The bleeding stomach ulcer
The bleeding stomach ulcer – the complication of stomach ulcer consisting in the expiration of blood in a stomach cavity from the damaged vessels (arrozirovanny arteries, veins or capillaries). Symptoms are defined by expressiveness of bleeding; the main manifestations – vomiting "a coffee thick", a "tar-like" chair, signs of a gipovolemiya and system violations of haemo dynamics. The most important method of diagnostics is the ezofagogastroduodenoskopiya during which the hemostasis can be executed. Treatment in most cases surgical; at the small volume of blood loss, and also at patients of group of high risk the conservative stop of bleeding is carried out.
The bleeding stomach ulcer
The bleeding stomach ulcer – one of the most widespread complications of stomach ulcer of a stomach which occurs at 10-15% of patients of all age groups and makes about 50% of all gastrointestinal bleedings. However statistics inexact: the big percent of cases just is not registered - not plentiful blood loss masks symptoms of an exacerbation of the main disease. The most often this pathological state develops at the ulcers localized on small curvature of a stomach. Gastric bleeding is an urgent problem of gastroenterology as its prevalence grows, and, despite constant improvement of methods of an endoscopic, medicamentous hemostasis and early diagnostics, the lethality remains high – about 9%.
The reasons of the bleeding stomach ulcer
Most often chronic kallezny, sharp stomach ulcers in the presence at the patient of pathology of cardiovascular system, and also the ulcer defects developing against the background of application of glucocorticosteroids are complicated by bleeding. Progressing of inflammatory and destructive processes in a defect zone, the increased permeability of capillaries, and also fibrillation violation are the main reasons for development of this complication. Usually the arrozirovanny artery bleeds, is more rare – a vein or a large number of the small vessels localized in the field of an ulcer bottom (the latent diapedezny bleeding in that case develops). Formation of the bleeding ulcer can be promoted by mechanical or chemical injuries mucous, a physical or psychoemotional overstrain, neurotrophic and tromboembolichesky defeats of a wall of a stomach and hypovitaminoses.
Blood loss is the reason of serious condition of patients. At loss less than 15% of volume of blood of essential violations there is no system haemo dynamics as protective mechanisms are activated: angiospasm of skin and abdominal organs, opening of arteriovenozny shunts, increase in ChSS. The blood-groove in vitals remains, and in the conditions of the termination of blood loss the volume of the circulating blood is restored at the expense of natural depots. At loss more than 15% of OTsK the generalized spasm of blood vessels, substantial increase of frequency of reductions of heart and transition of interfabric liquid to the vascular course initially have compensatory character, and then pathological. The system blood-groove is broken, microcirculation, including in heart, a brain, kidneys suffers, arterial hypotension develops, compensation mechanisms are exhausted. Development of a liver, renal failure, hypostasis of a brain, a myocardial infarction and gipovolemichesky shock is possible.
Symptoms of the bleeding stomach ulcer
Symptoms of this pathological state are defined by degree of blood loss and duration of bleeding. The latent bleeding ulcers are shown by the general weakness, dizziness, pallor of skin. Hemoglobin in acidic environment of a stomach is metabolized, gaining dark color, and in case of vomiting coloring of emetic masses at "coffee with milk" color is characteristic.
In case of profuzny bleeding the main sign is bloody vomiting which can be single or repeating. Emetic masses has characteristic color of "a coffee thick". In rare instances of massive bleeding from an artery vomiting scarlet blood with clots is possible.
Obligatory symptom of the bleeding stomach ulcer with loss more than 50 ml of blood are the "tar-like" chair arising in several hours or next day. At bleeding which volume does not exceed 50 ml the kalovy mass of a normal consistence is painted in dark color.
Many patients note strengthening of intensity of symptoms of stomach ulcer (stomach pain, the dispepsichesky phenomena) for several days, and also their disappearance from the beginning of bleeding (Bergman's symptom). Also such signs as thirst, dryness of skin, decrease in a diuresis, morbidity at a stomach palpation are possible.
The general symptoms of the bleeding ulcer are caused by blood loss degree. At deficiency of volume of the circulating blood less than 5 percent (1 severity) arise insignificant violations of system haemo dynamics; the health of the patient remains satisfactory, arterial pressure within a noma, pulse is speeded a little up. At deficiency of 5-15 percent of volume of the circulating blood (the 2nd degree of blood loss) patients note slackness, dizziness, unconscious states are possible, systolic arterial pressure is lower than 90 mm of mercury., pulse is considerably speeded up. At loss more than 15-30 percent of OTsK (the 3rd degree) a condition of patients heavy, the expressed pallor of skin and mucous, pulse threadlike, frequent, systolic arterial pressure lower than 60 is noted. Deficiency more than 30 percent of volume of blood (the 4th degree) is followed by consciousness violation, the state extremely heavy, arterial pressure is lowered to critical level, pulse is not defined.
Diagnosis of the bleeding stomach ulcer
Consultation of the gastroenterologist with detailed studying of the anamnesis of a disease, complaints of the patient and objective data allows to assume existence of this pathology even at the small volume of blood loss. At objective inspection of the patient pallor of integuments, decrease in turgor of skin attracts attention, morbidity at a stomach palpation in epigastralny area is possible. In the general blood test decrease in hemoglobin and erythrocytes is defined.
Obligatory method of diagnostics at gastric bleeding is the ezofagogastroduodenoskopiya. Diagnostic endoscopy is carried out in all cases when there are reasonable suspicions on existence of ulcer bleeding. The only contraindication is the agonalny condition of the patient when results of a research cannot affect a disease outcome. EGDS allows to visualize a bleeding source, to differentiate the bleeding ulcer from other reasons of gastrointestinal bleeding. In most cases the diagnostic procedure passes into medical. It is proved that the early endoscopic hemostasis considerably reduces the frequency of a recurrence, need of surgical interventions, and also a lethality.
Differential diagnostics is carried out with gastric bleeding of other etiology: at malignant tumors, stomach polyps, Mallori-Weiss's syndrome, pathology of the curtailing system of blood, cardiovascular system.
Treatment of the bleeding stomach ulcer
Suspicion of the bleeding stomach ulcer is the direct indication to the emergency hospitalization of patients in surgical office. Inspection in out-patient conditions is categorically inadmissible. To all patients the high bed rest, full hunger is appointed (after a bleeding stop – Meylengrakht's diet). The conservative hemostasis includes transfusion of medicines of blood, plasma, introduction of fibrinogen, aminocaproic acid, chloride calcium, Vikasolum, atropine, and also oral administration of aminocaproic acid. Conservative treatment can be carried out to patients of group of high risk (advanced age, the heavy accompanying pathology), and also at easy and moderate severity of bleeding.
Now effective methods of an endoscopic hemostasis are developed: thermal (electrothermic coagulation, the thermoprobe, laser, radio-frequency and argonoplazmenny coagulation), injection (local introduction of adrenaline, novocaine, physiological solution and sklerozant), mechanical (a stop of gastroduodenal bleeding by clipping or an alloying of the bleeding vessels at a gastroduodenoskopiya) and use of haemo static materials (biological glue, haemo static powder).
Indications to performing surgical treatment are heavy degree of bleeding irrespective of ulcer type, the combination to other complications of stomach ulcer (a penetration, a piloroduodenalny stenosis), the repeated and not stopping under the influence of conservative methods of a hemostasis bleedings. The concrete choice of operation is defined by localization of an ulcer and specific features. The stomach resection according to Billroth of I or II can be executed, excision, ushivany stomach ulcers, a proshivaniye of vessels of a bottom of ulcer defect, is possible a combination to a vagotomiya.
Forecast and prevention
The forecast is defined by the volume of blood loss and timeliness of rendering the specialized help. Now only active surgical tactics of treatment is considered correct (in the absence of contraindications). Besides bleeding stop speed, the forecast depends on safety of compensatory mechanisms of the patient, adequate completion of volume of the circulating blood. At profuzny bleedings the high percent of a lethality is registered.
Prevention of the bleeding stomach ulcer consists in the timely address to the gastroenterologist in the presence of complaints from a stomach, adequate treatment of stomach ulcer according to the existing standards, medical examination of patients and regular inspection.