Today, the problem of therapy for gastroduodenal bleeding in surgery is one of the most important, as it is a serious complication of peptic ulcer disease and is diagnosed in 20% of patients with this disease. In modern medicine, the tactics of treating patients with this pathology are not sufficiently developed. In addition, the used methods of endoscopic hemostasis are unsafe, insufficiently effective and reliable, as a result of which there is a high risk of a person developing a fatal outcome before and after surgery. In men, this pathology occurs three times more often than in women.
Description of the problem
Gastroduodenal bleeding is a dangerous disease in which blood from the area affected by the pathological process (stomach or duodenum) or a damaged vessel enters the lumen of the gastrointestinal tract. Such a dangerous phenomenon can be observed with the development of peptic ulcer, Crohn's syndrome, acute intestinal infections, pathologies of the pancreas and gall bladder, as well as blood diseases. In this case, bleeding can form in different parts of the tract, starting from the upper esophagus and ending with the rectum. But most often (60% of cases), the stomach and duodenum act as a source of bleeding.
Ulcerative gastroduodenal bleeding is always a dangerous symptom and condition, which provokes a threat to the patient's life, the occurrence of a fatal outcome. Therefore, it is recommended to carefully study the causes of development and the clinical picture of the disease, so that when the first signs appear, immediately contact a medical institution.
Causes of the disease
In 70% of cases, acute gastroduodenal bleeding develops as a result of peptic ulcer of the duodenum and stomach, erosive gastritis. With the same frequency, the pathology is formed due to a cancerous tumor or varicose veins in the stomach as a result of hypertension syndrome. Rarely, the disease is observed with pathologies of the circulatory system, injuries, Rendu-Osler syndrome, and others.
In medicine, there are more than eighty reasons for the development of this disease. They are conditionally divided into three large groups:
- Diseases of the stomach and duodenum. The main symptom in peptic ulcer disease is hidden bleeding, and extensive ulcerative gastroduodenal bleeding is a complication of this disease. The occurrence of such a pathology is often provoked by strong physical exertion during an exacerbation of the underlying disease, stress, smoking and alcohol consumption, treatment of the disease with drugs that contain acetylsalicylic acid. Bleeding can develop as a result of peptic ulcer of various origins, a decaying malignant tumor, erosive gastritis, duodenitis, as well as with abdominal injuries, severe vomiting, varicose veins, heart failure.
- Diseases of the cardiovascular system. In some cases, acute gastroduodenal bleeding occurs due to myocardial infarction, Randu-Osler disease, periarteritis, septic endocarditis, vasculitis, and scurvy.
- Blood diseases. Pathology can occur as a result of thrombosis, an overdose of anticoagulants, aplastic anemia, congenital pathologies of the circulatory system.
The risk group includes:
- Elderly people.
- People who use NSAIDs, anticoagulants and glucocorticosteroids for a long period of time.
- Abusing nicotine and alcohol.
Symptoms and signs of the disease
In some cases, the pathology is hidden. With bleeding of the affected mucous membranes of the blood, very little is observed, usually it can only be detected by examination of feces. In such cases, the symptoms of the underlying disease prevail, such as ulcers or gastritis. But it also happens that the pathology does not show signs, therefore, the detection of blood in the feces during analysis is the main symptom of diseases of the gastrointestinal tract.
A great danger is chronic gastroduodenal bleeding, which occurs for a long period of time, provoking the development of anemia. The danger of such phenomena is that they can mimic the symptoms of many other diseases that are not related to the digestive tract.
The most typical manifestations of the pathology are blood discharge with vomiting or bowel movements (black feces) and acute vascular insufficiency. At the same time, the patient has weakness, fainting, pallor of the skin, impaired vision and hearing, a drop in blood pressure, tachycardia, shortness of breath, heart palpitations. Symptoms intensify when a person takes a vertical position of the body. In some cases, the pathology develops so quickly that death can occur from shock earlier than the symptoms appear.
Symptoms of venous bleeding
As a result of varicose veins, bleeding may develop. In this case, the color of the blood during vomiting will be changed due to the interaction of hemoglobin with hydrochloric acid. With this interaction, brown hematin hydrochloride is formed, so vomit will resemble coffee grounds. In the absence of hydrochloric acid in the gastric juice, vomit will contain an admixture of unchanged red blood.
Duodenal bleeding
Gastroduodenal bleeding from the duodenum or other parts of the intestine shows symptoms in the form of black tar-like feces (melena). This phenomenon is observed as a result of the formation of hemoglobin of sulfur dioxide under the influence of digestive enzymes that affect the blood when it moves through the intestines. Melena can also be observed due to the fact that not all blood came out together with vomit, and part of it got into the intestine. Sometimes profuse bleeding that occurs in the upper intestines quickly moves along it, so a person may have blood stools in its unchanged form.
The severity of the pathology
In medicine, several degrees of severity of the pathology are distinguished, depending on the amount of blood loss:
- A mild degree in which there is a slight loss of blood (about half a liter). The patient's condition is satisfactory, moderate tachycardia is observed, blood pressure is within normal limits.
- The moderate severity is characterized by moderate blood loss, in which a person loses from seven hundred to one liter of blood. The patient has lethargy, dizziness, nausea, decreased blood pressure, pallor of the skin, tachycardia, fainting.
- A severe degree is caused by profuse loss of blood - about one and a half liters. In this case, the skin becomes pale, there is cold sweat, thirst, a person constantly yawns, the pulse increases, and blood pressure drops.
- Extremely heavy blood loss, in which a person loses about two liters of blood. The patient's condition is very serious, there is a prolonged loss of consciousness, the pulse and blood pressure cannot be determined.
Diagnostic measures
In surgery, ways to optimize the diagnosis and treatment of gastroduodenal bleeding are constantly being developed. Of great importance here is the definition of the clinical stages of the disease and the degree of bleeding activity. An integrated approach to the problem makes it possible to choose more effective methods of treating patients.
When a patient is hospitalized, diagnostic measures begin with an assessment of the severity of blood loss, then esophagogastroscopy is performed. But its implementation often aggravates the patient’s situation, as the formation of new tears, the urge to vomit, or an increase in an already existing gap is provoked. Therefore, the procedure is performed after administration of anti-vomiting drugs and intravenous administration of a small dosage of anesthesia to relax a person.
Always diagnosing gastroduodenal bleeding should pursue several goals:
- Establishing accurate localization of bleeding. Upon confirmation of bleeding from the digestive tract, the patient is transferred to the surgical department and further diagnosis is carried out.
- Determination of the duration of this pathology.
- Identification of the cause of the disease and the degree of its manifestation.
- Differentiation of the pathology with myocardial infarction, pulmonary hemorrhage and other diseases that have similar symptoms.
Then the tactics for gastroduodenal bleeding is that the doctor prescribes the following studies:
- Laboratory tests of blood and urine.
- FGDS, which makes it possible to determine the source and nature of the bleeding.
- Radionuclide study.
- Colonoscopy
- ECG.
- Probe test, which involves prolonged gastric lavage with clean water. If it is not possible to reach clean water, this indicates ongoing bleeding.
Properly designed and carried out optimization of the diagnosis and treatment of gastroduodenal bleeding makes it possible to reduce the risk of relapse and save a person’s life. If a pathology is detected, its immediate elimination is carried out. If there are signs of pathology, you can not self-medicate, you must urgently contact a medical institution for an examination and to stop bleeding.
Disease therapy
Treatment of gastroduodenal bleeding will depend on the patient’s condition, endoscopic picture, degree of blood loss, its duration, location of the pathology source, as well as the person’s age. Hospitalization of the patient in the surgical department is necessary on a stretcher.
The tactics of therapy necessarily include endoscopic hemostasis for gastroduodenal bleeding to stop blood loss and prevent relapse. Then, intensive treatment is carried out, which is aimed at stabilizing the human condition, correction of hemodynamic parameters and surgical intervention. The highest risk of relapse (94%) falls on the first four days after the bleeding stops. At this time, the doctor must exercise control over the patient, to prevent the development of bleeding.
Usually, a relapse of the pathology occurs in 30% of cases. Therefore, it is reasonable to perform repeated endoscopy one day after the primary procedure. This approach makes it possible to reduce the risk of death by several times.
Preoperative treatment
Before surgery, the following activities are carried out:
- The patient is urgently hospitalized in the department of surgery on a stretcher.
- Conduct complex hemostatic therapy. At the same time, the patient must observe bed rest, he is given gastric lavage, a Blackmoor probe is introduced, through which adrenaline or norepinephrine will enter the stomach.
- Medical endoscopy is performed by chipping an ulcer with an adrenaline solution, as well as electrocoagulation, laser coagulation, flashing a vessel with a metal clip.
- An artificial embolus is inserted through the femoral artery in order to embolize a vessel that bleeds.
Surgical treatment of gastroduodenal bleeding
Indications for emergency operations are:
- Bleeding that does not stop.
- Severe blood loss.
- A high risk of developing a relapse of the pathology.
Routine surgery is usually performed on the second day after the bleeding stops. Preparation for surgery should include a set of conservative medical measures. The main objectives of surgical treatment are: achieving hemostasis, eliminating the cause of bleeding, resection of the stomach or duodenal vagotomy.
In severe cases of gastroduodenal bleeding, surgery involves excision of a bleeding area on the front wall of the organ, and on the back wall it is stitched. With vagotomy, pyloroplasty is additionally performed. In case of bleeding from the veins of the stomach or esophagus, they are stitched from the epithelium with the help of special forceps. With malignant tumors or metastases, they resort to palliative resection.
With gastroduodenal bleeding, as directed by a doctor, it is necessary to adhere to a special diet, to prevent stress ulcers. Your doctor may prescribe antacids, protein pump inhibitors, and other medications to prevent future bleeding.
Postoperative period
After the operation, treatment is carried out depending on the degree of blood loss, the volume of surgical intervention and the presence of concomitant pathologies. Patients must observe bed rest for five days. During this period, they receive a blood transfusion, they inject protein and albumin, glucose, vitamin C and other drugs. Antiulcer treatment is also carried out under the supervision of a gastroenterologist using drugs such as Amoxicillin and Metronidazole. A doctor and antibacterial drugs are prescribed to prevent the development of infectious processes. With gastroduodenal bleeding, clinical recommendations are aimed at following the Meilengrach diet.
Rehabilitation
During the rehabilitation period, patients should follow a sparing diet and moderate physical activity for eight months after surgery. For those who have been operated on for gastroduodenal bleeding, the recommendations come down to undergoing follow-up examinations every six months. It is necessary to carry out treatment aimed at preventing the development of relapses. With a complication of peptic ulcer, the question of planned surgical intervention is resolved.
Forecast
Among the factors that affect the risk of bleeding are the age of the patients, the presence of concomitant pathologies, the severity of blood loss, the size of the ulcer and its location. Many doctors claim that the risk of bleeding is high in people who are over sixty years old. An unfavorable prognosis will be in the event of a collapse in a person before admission to a medical institution, as well as the development of anemia.
Prevention
In order to prevent the development of bleeding, it is recommended to conduct timely treatment of peptic ulcer and other pathologies that can provoke them. Such patients should be under the supervision of a gastroenterologist. Usually, an exacerbation of diseases is observed in autumn and spring, so at this time it is recommended to undergo routine examinations, to take the necessary tests. Over time, such procedures can be performed once a year.
In the absence of recurrence of pathology for two years of continuous treatment, therapy is prescribed once every two years for one month. This approach reduces the risk of bleeding to a minimum.
It is also necessary to constantly monitor the state of the gastrointestinal tract, apply therapeutic diets No. 1 and No. 5. This will make it possible to gradually reduce the degree of thermal, mechanical and chemical sparing of the epithelium of the stomach and intestines.
Gastroduodenal bleeding is a dangerous condition that causes a fatal outcome. Modern medicine today has insufficiently developed methods for treating patients with such a disease. All these methods are not effective enough, therefore, the risk of death is always there. To prevent the development of pathology, it is necessary to comply with all the appointments and recommendations of doctors, lead a healthy lifestyle and eliminate bad habits. An integrated approach to this problem will help solve the difficult tasks assigned to surgeons during the treatment of such a dangerous pathology.