Gastrointestinal bleeding – the expiration of blood from the erozirovanny or injured by pathological process blood vessels in a gleam of digestive bodies. Depending on degree of blood loss and localization of a source of gastrointestinal bleeding there can be vomiting of color of "a coffee thick", a tar-like chair (melena), weakness, tachycardia, dizziness, pallor, cold sweat, unconscious states. The source of gastrointestinal bleeding is established in the course the given FGDS, enteroskopiya, kolonoskopiya, rektoromanoskopiya, a diagnostic laparotomy. The stop of gastrointestinal bleeding can be made in the conservative or surgical way.
Gastrointestinal bleeding serves as the most frequent complication of a wide range of sharp or chronic diseases of the digestive system posing potential hazard to life of the patient. Any department of a GIT – a gullet, a stomach, a small and large intestine can be a source of bleeding. On occurrence frequency in gastroenterology gastrointestinal bleeding costs on the fifth place after an acute appendicitis, cholecystitis, pancreatitis and the restrained hernia.
Reasons of gastrointestinal bleeding
Today more than hundred diseases which can be followed by gastrointestinal bleeding are described. Everything gemorragiya can conditionally be divided into 4 groups: bleedings at damage of a GIT, portal hypertensia, damages of vessels and diseases of blood.
The bleedings arising at damages of a GIT can be caused by stomach ulcer of a stomach or stomach ulcer of 12 items of a gut, ezofagity, new growths, diverticulums, hernia of an esophageal opening of a diaphragm, a disease Krone, nonspecific ulcer colitis, hemorrhoids, an anal crack, helminthoses, injuries, foreign matters etc. Gastrointestinal bleedings against the background of portal hypertensia, as a rule, arise at chronic hepatitises and cirrhoses of a liver, thrombosis of hepatic veins or systems of a vorotny vein, a konstriktivny perikardit, squeezing of a vorotny vein tumors or hems.
The gastrointestinal bleedings developing as a result of damage of vessels of an etiologicheska and pathogenetic can be connected with a varicosity of a gullet and stomach, a nodular periarteriit, a system red volchanka, a sklerodermiya, rheumatism, a septic endocarditis, avitaminosis With, atherosclerosis, Randyu-Osler's disease, thrombosis of mezenterialny vessels, etc.
Gastrointestinal bleedings quite often arise at diseases of system of blood: hemophilia, sharp and chronic leukoses, hemorrhagic diathesis, avitaminosis To, gipoprotrombinemiya and so forth. Reception of aspirin, NPVS, corticosteroids, alcoholic intoxication, vomiting, contact with chemicals, physical tension, a stress, etc. can be the factors which are directly provoking gastrointestinal bleeding.
The mechanism of developing of gastrointestinal bleeding can be caused by violation of integrity of vessels (at their erosion, a rupture of walls, sclerous changes, an embolism, thrombosis, a rupture of aneurisms or varicose knots, the increased permeability and fragility of capillaries) or changes in system of a hemostasis (at a trombotsitopatiya and thrombocytopenia, violations of system of fibrillation). Quite often both the vascular, and gemostaziologichesky component is involved in the mechanism of development of gastrointestinal bleeding.
Classification of gastrointestinal bleedings
Depending on department of the digestive tract which is a gemorragiya source distinguish bleedings from the top departments (esophageal, gastric, duodenal) and the lower departments of a GIT (tonkokishechny, tolstokishechny, gemorroidalny). Gastrointestinal bleedings of the top departments of a digestive tract make 80-90%, of lower - 10-20% of cases.
According to the etiopatogenetichesky mechanism allocate ulcer and not ulcer gastrointestinal bleedings. On duration of a gemorragiya distinguish sharp and chronic bleedings; on expressiveness of clinical signs – obvious and hidden; by quantity of episodes – single and recidivous.
On weight of blood loss allocate three degrees of bleedings. Easy degree of gastrointestinal bleeding is characterized by ChSS – 80 in min., systolic HELL – is not lower than 110 mm of mercury., satisfactory condition, safety of consciousness, slight dizziness, normal diuresis. Blood indicators: Er - higher than 3,5Õ1012/l, Hb – is higher than 100 g/l, Ht – more than 30%; deficiency of OTsK – no more than 20%.
At gastrointestinal bleeding of average weight of ChSS makes 100 in min., systolic pressure – from 110 to 100 mm of mercury., consciousness is kept, integuments pale, are covered cold then, the diuresis is moderately lowered. In blood decrease in quantity of Er to 2,5Õ1012/l, – to 100-80 g/l, Ht – to 30-25% is defined by Hb. Deficiency of OTsK is equal to 20-30%.
It is necessary to think of heavy degree of gastrointestinal bleeding at ChSS more than 100 . in min. weak filling and tension, systolic HELL less than 100 mm of mercury., block of the patient, adinamiya, sharp pallor, oliguriya or anury. The quantity of erythrocytes in blood less than 2,5Õ1012/l, the Hb level – is lower than 80 g/l, Ht – less than 25% at deficiency of OTsK of 30% and above. Bleeding with massive blood loss call profuzny.
Symptoms of gastrointestinal bleeding
The clinic of gastrointestinal bleeding demonstrates from the symptoms of blood loss depending on intensity of a gemorragiya. Bleeding from a GIT is followed by weakness, dizziness, poverty of skin, perspiration, noise in ears, tachycardia, arterial hypotonia, confusion of consciousness, sometimes – faints.
At bleedings from the top departments of a GIT there is bloody vomiting () having an appearance of "a coffee thick" that is explained by contact of blood with hydrochloric acid. At profuzny gastrointestinal bleeding emetic masses has scarlet or dark red color. The tar-like chair (melena) is other characteristic sign of sharp gemorragiya from a GIT. Existence in excrements of clots or a streak of scarlet blood testifies to bleeding from obodochny, a rectum or the anal channel.
Symptoms of gastrointestinal bleeding are followed by symptoms of the main disease which led to a complication. At the same time can note pains in various departments of a GIT, ascites, intoxication symptoms, nausea, a dysphagy, an eructation etc. The latent gastrointestinal bleeding can be revealed only on the basis of laboratory signs - anemia and positive reaction a calla on the hidden blood.
Diagnosis of gastrointestinal bleeding
Inspection of the patient with gastrointestinal bleeding there begin with careful clarification of the anamnesis, assessment of character of emetic masses and excrements, carrying out a manual rectal research. Pay attention to coloring of integuments: existence on skin of teleangiektaziya, petekhiya and hematomas can testify to hemorrhagic diathesis; yellowness of skin - about trouble in gepatobiliarny system or a varicosity of a gullet. The palpation of a stomach is carried out carefully, in order to avoid strengthening of gastrointestinal bleeding.
From laboratory indicators calculation of erythrocytes, hemoglobin, gematokritny number, platelets is carried out; koagulogramma research, determination of level of creatinine, urea, hepatic tests. Depending on the suspect of a source of a gemorragiya of diagnosis of gastrointestinal bleedings various radiological methods can be applied: gullet X-ray analysis, stomach X-ray analysis, irrigoskopiya, angiography of mezenterialny vessels, tseliakografiya. The most bystry and exact method of inspection of a GIT is the endoscopy (an ezofagoskopiya, gastroscopy, FGDS, a kolonoskopiya) allowing to find even superficial defects mucous and a direct source of gastrointestinal bleeding.
For confirmation of gastrointestinal bleeding and identification of its exact localization radio isotope researches (a GIT stsintigrafiya with marked erythrocytes, a dynamic stsintigrafiya of a gullet and stomach, a static stsintigrafiya of intestines, etc.), MSKT of abdominal organs are used. Gastrointestinal bleedings need to be differentiated from pulmonary and nasopharyngeal bleedings for what use radiological and endoscopic inspection of bronchial tubes and a nasopharynx.
Treatment of gastrointestinal bleedings
Patients with suspicion of gastrointestinal bleeding are subject to immediate hospitalization in surgical office. After specification of localization, the reasons and intensity of bleeding medical tactics is defined.
At massive blood loss haemo transfusion, infusional and haemo static therapy is carried out. Conservative tactics at gastrointestinal bleeding is reasonable in case of the gemorragiya which developed because of violation of a hemostasis; existence of a serious interkurrentny illness (heart failure, heart diseases, etc.), inoperable cancer processes, heavy leukosis.
At bleeding from varikozno expanded veins of a gullet its endoscopic stop by an alloying or a sklerozirovaniye of the changed vessels can be carried out. According to indications resort to an endoscopic stop of gastroduodenal bleeding, a kolonoskopiya with electrothermic coagulation or an obkalyvaniye of the bleeding vessels.
In some cases the surgical stop of gastrointestinal bleeding is required. So, at stomach ulcer the proshivaniye of the bleeding defect or an economical resection of a stomach is made. At an ulcer of the 12-perstny gut complicated by bleeding, proshivany ulcers supplement stem vagotomiy and piloroplastiky or antrumektomiy. If bleeding is caused by nonspecific ulcer colitis, make a subtotal resection of a thick gut with imposing ileo-and sigmostoma.
The forecast at gastrointestinal bleedings depends on the reasons, degree of blood loss and an all-somatic background (age of the patient, associated diseases). The risk of a failure is always extremely high.