Profuse ulcerative bleeding. Clinical picture and diagnosis of ulcer bleeding
Profuse bleeding from an eroded vessel in the area of an ulcer is a very dangerous complication of peptic ulcer disease, which is observed in about 15% of patients. Callous penetrating ulcers, especially gastric localization, and ulcers located on the posterior wall of the duodenal bulb bleed more often. Bleeding is often repeated, and subsequent bleeding is often heavier than the previous one. More often bleeding is observed during periods of exacerbation of peptic ulcer disease (spring and autumn). Of the provoking factors, one should bear in mind alcohol, the use of glucocorticoids, reserpine, acetylsalicylic acid, butadione and apticoagulants.
The clinic of bleeding largely depends on the massiveness of the blood loss. There may be dizziness, nausea, weakness, vomiting of blood (usually the color of coffee grounds), often mixed with blood clots, less often – vomiting of scarlet blood. Repeated vomiting of blood is observed, as a rule, with bleeding of moderate severity and severe. If bleeding occurs in the presence of medical personnel, vomit should be carefully examined, for often the so-called vomiting of blood turns out to be vomit of eaten food, only superficially resembling blood. Patients tend to exaggerate the amount of blood that has poured out, therefore, when establishing the amount of blood loss, one should be guided by an objective picture.
Ulcerative bleeding is not always manifested by vomiting of blood. In some cases, especially with duodenal and sometimes gastric ulcers, blood enters the intestines. Then the picture of acute anemia (collapse) comes to the fore. Depending on the severity of the blood loss, there may be pallor of the skin, cyanosis of the lips, acrocyanosis, cold sweat, flickering “smushies” before the eyes, frequent low pulse, lowering blood pressure, confusion, etc. A few hours after massive blood loss, and more often on the next day, tarry stools (melena) are observed. In severe cases, there may be cherry-colored stools.
If there are clinical signs of stopping bleeding, but melena is repeatedly noted within 1-2 days, this does not always indicate renewed bleeding, since the capacity of the intestine is very significant, and emptying is gradual. The diagnosis of gastric bleeding should be rejected if, according to the patient, vomiting of “coffee grounds” was observed, but there was no tarry stool.
With bleeding from the so-called silent ulcers, that is, in patients without a previous ulcerative history and in the absence of vomiting, the only symptom of bleeding at first may be collapse, which makes diagnosis very difficult. “Dumb” ulcers account for 10-20% of the causes of ulcerative bleeding.
On the 2-3rd day after bleeding, the patient may experience hyperthermia and symptoms of intoxication due to rotting blood accumulated in the intestines. Changes in the blood picture, adequate to blood flow, develop after a considerable time after bleeding, therefore, in the first hours, the determination of blood hemoglobin is of very relative importance. The level of decrease in blood pressure is more consistent with the degree of blood loss. The most objective information can be obtained when determining the volume of circulating blood.
An important role is played by a careful study of the history of the disease preceding bleeding. To clarify the diagnosis, you can resort to an emergency X-ray examination. However, the best results will be obtained by an emergency endoscopic examination — esophagogastroduodenoscopy. This diagnostic procedure is performed under local anesthesia with preliminary gastric lavage and in most cases allows an accurate diagnosis.
Differential diagnosis should be carried out with such most common causes of bleeding as varicose veins of the esophagus due to portal hypertension, acute ulcers and ulceration of various origins, hiatal hernia, Mallory-Weiss syndrome, blood diseases (hemophilia, Werlhof’s disease). Often, bleeding can be caused by cancer of the stomach or esophagus, as well as ulceration of a benign tumor. Causes of this kind account for 25 to 30% of the causes of bleeding from the upper gastrointestinal tract. More rarely, the source of bleeding can be aneurysms of the vessels of the submucous layer of the stomach, as well as a breakthrough into the esophagus or stomach of an aneurysm of the aorta, splenic or other arteries. Esophageal foreign bodies with pressure ulcers can also be complicated by bleeding.
In addition, bleeding can occur with burn ulcers of the esophagus and stomach, chronic cholecystitis with ulceration of the gallbladder, hemobilin, hypertension, etc. In most cases, the study of the history of the disease, a thorough examination of the patient, the use of emergency X-ray and endoscopic examinations can correctly assess the source of bleeding.
Treatment . Surgical tactics provides for hospitalization of all patients with gastric bleeding in a surgical hospital. Treatment of such patients begins with the use of intensive hemostatic therapy, which consists in adequate transfusion of fresh citrated blood. In some cases, direct blood transfusion may be beneficial. As much blood should be injected to completely compensate for the blood loss. Infusion of plasma, epsilon aminocaproic acid, traenlol, or calcium chloride may be of some benefit. A positive effect can also be achieved by washing the stomach with a solution of silver nitrate at a dilution of 1: 1000, as recommended by E. L. Berezov. After washing, it is advisable to pour into the stomach through a tube epsilon-aminocaproic acid and thrombin, which contribute to the formation of a clot in the area of the bleeding vessel. During the period of ongoing bleeding, patients should not be fed. After stopping bleeding, it is advisable to prescribe the Meilengracht diet or diet No. 1a but Pevzner.
Conservative treatment is necessary for all patients, regardless of whether surgery is undertaken. In the second case, it will be a kind of preparation for the operation. If an endoscopic examination is undertaken for diagnostic purposes, then it, in addition, can be a medical procedure. In some cases, it is possible to successfully coagulate a bleeding vessel and apply a special glue to this area – lifuzol. If persistent hemostatic therapy, carried out for 3-6 hours, is ineffective, the patient must be urgently operated on. It is clear that operations at the height of bleeding are accompanied by greater mortality than operations in the cold period. In the most recent years, the method of selective catheterization of a bleeding artery with its subsequent embolization began to gain popularity.