vascular, mechanical and other lesions of the gastrointestinal tract. Excessive bleeding into the lumen of the digestive organs can lead to serious complications and death.

Stopping and treating gastrointestinal bleeding (GIB) is carried out promptly or using conservative medicine methods after receiving the results of laboratory, hardware and instrumental diagnostics.

Why is there bleeding from the stomach?

Bleeding in the intestines, stomach or other digestive organs can develop for the following reasons:

The most common causes of gastrointestinal bleeding are duodenal and gastric ulcers. They cause up to 35% of all bleeding from the gastrointestinal tract. Risk factors for the development of peptic ulcers are frequent stress, drinking alcohol and smoking.

Children have the most common reasons development of bleeding are volvulus (for infants) and intestinal polyposis (for preschoolers).

Some causes of intestinal bleeding (for example, hemorrhoids, anal fissures or polyps) provoke only scanty bloody issues or small amounts of blood in the stool. For ulcers, vascular pathologies, tumors and ruptures of the walls of the gastrointestinal tract blood is flowing abundantly, mixed with secretions (vomit, feces) in a modified or unchanged form.

Classification

Bleeding from the digestive tract is divided into groups depending on the etiology, source of hemorrhage and severity. According to the etiology of bleeding, they are divided into:

• for diseases caused by the gastrointestinal tract (ulcerative and non-ulcerative origin);
• to circulatory disorders caused by portal vein ();
• for bleeding with vascular diseases;
• on pathologies of the hematopoietic system, incl. hemorrhagic diathesis.

In accordance with the classification of bleeding by localization, the following types of this disorder are distinguished:

• bleeding from the upper parts of the digestive tract (stomach, esophagus, duodenum);
• bleeding from lower organs digestion (small and large intestines, rectum, hemorrhoids).

Most often, bleeding occurs from the upper gastrointestinal tract. Esophageal, duodenal and gastric bleeding are diagnosed in 8-9 out of 10 patients with hemorrhages in the digestive tract.

Classification of bleeding according to severity

Some experts also distinguish the fourth, most severe stage of bleeding. It is characterized by complete loss of consciousness in the patient and the development of coma.

Massive, accompanied by severe blood loss, is called profuse.

Additionally, bleeding in the gastrointestinal tract can be classified according to following criteria:

• duration of bleeding (acute or chronic bleeding);
• the presence of external manifestations of pathology (hidden or obvious);
• frequency and number of cases of blood loss (single or repeated, recurrent).

What are the signs and symptoms

Early symptoms of bleeding in the gastrointestinal tract include:

• general weakness, adynamia;
• dizziness, fainting, confusion and loss of consciousness;
• ringing in the ears, flickering spots in the eyes;
• nausea, vomiting;
• change in color of gastric and intestinal secretions (vomit and feces);
• sweating;
• strong thirst;
• increased heart rate;
• pallor of the skin, cyanosis of the lips, blue discoloration and decreased temperature of the fingertips.

The severity of the symptoms of the pathology depends on the intensity of bleeding, the volume of blood volume and the amount of blood lost. Due to the larger initial volume of circulating blood, signs of bleeding in adults may manifest later and less clearly than in children. Even minor blood loss in a small child may require immediate resuscitation.

Symptoms of internal bleeding in the stomach often appear simultaneously with signs of massive blood loss and a decrease in circulating blood volume. Against the background of manifestations of blood loss, pain may be observed in the affected part of the gastrointestinal tract, an increase in the volume of the abdomen due to the accumulation of fluid (ascites), fever caused by intoxication, loss of body weight, a sharp change or loss of taste and other pathological phenomena indicating the cause of the gastrointestinal tract.

The main symptom of gastric bleeding is bloody vomiting, the nature of which may indicate the cause of the pathology and the duration of the bleeding.

Vomiting when various pathologies upper gastrointestinal tract, which lead to blood loss:

“Coffee grounds” are a product of treating blood from the stomach with hydrochloric acid.

At ulcerative lesions During vomiting, stomach pain decreases. Bleeding is not accompanied by irritation of the peritoneum and tension of the muscles of the anterior abdominal wall. With massive blood loss and stomach cancer, the color of the stool also changes.

Repeated vomiting with blood 1-2 hours after the first episode indicates continued bleeding, and vomiting after 4-6 hours indicates its relapse.

With gastric bleeding, the symptoms of blood loss in most cases are more pronounced than with bleeding in the intestines. This is due to the fact that common causes of damage to the walls of the small, large and rectal intestines are injuries to hemorrhoids, polyposis and small cracks in the mucosa. They can provoke prolonged but insignificant blood loss, which is accompanied by a slight decrease in hemoglobin concentration and the development of compensatory tachycardia while maintaining normal blood pressure and the patient’s well-being.

Symptoms of intestinal bleeding, accompanied by massive blood loss, may include:

• black feces;
• discharge of melena (unformed, tarry stool with strong unpleasant smell);
• weakness, loss of consciousness, pale skin and other manifestations of acute blood loss.

Visual changes in the color and structure of stool are visible only with blood loss of more than 100 ml/day and damage to the direct and colon(cracks, polyps, bleeding hemorrhoids). In case of a one-time leakage of blood (with a stomach ulcer and pathologies of the lower parts of the digestive tract), the blood is excreted unchanged in the stool. With prolonged massive bleeding, a few hours after it starts, tarry stools (dark stool with small clots) are released.

The nature of stool changes in various intestinal pathologies:

In the chronic course of the pathology, symptoms of anemia may occur:

• weakness, fatigue;
• decreased performance;
• frequent dizziness;
• inflammation oral cavity and language;
• pallor of the mucous membranes and skin.

Diagnostics

Determining the cause of gastrointestinal bleeding syndrome requires a thorough clinical examination, laboratory tests, as well as the use of hardware and instrumental methods diagnostics

Clinical examination

For the primary diagnosis of internal bleeding in the stomach or intestines, clinical examination patient, during which the following data is analyzed:

• patient history;
• list of medications taken;
• color and consistency of discharge;
• skin color (pallor, yellowness);
• the presence of spider veins, hemorrhagic manifestations and other vascular pathologies on the skin.

If there is a suspicion of intestinal or gastric bleeding, palpation of the painful part of the abdomen and rectal examination are carried out with caution. Careless procedure can significantly increase blood loss.

Laboratory research

TO laboratory tests which are carried out for bleeding in the stomach, esophagus and lower gastrointestinal tract, include:

• general blood analysis;
• blood biochemistry (liver and kidney tests, markers of inflammatory processes, etc.);
• coagulogram;
• coprogram;
• analysis of antibodies to double-stranded DNA, etc.

Instrumental methods

The most informative hardware diagnostic methods that are used when intragastric and intraintestinal hemorrhage are suspected are:

• X-ray examination of the esophagus and stomach;
• celiacography;
• MR angiography of gastrointestinal tract vessels;
• static and dynamic scintigraphy of the digestive tract;
• CT organs abdominal cavity;
• X-ray of the nasopharynx, bronchi and lungs.

Gastric bleeding can be most quickly diagnosed using upper gastrointestinal endoscopy. For pathologies of the lower parts of the tract, irrigoscopy, sigmoidoscopy and colonoscopy are used.

If it is impossible to determine the source of hemorrhage using endoscopy and hardware methods, a diagnostic laparotomy is performed.

How to stop bleeding

Stopping bleeding must be done by doctors medical institution or emergency medical services. Even before rendering emergency care it is necessary to call an ambulance, describing the patient’s condition and the nature of the discharge.

Algorithm for providing emergency first aid if bleeding is suspected, includes the following steps:

• Place the patient on his back with his legs elevated using folded clothing or a pillow;
• do not allow the victim to drink or eat;
• apply a compress of ice wrapped in cloth to the painful area;
• When providing first aid, monitor your breathing pattern and heart rate;
• in case of loss of consciousness, bring the patient to his senses using cotton wool soaked in ammonia;
• when waiting for a long time for an ambulance, carry the patient on a stretcher towards the medical team.

During emergency care for gastric bleeding, it is forbidden to lavage the stomach. If you suspect intestinal pathology You can’t give a patient an enema.

An attempt to stop the bleeding without the help of doctors can lead to the death of the patient.

How to treat

For gastrointestinal bleeding, treatment is aimed at stopping it, eliminating the root cause of the pathology, restoring hemostasis of the body and normal blood volume.

The danger for the patient is not only the loss of red blood cells that carry oxygen, but also a sharp decline BCC, which leads to massive thrombosis of small vessels and the development of DIC syndrome.

Conservative treatment

Conservative treatment of gastric bleeding and intestinal blood loss is carried out as an addition to surgical intervention. It is used as the main method of therapy for the following indications:

• hemorrhagic syndromes;
• cardiovascular diseases;
• inoperable malignant tumors;
• congenital pathologies hematopoietic systems.

Therapy may include hemostatic agents, cytostatics, anti-inflammatory and other drugs.

If a large volume of blood is lost, the patient is prescribed IVs with saline solutions and transfusions of blood components.

Surgery

If bleeding in the gastrointestinal tract is suspected, the patient is taken to the surgical department of the clinic, where diagnosis and treatment tactics are determined.

Depending on the diagnosis, the patient may undergo following operations:

• endoscopic sclerosis, electrocoagulation and ligation of dilated vessels of the intestine, esophagus, etc.;
• suturing ulcerative defect and partial gastrectomy;
• suturing duodenal ulcer;
• subtotal resection of the large intestine with stoma.

Diet

Treatment tactics using diet therapy depend on the underlying disease. For pathologies of the stomach, the patient is prescribed table No. 1, No. 1a (immediately after stopping the bleeding), No. 1b or No. 2. For intestinal diseases, diet No. 3 or No. 4 is recommended.

If bleeding is a complication of liver pathology, the patient is prescribed table No. 5 and its variations.

Consequences and complications

Complications of bleeding from the gastrointestinal tract include:

• DIC syndrome;
• moderate to severe anemia;
• acute organ failure;
• coma.

Development risk severe consequences and mortality increases if you do not consult a doctor in a timely manner.

How to prevent the phenomenon

To prevent the development of this dangerous pathology it is necessary to undergo regular medical examinations, follow the rules for taking medications and maintain healthy image life.

Contacting a gastroenterologist at the first manifestations of ulcerative and vascular diseases (malaise, nausea, stomach pain, etc.) increases the likelihood of a favorable prognosis for the effectiveness of therapy.

To detect intestinal bleeding in the early stages, it is recommended to regularly take a stool occult blood test.

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 parts of the 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 USA, the annual number of hospitalizations for bleeding from the specified section of the gastrointestinal tract ranges from 36 to 102 patients per 100 thousand population. The gastrointestinal tract is detected twice as often in men. Bleeding from the lower gastrointestinal tract in general 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(duodenal), and destructive processes in the duodenum are twice as likely to lead to hemorrhagic complications. The mortality rate from upper GI bleeding ranges from 3.5-7% in the US to 14% in the UK, and the mortality rate from lower GI bleeding is 3.6%.

There are hidden, usually chronic, gastrointestinal bleeding and obvious (massive) hemorrhages.

In acute bleeding, the degree of blood loss may vary.

In the case of massive blood loss, the volume of circulating blood decreases, there is a discrepancy between its vascular bed, a decrease in blood pressure, an increase in heart rate, a decrease in the minute volume of blood circulation, which causes an increase in total peripheral vascular resistance due to compensatory, generalized vascular spasm. This compensatory mechanism is short-term, and with continued blood loss, irreversible hypoxic phenomena may occur in the body. 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 clear signs blood loss, such 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.

Upper gastrointestinal bleeding

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.

It was found that 44% of all hospitalizations for upper gastrointestinal bleeding occur in patients over 60 years of age, and mortality rates are also significantly higher in older people. However, it should be noted that approximately 80% of upper GI bleeding episodes are self-limiting or require non-massive therapy.

An analysis of the causes of deaths from bleeding from the upper gastrointestinal tract 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 prognostically. Risk factors for rebleeding include endoscopically detectable signs of a threat of rebleeding (streaming ongoing bleeding, blood leakage, a thrombosed vessel and a 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 a gastric ulcer than for a duodenal ulcer.

Other signs that may cause or influence the outcome of bleeding include factors such as the size of the ulcer (giant ulcers), concomitant pathology ( renal failure, liver cirrhosis, acute coronary insufficiency, chronic failure blood circulation, tumor, endocrine, systemic diseases).

In general, the first place for causes of bleeding (see Table 1) is erosive and ulcerative lesions of the stomach and duodenum. And this despite the undoubted successes in the treatment of peptic ulcers achieved over the past last years. Apparently, there are several reasons, and the main ones are asymptomatic ulcers and uncontrolled use of nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, alcohol, and a combination of these factors. Thus, it is the use of NSAIDs in patients with peptic ulcers that can give a blurred picture of the disease, on the one hand, and fatal bleeding, on the other. Of no small importance in the etiology of gastrointestinal bleeding and its recurrence in patients with peptic ulcer disease is infection of patients Helicobacter pylori (NR), especially in cases of incomplete eradication of HP, as well as the acid-peptic factor.

An overt period of upper GI bleeding usually begins with vomiting of blood (bright red blood, dark clots, or "coffee ground" vomit) or the appearance of melena (black, tarry, spotty stool with a peculiar, foul odor), however, it should be noted that with massive bleeding from the upper gastrointestinal tract, copious scarlet blood may also appear in the stool.

At the same time, the patient experiences anxiety or lethargy, pallor, decreased blood pressure, tachycardia, and in some cases, in patients with serious blood loss, bradycardia associated with vagal influence may be recorded. A critical hemodynamic situation occurs when blood loss reaches 40% of the total circulating blood volume. 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, level residual nitrogen blood) - auxiliary. As a rule, endoscopic diagnosis of ulcerative bleeding, especially of gastric localization, is not difficult. The situation is different with gastropathy, as a source 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 stress.

Bleeding from dilated veins of the esophagus and stomach is more often observed from large nodes or common varicose veins. When assessing the situation, endoscopists often focus on the color of the nodes. Red and Blue colour one node is considered a risk factor for bleeding. White spot on a varicose node may be a fibrin plug and be considered as a diagnostic factor of previous bleeding, but does not indicate the possibility of re-bleeding. Isolated gastric varices in the fundus may be the result of splenic vein thrombosis, detected by angiography. Varicose veins in the duodenum rarely bleed.

In Mallory-Weiss syndrome, the source of bleeding is a rupture of the mucosa near the gastroesophageal junction, caused by intense vomiting that accompanies prolapse of the stomach lining. In patients with this syndrome, there is an association with chronic alcohol consumption 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 set of necessary measures includes: ensuring cross-country ability respiratory tract(side position, insertion of a nasogastric tube), as well as intravenous access, determination of blood type, Rh factor and biological compatibility. In addition, a blood test is taken from the patient for hemoglobin and hematocrit, 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. In case of significant blood loss, it is necessary to restore the volume of blood volume (transfusion of saline solution, and if there are signs of sodium retention in the body, a 5% dextrose solution). If signs of a drop in blood volume appear, a transfusion should be carried out within an hour: 500 ml - 1 liter of colloidal solution, followed by blood transfusion of erythromass or whole blood(if there is a large volume of blood loss, the second is preferable). During infusion therapy, care should be taken to ensure urine output is greater than 30 ml/h and to avoid 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 using therapeutic methods: gastric lavage with ice water and administration of antisecretory agents, which, in addition to affecting secretion, have the ability to reduce blood flow in the mucous membrane. The use of acid production blockers for erosive and ulcerative bleeding is especially indicated. According to the latest data, the use of H2-histamine receptor blockers and inhibitors proton pump(PPI) may reduce the likelihood surgical intervention and mortality by 20 and 30%, respectively. Modern PPIs, characterized by rapid action, are especially effective. Typically, patients are given 40 mg of omeprazole (Losec) or 50 mg of ranitidine (Zantac, etc.) intravenously. The use of famotidine (quamatel at a dose of 20 mg from 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 blockers of acid production, 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 treatment of bleeding from the upper gastrointestinal tract. According to available data, for bleeding caused by erosions, intraarterial infusion of vasopressin during angiography and catheterization has a good effect (80-90%), the effect is less pronounced after intravenous infusions vasopressin. In ulcerative bleeding, the effect of vasopressin is subtle, possibly due to the larger caliber of bleeding vessels. Otherwise, the treatment of bleeding in gastropathy does not differ from that described above.

As for bleeding from dilated veins of the esophagus and stomach, 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/hour as a continuous infusion over five days. It also has an effect combined use metoclopramide and intravenous infusions nitroglycerin. The main forms of treatment for this type of bleeding are urgent sclerotherapy or ligatures.

Bleeding from 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 treatment 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 rational treatment for the underlying disease that caused the blood loss. Thus, for the treatment of erosive and ulcerative processes associated with HP, the need to prescribe full-fledged eradication therapy, taking into account not only the resistance of HP to metronidazole, but also multiresistance to other antibacterial agents, is absolutely obvious. According to 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). A weekly or, if resistant to metronidazole, 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 daily). Eradication of HP with this treatment reaches 85.7-92%.

To prevent bleeding caused by taking NSAIDs in association with HP, patients who continue to take anti-inflammatory drugs according to indications should undergo similar eradication therapy with the mandatory inclusion of a PPI (Losec, Pariet) 20 mg twice a day in the regimen, with subsequent transfer to maintenance course of PPI at half daily dose. You can take misoprostol (200 mcg four times a day). Misoprostol is also effective in preventing stress erosions, although it causes diarrhea in some patients.

Bleeding from the lower gastrointestinal 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 diseases;
• infectious colitis;
• intestinal tuberculosis;
• hemorrhoids and anal fissures;
• foreign bodies and intestinal injuries;
• aortointestinal fistulas;
• helminthiasis.

The average age of patients with lower GI bleeding is higher than that of patients with upper GI bleeding. In the last few decades, mortality rates from acute bleeding from the lower gastrointestinal tract have decreased slightly, which is associated, first of all, with the improvement in the diagnosis of bleeding, thanks to the use of colonoscopy and angiography, which make it possible to select optimal algorithm surgical or angiographic treatment.

As with upper gastrointestinal bleeding, 80% of all episodes of lower gastrointestinal bleeding stop spontaneously, and 25% of patients with stopped bleeding experience recurrence. Unlike upper GI bleeding, most lower GI bleeding is subtle or minor, intermittent, and does not require hospitalization.

Of all the above causes of bleeding from the lower sections of the 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 the bleeding cannot be determined.

With diverticulosis, bleeding diverticulum is most often found in the left parts of the colon. More often, bleeding occurs with concomitant diverticulitis and trauma to blood vessels. The amount of blood loss can be dangerous for older people.

Tumor processes rarely cause acute bleeding; they mainly cause chronic, hidden blood loss and iron deficiency. Hidden bleeding also often accompanies ulcerative colitis and Crohn's disease, since with this pathology large vessels, as a rule, are not damaged.

Bleeding from hemorrhoids is often not profuse, but in some cases massive blood loss may occur, requiring urgent surgical measures.

Diverticular bleeding often presents as acute, painless, and manifests itself as bright red unchanged blood (hematochezia) in the stool, although melena may occur if the source of the bleeding is located in the small intestine. Moreover, the lighter the blood, the more distal the bleeding site is located. A similar picture is often observed with angiodysplasia. Differential diagnosis in these cases it is usually based on colonoscopy or angiography. In neoplastic processes, the clinical picture of bleeding is usually represented by weak, intermittent bleeding and stool with positive reaction for occult blood. At internal hemorrhoids pain syndrome is most often absent, and bleeding can be in the form of a stream of scarlet blood or manifested by the presence of blood on toilet paper or around the stool, but not mixed with stool, which retains its normal color. In general, when, in the presence of signs of bleeding, the intestinal contents retain their normal color, this indicates a low location of the source of bleeding (in the rectosigmoid sector). Bleeding from hemorrhoids is often observed when straining or when passing hard stool. A similar picture is also typical for patients with bleeding from anal fissures, but in this case it is often accompanied by severe pain. In addition, the same symptoms may accompany rectal polyps and rectal carcinoma. In this regard, patients with these symptoms must undergo anoscopy and sigmoidoscopy.

Bleeding, the source of which is Meckel's diverticulum, is more often observed in childhood. This is painless bleeding that may present as melena or bright scarlet blood, classically described as "currant jelly" stool. 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 diseases intestines is characterized by pain, which, as a rule, precedes bleeding. In these patients, blood usually mixes with the stool, which changes its color, since the source of bleeding is often located above the rectosigmoid colon. At the same time, other signs of the disease were detected, 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. Diagnosis in in this case diagnosed on the basis of sigmoidoscopy with biopsy and stool culture.

If the intestinal damage is ischemic in nature, colicky pain is observed in the abdominal cavity, often on the left, accompanied later (within 24 hours) by bloody diarrhea. This type of bleeding is characterized by minimal blood loss; 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 from collecting anamnesis and objective examination of the patient. A significant role is played by burdened heredity, transferred and existing chronic pathology (oncological diseases in the patient and relatives, including familial polyposis of the colon, hepatitis, cirrhosis of the liver, urogenital pathology), as well as living and working conditions, contact with animals, etc.

Examination of the patient often allows one 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 symptoms of existing posthemorrhagic iron deficiency anemia, abdominal pain, diarrhea, anorexia, weight loss, or the presence of palpable abdominal masses. Colonoscopy is invaluable in the diagnosis of bleeding from the lower gastrointestinal tract, and in cases of progressive blood loss, angiography is indicated for patients.

However, despite the fact that currently there is a rich arsenal technical means, do not forget about simple, but sufficient informative methods studies available in any conditions - digital rectal examination, which can answer many questions, especially in cases of rectal pathology. It is no coincidence that in the list of diagnostic measures for bleeding from the lower gastrointestinal tract this procedure comes first. In addition to the above measures (anoscopy, sigmoidoscopy, colonoscopy with biopsy, angiography), one should not forget about the need to examine stool for occult blood with benzidine (after careful preparation of the patient). In some cases, staged correct diagnosis radioisotope studies help, CT scan and NMR diagnostics.

In 80% of cases acute bleeding from the lower sections of the gastrointestinal tract are stopped independently or during therapeutic measures aimed at treating the underlying disease. Most effective therapy Diverticular and angiodysplastic bleeding are: selective catheterization with intra-arterial administration of vasopressin; transcatheter embolization of intestinal arteries; endoscopic electro- and laser coagulation; sclerotherapy. For hemorrhoids, methods such as local (in suppositories) vasoconstrictor therapy can be used; A 10% solution of calcium chloride is prescribed orally (one tablespoon four to five times a day). In case of massive bleeding, rectal tamponade can be used. In case of repeated bleeding it is indicated surgical treatment. For internal hemorrhoids, in some cases sclerosing therapy with varicocid, ethaxiscleron and other agents is prescribed. Great importance in the prevention of hemorrhoidal recurrent bleeding is attached to the treatment of chronic obstipation syndrome in these patients.

Considering the fact that bleeding from the lower gastrointestinal tract is much more often hidden and accompanied by chronic iron deficiency anemia, it is necessary in each case to diagnose occult blood loss and their timely therapeutic correction. The presence of concomitant pathology of the gastrointestinal tract in most patients with chronic blood loss (chronic atrophic gastritis, intestinal dysbiosis), malnutrition with vitamin deficiency, and in some cases alcohol abuse, creates the need to prescribe complex therapy, which is preferably carried out using combination 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 mcg) 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 in the preparation, as a carrier, 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 based on laboratory and clinical indicators. Usually the drug is prescribed 1 capsule two to three times a day.

In any case, therapy for patients with gastrointestinal bleeding should be comprehensive and take into account the individual characteristics of patients and concomitant pathology.

For questions about literature, please contact the editor

I. V. Mayev, Doctor of Medical Sciences, Professor
A. A. Samsonov, Doctor of Medical Sciences
G. A. Busarova, Candidate of Medical Sciences
N. R. Agapova
MGMSU, Moscow