Gastrointestinal bleeding

Gastrointestinal bleeding in medicine is considered the outflow of blood into the lumen of the gastrointestinal tract. Definition is important to remember and distinguish from bleeding in the abdominal cavity, when the source is the digestive system( example - rupture of the intestine).

The most developed vasculature in the esophagus, stomach and duodenum. Therefore, bleeding from the upper part of the gastrointestinal tract( GIT) is characterized by massive blood loss, rapid formation of anemia, severe shock state of patients.

What diseases are bleeding?

The source of bleeding may be in different parts of the gastrointestinal tract. Complication in the form of perforation of the vessel wall occurs with many diseases, differ in frequency. In the first place - esophageal and gastroduodenal hemorrhages. They are considered dangerous for the life of the patient.

From the lower parts, represented by a thin, large intestine, bleeding occurs less frequently, accompanies chronic diseases, does not cause acute blood loss and anemia. Group # 1 - is represented by the most frequent reasons, in practice it is precisely the "supplier" of all severe cases. It includes:

• peptic ulcer of the stomach and duodenum( 55-80% of all bleedings);
• development of acute ulcers on the background of stress, medication;
• Mallory-Weiss Syndrome;
• disintegrating tumors;
• erosive or hemorrhagic form of gastritis and duodenitis;
• portal hypertension with cirrhosis of the liver with varicose veins of the esophagus, the initial part of the stomach.

Group 2 - unites the more rare causes of bleeding: diverticula and polyposis proliferation in the stomach and duodenum, infringement of the hernia in the esophageal aperture of the diaphragm, Randyu-Osler syndrome and Zollinger-Ellison.

Group number 3 - consists of a pathology that represents casuistic cases: blood diseases( hemophilia, thrombocytopenic states, Shenlaine-Henoch), the result of radiation sickness, beriberi, rare cases of tuberculosis or syphilis of the stomach, vasculitis and hemorrhagic diathesis.

Developmental mechanism

Bleeding from the upper gastrointestinal tract in case of peptic ulcer, Mallory-Weiss syndrome, disintegrating stomach tumor originate from arterial vessels or mixed( arterial-venous).With the expiration of blood from the enlarged veins of the esophagus by massiveness, the venous form is comparable with the arterial form. These species are characterized by severe blood loss, shock.

Erosive gastroduodenitis first causes a small discharge of blood from the superficial ulcers due to damaged capillaries. But with a large area of ​​damage, deepening the process of destruction involve large vessels. This can also cause severe blood loss. Such life-threatening bleeding causes a lethal outcome, according to various sources, in 6-20% of cases.

As a result of hemorrhage, the picture of hemorrhagic shock develops against the background of a decrease in the volume of circulating blood. With disturbed microcirculation, acidic residues accumulate in the tissues, acidosis and oxygen starvation occur. The process goes on in all organs and systems. If the loss of blood is not prolonged for a long time, the functions of the organs are violated, a partial cell death occurs.

Physiologists call the process a transition from a labile stage to a torpid one. Necrosis provokes the continuation of bleeding. The appearance of new ulcers and erosions of hypoxic origin is observed in the stomach. A "vicious circle" is formed. With prolonged bleeding, changes occur in the coagulation system. In 50% of patients, the coagulation and recalcification times are reduced by a factor of 2.

Simultaneously, plasma resistance to heparin increases. The condition indicates the development of hypercoagulation. Continuation of the disease leads to activation of the anticoagulation system, a decrease in the content of fibrinogen. Prolonged bleeding from the gastrointestinal tract passes into the DIC syndrome( massive intravascular coagulation).

Classification of

In Forrest, a classification is distributed that identifies endoscopic signs of bleeding. Forrest I - continuing forms:

• Ia - arterial;
• Ib - venous.

Forrest II - bleeding stopped, confidence in stability no:

• IIa - visually determined thrombosed artery;
• IIb - a loosened blood clot is seen in the area of ​​the ulcer.

Forrest III - a stable stop of bleeding, on the ulcerous fibrin film. Depending on the degree, two classifications are popular: clinical and hematocrit. They are combined in practice. Blood loss is divided by the degrees shown in the table.

Signs of bleeding	Easy( 1 degree)	Severity( 2 degree)	Severe( grade 3)
Deficiency of bcc *	up to 20%	20-30%	30% or more
Blood pressure	normal, insignificant decrease( 100/ 60)	not lower than 80/50	systolic at level 60-80, lower is not determined
Heart rate per minute	80-90	100-130	130 or more
Hematocrit	30 or more	25-30%	less than25%
Number of erythrocytes	up to 3.5 million	2.5-3.5 million	2-2.5 million
ClinicalSingle symptomatology	black stools singly + hematemesis, overall slightly changed.	vomiting and loose stools are repeated, severe weakness, pale skin, shortness of breath, sticky sweat, small discharge of urine, temporary loss of consciousness is possible.	repeated vomiting and tarry stools, pale skin with a bluish tinge, inhibition, often loss of consciousness, superficial frequent breathing( transition to rare is possible), urine is not secreted, body temperature is lowered, limbs are cold.

* BCC - volume of circulating blood.

To determine blood loss, doctors use a table in which, depending on the hematocrit indicator, there are data on the blood rate per kilogram of patient weight and deficiency.

Symptoms of

Cases of bleeding from highly located parts of the gastrointestinal tract are very similar in appearance. Differences are minor, but they can be more accurately established source. The symptomatology consists of the signs of hemorrhagic shock and acute anemia( anemia), external symptoms.

In acute anemia, which turns into hemorrhagic shock, the patients experience:

• sudden dizziness;
• is exacerbated by weakness;
• flashes of small spots before your eyes;
• possible short-term attacks with loss of consciousness;
• pain in the region of the heart;
• shortness of breath.

. The initial stage activates protective mechanisms: the blood exits the depot, the blood circulation is centralized to provide the functions of vital organs. Blood pressure remains normal or increases. The drop in pressure indicates a depletion of reserve capacity and the continuation of bleeding, therefore it is a bad prognosis.

Blood counts change steadily only 12-24 hours after the onset of hemorrhage: the hematocrit, the number of red blood cells, the hemoglobin value and the color index can be used to judge the degree of blood loss. A more accurate technique is the measurement of bcc. External manifestations include the following manifestations.

Bloody vomiting - often occurs with lesions of the esophagus and stomach. If the blood expires from the esophagus, then it has a cherry color, liquid or with clots. With gastric emesis, the hemoglobin of the erythrocytes reacts with hydrochloric acid and forms a brown hydrochloric acid hematin. Therefore, vomiting resembles "coffee grounds".

Black tarry stool( melena) - can be without vomiting, accompanies bleeding from the duodenum. When the source is located in the esophagus or stomach, it is combined with bloody vomiting. The more massive the bleeding, the faster melena appears. Blood upon ingestion in the intestine enhances its peristalsis.

Based on the color of feces, a differential source is diagnosed from the upper gastrointestinal tract and large intestine. In the lower part of the digestive tract, no hydrochloric acid is formed, so the stools are colored in a bright crimson color. And the presence of mucus makes the feces look like a "raspberry jelly".

How to identify the source?

The task of the doctor to establish not only a source of bleeding, but also to determine the condition of the damaged vessel( continues to heal, there is a tight thrombus, relapse likely).If vomiting blood or melena were in the presence of an ambulance doctor, or hospital, the fact of bleeding is considered proven.

If this does not happen, the rectum is examined with a finger. There are traces of black blood on the glove. Latent bleeding in chronic diseases is established by the analysis of feces on Gregersen's reaction. To do this, it is necessary to prepare the patient: it is forbidden even to brush your teeth.

deterioration condition of the patient, reduced pressure, re diarrhea and vomiting indicate continued bleeding. As an objective feature, the introduction of a gastric tube and gastric lavage to clean water are used. After an hour and a half of the probe comes again blood. Endoscopy specialists are on duty around the clock in surgical hospitals. The survey is included in the standard of care.

Also source endoscopist draws the conclusion: "the bleeding has stopped," - means the source is closed dense fibrin clots, it is unlikely a repeat against a background of medical procedures, "hemostasis unstable" - the defect is closed loose black clot, rarely seen pulsating vessel, it remains a threat to rebleeding.

How to distinguish from internal bleeding?

In differential diagnosis, it is necessary to take into account the symptoms of internal bleeding. Internal trauma leads to internal bleeding, ruptures of internal organs, fractures of ribs and other bones. We have already considered the general signs of hemorrhage. Symptomatology depends on the cavity or organ where the blood has been poured.

With hemothorax

Blood enters the pleural cavity with fracture of the ribs. The patient feels severe pain during breathing, difficulty breathing, a cough appears with a foamy bloody sputum. On the X-ray, the heart is shifted to the undamaged side.

With uterine bleeding

The woman has abdominal pains, pressure on the anus. It is determined by examination of the gynecologist.

When the blood flows into the urinary tract

Blood of scarlet color is detected in the urine. Laboratory leachate red blood cells are found in the search for the level of damage.

Features for diseases of the digestive tract

We will focus on the most common diseases for which bleeding is considered a serious complication.

erosive or haemorrhagic gastritis

at multiple surface defects of character form the mucosa of the stomach or duodenum. At the beginning of the disease in the wall of the stomach, the blood vessels spasmodic. This causes areas of ischemia( tissue hypoxia).As a result, a large amount of pepsin and histamine is released.

These hormonal substances promote mucosal hemorrhage and edema, the formation of ulcers, a few days defects reach a size of 20 mm, coalesce into large ulcers. Usually the process is acute, occurs under the influence of poisonous or medicinal agents( Aspirin, Atofan, steroids).

Acute ulcers can be stressful. They appear after trauma, burn, surgery, freezing, sepsis, myocardial infarction, renal-hepatic insufficiency. The mechanism does not differ from erosion. They reach the depth only to the muscle layer. In the formation of erosions, the vascularization of different parts of the stomach matters.

Mallory-Weiss Syndrome

Fibrogastroscopy is manifested by linear longitudinal ruptures of the esophageal mucosa and stomach caries. More often men are sick 30-50 years. The main cause of rupture of vessels is a sudden increase in intragastric pressure due to disruption of communication in the sphincter function. Stretched stomach causes vomiting and rupture of the mucous layer.

Varicose veins of the esophagus

It is considered a complication of portal hypertension. It is caused by: cancer and cirrhosis of the liver, less often - thrombosis of the hepatic veins. Bleeding is formed with a significant increase in pressure in the portal vein system and the available anastomoses between the veins of the esophagus and stomach.

These vessels become auxiliary and outflow from the portal system. The destruction of the vascular wall is facilitated by the action of acid and pepsin in gastro esophageal reflux. In patients, blood coagulability is often impaired due to liver disease.

Zollinger-Ellison Syndrome

Pancreatic adenoma, called "ulcerogenic" due to ulceration stimulation. In sizes it reaches up to 12 cm in diameter. Sprouts the duodenum

Half the cases, it gives malignant metastases to the lymph nodes, liver, lungs. Has the ability to activate the secretion of hydrochloric acid in the stomach. In 94% of patients, an ulcer is found in the jejunum or duodenum.

Adenomatous course of the disease with hormonal disorders is possible. Excess gastrin stimulates the release of an abundance of gastric juice, pancreatic secretions, bile, disrupts the ratio of contractions of sphincters. In 1/5 of patients multiple ulcers. It is important that the disease is resistant to conservative therapy. The main treatment is vagotomy and resection of the damaged bowel area.

Treatment and first aid

To suspect a non-medical worker of bleeding from the digestive tract is easy on the characteristic vomiting and diarrhea. An ambulance should be called immediately, even if vomiting does not recur. When pre-hospital care is needed:

• laying the victim on his side;
• creation of rest.

Tactics of treatment are defined by the algorithm of emergency care beginning with the stage of "First Aid".In the car, the patient is administered Dicinon, Vikasol, calcium chloride, a system with Ringer's solution is put. In the surgical department, further actions depend on the degree of blood loss:

• at grade 3 - emergency surgery for vital signs is necessary;
• 2 degree - requires surgical intervention if there are signs of continued bleeding, confirmed by fibrogastroduodenoscopy or a probe, repeated vomiting and melena.

. Other cases are subject to conservative treatment under the supervision of a surgeon. If bleeding has occurred with thrombocytopenic conditions, blood diseases, hemorrhagic diathesis in children, the operation is contraindicated.

Conservative treatment includes:

• bed rest;
• bubble with ice on the epigastric region;
• prohibition of eating and drinking( the issue of dieting is resolved 1-2 days after stabilization of the patient's condition);
• , aminocaproic acid is injected directly into the stomach in a cooled form with the addition of adrenaline.

To judge the appropriateness of blood transfusion is necessary in accordance with the recommendations for the treatment of hemorrhagic shock. Doctors calculate how many blood substitutes, erythromass, fresh frozen plasma, cryoprecipitate, Reopoliglyukin and other solutions are needed. Intravenously prescribed hemostatic drugs: Etamsilate, Vikasol, Aminocaproic acid.

When determining the scope of the operation, they are guided by the pathology that caused bleeding, the probability of relapse. Most often it is necessary to remove a large part of the stomach, duodenum, create an anastomosis for the passage of food. If the edges of the ulcer are allowed, then the defects are sewn up. The enlarged veins of the esophagus are swabbed with special balloons, and the left gastric and splenic arteries are bandaged.

The method of endoscopy is limited. The hemorrhage is stopped by electrocoagulation of the vessel, plasma treatment in a helium environment. Bleeding from the gastrointestinal tract is a serious illness requiring emergency medical actions. Therefore, the best help is calling an ambulance or taking the patient to the nearest hospital.