Gastrointestinal bleeding

Reasons

Syndrome of gastrointestinal bleeding of different severity occurs as a complication of various diseases, which number more than two hundred (Brasu W., Peterson WL, 1997; Aabakken S., 2001; Karanicolas PJ et oth., 2008; Neu B. et al. 2005). It is characterized by the presence of blood in the digestive tract, which comes from damaged vessels, ensuring the influx and outflow of blood from the digestive system. It manifests itself in a greater or lesser amount of blood and its decay products in the feces, and in some patients with the occurrence of bloody vomiting ^[2] .

Gastrointestinal bleeding syndrome can be fatal. All bleeding is primarily divided 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 Treitz ligament ) ^[3] .

History

The history of the study of gastrointestinal bleeding is extremely complex, since this syndrome is a manifestation of a wide range of diseases. At the moment, bleeding with Meckel’s diverticulum , polyposis, typhus and typhoid fever , cholera , intussusception and a number of other diseases of various etiologies and nature are described.

The first cases of gastrointestinal bleeding include two autopsy cases of gastrointestinal bleeding from superficial and small stomach ulcers described by T. Gallard in 1884. 14 years later, Dieulafoy (Delafua) in 1897-1898. re-described this pathology and verified it as an independent disease called Delafua's ulcer.

It is also worth mentioning the works of Carman, Fineman, (1924) and Hedbloom (1925) in which bleeding and anemia were first described as one of the complications of hiatal hernia.

1929 Mallory and Weiss described mucosal ruptures of the cardioesophageal zone, later called Mallory-Weiss syndrome .

In the 30s of the 20th century, a number of works were devoted to the development of acute gastrointestinal bleeding as complications of malignant and benign tumors of the digestive system. In particular, A. A. Dikshtein (1939) on the basis of sectional data found that gastric cancer complicated by profuse bleeding, from 4.6 to 15.9% of cases is the cause of death among all deaths from acute gastrointestinal bleeding.

In the future, every decade of the 20th and 21st centuries, the scientific community received new data on the causes of gastrointestinal bleeding and there was a consistent expansion of the list of diseases that may be accompanied by this complication.

Thus, it is obvious that in fact the history of the study of gastrointestinal bleeding is being written to the present day.

Bleeding is distinguished from the upper part of the gastrointestinal tract ( esophagus , stomach , duodenum 12 ) and the lower part (small and large intestines , rectum ), which are usually manifested by various signs and thus contribute to a certain extent to establish the causes of bleeding and conduct appropriate therapeutic measures ^[2] .

The distinction between them takes place at the level of the ligament of the Treitz. Some authors (P.R. McNaLly, 1998; BSLewis, 1995; May A. et al. 2005; Karanicolas PJ et al. 2008) identify bleeding from the small intestine as a separate group of bleeding from the lower gastrointestinal tract due to the peculiarities of their manifestations. and diagnostics. In such cases, the source of bleeding is located in the intestinal tube between the Terez ligament and the ileocecal valve.

Upper GI Bleeding

The main causes of bleeding from the upper gastrointestinal tract are presented in table 1 ^[3] .

Lower GI bleeding

The most common causes of bleeding from the lower gastrointestinal tract according to A. A. Sheptulin (2000) are:

• angio dysplasia of the small and large intestine;

• intestinal diverticulosis (including Meckel diverticulum );

• tumors and polyps of the colon;

• tumors of the small intestine;

• chronic inflammatory bowel disease;

• infectious colitis;

• intestinal tuberculosis;

• hemorrhoids and anal fissures ;

• foreign bodies and intestinal injuries;

• aortic intestinal fistula;

• helminthiases .

Symptoms of bleeding are heterogeneous. Expanded symptoms of gastric bleeding in patients include bloody vomiting and charcoal-black stools ( melena ). They are preceded by a period characteristic of all types of bleeding - a syndrome of increasing weakness. In a patient with bleeding, blanching of the sclera and skin is observed. A man throws cold sweat. With massive blood loss, moderate acute anemia, fainting, collapse and shock are recorded.

But the presence of bloody vomiting and tar-like stool does not apply to the initial symptoms. Black stool is able to form both in a few hours, and on the second day after bleeding has opened. Scarlet blood during bowel movements, as well as tarry stools, are more likely to indicate localization of bleeding in the upper part of the digestive tract ^[4] .

The problem is that the appearance of these classic signs requires a serious enough blood loss. So, vomiting with blood is usually observed with blood loss of more than 500 ml and is always accompanied by chalk. In this case, the doctor immediately has the opportunity to differential diagnosis of the cause of bleeding, because when bleeding from the artery of the esophagus in the vomit there is unchanged blood, when bleeding from the varicose veins of the esophagus, the blood in the vomit is dark cherry in color, and when bleeding from the stomach the vomit gets a characteristic brown color ( the color of "coffee grounds"). However, in the latter case, vomiting of coffee grounds may simultaneously contain unchanged blood, which indicates a low level of acidity in the patient’s stomach. Blood acquires a brown color when hemoglobin interacts with hydrochloric acid, therefore, with massive bleeding against a background of low acidity, the blood does not have time to completely oxidize and vomiting is mixed ^{[5] [6] [7]} .

In turn, melena (plentiful liquid tarry stools) can both supplement vomiting with blood, and can be an independent symptom of gastrointestinal bleeding. Regardless of vomiting, melena occurs with bleeding from the duodenum or with the slow development of gastric bleeding. In any case, melena indicates that the patient has been bleeding for several hours (usually more than 8), while the amount of blood loss should also be at least 500 ml. With less blood loss, darkening of the stool will occur, but it will remain framed. The same picture will be observed when the passage of intestinal contents is slowed ^{[8] [9] [10]} .

On examination, patients with gastrointestinal bleeding can be both restless and inhibited, they may experience a decrease in blood pressure with the simultaneous development of tachy or bradycardia, weakness, pallor of the skin and mucous membranes.

If gastrointestinal bleeding is suspected, it is advisable to prescribe a general blood test to the patient with a determination of the level of hemoglobin and other main blood cells, as well as a leukocyte count and ESR. Initially, the composition of the blood during bleeding may practically not change, however, over time, moderate leukocytosis will gradually appear, which may be supplemented by a slight increase in the number of platelets and ESR. Further (most often on the second day) there is a decrease in the number of hemoglobin and red blood cells, which will be determined in the blood even if the bleeding has stopped.

An additional source of data can be a coagulogram , because after acute profuse bleeding, blood coagulation activity increases significantly.

In a biochemical analysis, bleeding may indicate urea growth against normal creatinine levels.

Referral of a patient for a test for occult blood can be a good help.

At the moment, such a diagnostic procedure is not too often used by Russian doctors, although for all its simplicity it is an important element in the timely diagnosis of gastrointestinal bleeding. In particular, according to the recommendations of the World Health Organization (WHO), all men and women aged 50 to 74 years must undergo this analysis at least once every year.

The use of an immunochemical test for occult blood is optimal, since unlike the guaiacol test, the immunochemical test significantly reduces the likelihood of false results, and also simplifies the procedure for collecting material for analysis ^[11] .

To identify the source of gastrointestinal bleeding, first of all, as a rule, an endoscopic examination is prescribed, in which the esophagus, stomach and duodenum are examined. Often, it is the endoscopy of the mucosa that confirms the diagnosis and indicates the localization of the site of bleeding.

To diagnose chronic gastrointestinal bleeding, a contrast radiography is performed. The study gives a picture of the state of the walls of the digestive tract with the identification of possible ulcers, hernias and other pathological conditions.

In case of vascular disorders, angiography is connected to the examination procedure. For a more complete clinical picture, in cases of possible complications, a radioisotope scan and magnetic resonance imaging are performed if the medical institution has equipment of this class ^[4] .

The basis of first aid is ice, peace and emergency call. While the ambulance is on the way, create an atmosphere of peace around the patient. Quickly lay the person horizontally and raise his legs. It is advisable to put ice on the stomach. Uncontrolled intake of drugs is fraught with consequences, especially with gastrointestinal bleeding. But in emergency cases, when the symptomatology takes on a pronounced character, calcium gluconate 10% and two cubes of vicasol are intramuscularly administered.

In a first-aid kit, a potential patient should have drugs:

• glacial aminocaproic acid ;

• calcium chlorine 10% in ampoules;

• syringes for 5 and 10 cubes;

• Dicinon tablets;

• Vikasol 5% in injections.

Tablets are taken in extreme cases. It is better to grind a tablet, and instead of water, “wash down” the powder with pieces of ice. Drinking water during gastrointestinal bleeding is strictly prohibited! ^[4] .

Separate bleeding in children and in the elderly

Gastrointestinal bleeding in children

The main feature of gastrointestinal bleeding in children is the etiology of gastrointestinal bleeding syndrome in childhood. Unlike adult patients, whose ulcer bleeding is the main cause of this type of bleeding, in pediatric patients this syndrome is usually caused by pathology in the development of organs and systems of the child’s body.

The main causes of gastrointestinal bleeding in children include:

• Hemorrhagic disease of the newborn
• Esophagitis and reflux esophagitis in infants and infants
• Gastritis and peptic ulcer of the stomach and duodenum
• Gastric Doubling
• Incomplete bowel rotation with obstruction.
• Ulcerative necrotic enterocolitis of newborns.
• Doubling of the small intestine.
• Mallory Weiss Syndrome
• Esophageal hernia
• Intestinal polyps, in particular juvenile (hamartomic) polyps
• Meckel's diverticulum
• Dielafua disease

In children older than 3 years, the most likely cause of gastrointestinal bleeding from the upper gastrointestinal tract is varicose veins of the esophagus. In 85% of children, bleeding from the veins of the esophagus occurs at the age of 5-10 years, is one of the frequent clinical manifestations of portal hypertension syndrome.

Gastrointestinal bleeding in the elderly

The elderly patient is one of the main risk factors for gastrointestinal bleeding, and also increases the likelihood of death in acute massive gastrointestinal bleeding.

Also, the specificity of bleeding from the gastrointestinal tract in the elderly should include a significant increase in the proportion of colon diverticulosis in the list of the main causes of bleeding. The frequency of this pathology increases with age ^[12] ; after 70 years, diverticula are detected by colonoscopy in every 10th patient. A sedentary lifestyle, impaired colon function (a tendency to constipation), intestinal dysbiosis, and bleeding, often massive, contribute to the formation of diverticulums, and complicate the course of diverticulosis in 10-30% of cases. It is believed that diverticula are more often localized in the descending and sigmoid colon, however, they are found in the transverse colon and in the right half of the colon. Bleeding with diverticulosis may be preceded by abdominal pain, but often it begins suddenly and is not accompanied by pain. Blood flow can stop on its own and recur after a few hours or days. In almost half of cases, bleeding is single

Gastrointestinal bleeding can cause severe complications such as:

• hemorrhagic shock (a serious condition associated with massive blood loss);
• anemia (anemia);
• acute renal failure (severe renal impairment );
• multiple organ failure (severe nonspecific stress response of the body, developing as the final stage of most acute diseases and injuries).

In case of untimely seeking medical help, gastrointestinal bleeding can cause not only serious complications, but also the death of the patient.

After confirming the fact of gastrointestinal bleeding and establishing its source, treatment begins, which can be either conservative in nature or require surgical intervention. Surgical treatment, as a rule, is planned, after undergoing a course of conservative therapy, however, in life-threatening conditions, indications for emergency surgical intervention may occur. In general, the management of a patient with gastrointestinal bleeding depends on the underlying disease, the complication of which was bleeding.

General principles for the treatment of patients with gastrointestinal bleeding are determined by the severity of his condition.

With a low severity:

• больному рекомендуют принимать только измельченную пищу, не травмирующую слизистую;
• назначаются уколы викасола;
• выписываются кальцийсодержащие препараты и витамины.

При состоянии средней тяжести:

• проводится лечебная эндоскопия, при которой химически или механически воздействуют на кровоточащий участок;
• в некоторых случаях проводят переливание крови.

При высокой тяжести состояния:

• проводятся срочные реанимационные мероприятия и хирургическое вмешательство;
• рекомендуется реабилитация в стационаре.

Профилактика кровотечений ЖКТ

Учитывая, что кровотечения ЖКТ являются синдромом на фоне различного рода заболеваний, основой профилактики желудочно-кишечных кровотечений являются регулярные осмотры врачами-специалистами, а также своевременное и адекватное лечение уже выявленной патологии. Лицам пожилого возраста можно рекомендовать ежегодно сдавать анализ на скрытую кровь.

Диета при ЖКТ кровотечениях

Диета при ЖКТ кровотечениях должна определяться основным заболеванием. К примеру, при заболеваниях желудочно-кишечного тракта может назначаться диета № 1 (при язвенной болезни желудка или двенадцатиперстной кишки в стадии затихания обострения при рубцевании язвы, а также в период ремиссии), диета № 1а (при обострении язвенной болезни в течение первых 8-10 дней лечения при кровотечении), диета № 1б (после диеты № 1 а), диеты № 2, 3, 4, 5, 5п. Своя специфика диетического питания будет наблюдаться и при прочих заболеваниях осложнением которых являются кровотечения ЖКТ. Поэтому подбор конкретной диеты должен производиться лечащим врачом с учётом основного и сопутствующих заболеваний пациента.