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Bleeding in gastric ulcer as an example of bleeding from the upper gastrointestinal tract

Gastric and duodenal ulcers cause about 50.% of cases of bleeding from the upper gastrointestinal tract (Table 9-2). Despite the introduction of new effective methods of treating peptic ulcer in the past 15 years, the frequency of bleeding with this pathology has not practically decreased. One of the reasons for this situation is the fact that often peptic ulcer disease makes its debut clinic bleeding. In elderly patients, the frequency of bleeding from the upper gastrointestinal tract increases due to their widespread use of aspirin and other non-steroidal anti-inflammatory drugs. In most cases, episodes of repeated bleeding occur when ulcers are located on the lesser curvature of the stomach and on the posterior lower surface of the duodenal bulb. Bleeding begins with erosion of the vessel wall in a peptic ulcer. The vessel often rises above the surface of the bottom of the ulcer, forming aneurysmal expansion. With repeated episodes of bleeding, the vessel, when it is cut into sections, has an irregular shape due to frequent constrictions of the vascular wall (the main mechanism of hemostasis). The highest mortality in peptic ulcer disease is observed in patients with prolonged bleeding or with frequent repeated bleeding. Therefore, treatment is aimed at stopping bleeding and preventing its recurrence.



Stop bleeding with peptic ulcer

One of the methods to stop bleeding from the upper gastrointestinal tract is to wash the stomach with cold saline. Usually this procedure is carried out through a nasogastric tube. It is theoretically believed that this procedure slows down bleeding, however, a cold solution may interfere with the action of coagulation factors. In addition, it is uncomfortable for the patient. Controlled studies did not reveal any benefits when using lavage with cold solutions. Therefore, washing can be carried out with room temperature water to control the intensity of bleeding.



Table 9-2

. CAUSES OF BLEEDING FROM UPPER DEPARTMENTS OF THE GASTROINTESTINAL TRACT

(2225 PATIENTS)

By: Silverstein FE, Gilbert DA, Tedesco FA The national ASGE survey on upper gastrointestinal bleeding. Gastrointest. Endosc. 1981; 27; 73, 1981



Numerous studies of various pharmacological preparations have not revealed their ability to increase the survival of patients with bleeding from the upper gastrointestinal tract. When analyzing the long-term results of treatment of 2500 patients with H2-histamine-blockers, it was found that the frequency of surgical interventions and mortality due to bleeding significantly decreased by 20% and 30%, respectively. Despite the relatively low efficiency, H2 blockers are widely used in patients with ulcerative bleeding. There is a point of view, although not confirmed by studies, that H; blockers administered intravenously and omeprazole (proton pump blocker) in high doses are more effective for suppressing gastric secretion of hydrochloric acid.

In case of failure of drug therapy, endoscopic or surgical treatment is performed. In emergency bleeding surgery, mortality is very high, so preference should be given to endoscopic methods, which are divided into thermal (cauterization) and non-thermal.
Non-thermal methods include the introduction of sclerosing substances (alcohol, ethanolamine), vasoconstrictors such as adrenaline or simply physiological saline into the site of bleeding. The effectiveness of thermal and non-thermal methods is approximately the same. Thermal methods include the use of an Nd-YAG (neodymium yttrium aluminum garnet) laser, heating, electrocoagulation. With electrocoagulation, compression and cauterization of the site of bleeding are used. A similar scheme is also suitable for stopping bleeding by heating. Both techniques are very simple and easy to use. The use of an Nd-YAG laser is also very effective, but the complexity of the technique, the large size of the device, its high cost, the need for well-trained personnel reduce the attractiveness of this treatment method. If it is not possible to stop the bleeding, or when it is repeated, it is necessary to immediately undergo a surgical operation, since any delay increases the likelihood of an adverse outcome. Surgical treatment of ulcerative bleeding gives good results. In severely weakened patients, it is advisable to carry out angiographic embolization of blood vessels at the site of bleeding.



Prevention of repeated bleeding with peptic ulcer

The effectiveness of acid-lowering therapy for the prevention of bleeding and stopping it is not yet fully understood. It is performed to prevent the destruction of a blood clot and accelerate the healing of a peptic ulcer. In vitro processes of coagulation, adhesion and platelet aggregation are maximum at a neutral pH. A blood clot is usually stable in an acidic environment, but the pepsin contained in the gastric juice can destroy it. Pepsin activity depends on the pH of the medium (at high pH it does not destroy blood clots). However, clinical observations have shown that acid-lowering therapy has only a small effect on reducing the frequency of repeated bleeding. The reason for this may be either an insufficient decrease in acidity, or the absence of its significant effect on blood clots. Even active drugs such as an Na + inhibitor, H + -ATPase-omeprazole and H2-blockers, when administered intravenously (both can increase the pH in the stomach to neutral values) do not significantly affect the frequency of repeated bleeding. Despite its low effectiveness, acid-lowering therapy is usually carried out to prevent relapse of bleeding due to its theoretically high efficiency and low toxicity of drugs.

Endoscopic treatments are rarely used to prevent rebleeding in patients with an increased risk of bleeding and with signs of bleeding. One of the reasons for this is the lack of a clear definition of which of the signs (manifestations) of previous bleeding are indications for endoscopic procedures. Another reason is the risk of renewed bleeding during the endoscopic procedure (in about 20% of cases) and the risk of perforation (about 1%). Endoscopic methods of treatment, being very expensive, are unable to significantly reduce the frequency of surgical interventions and affect the duration of hospitalization. Therefore, the use of endoscopic treatment methods should be clearly justified.
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Bleeding in gastric ulcer as an example of bleeding from the upper gastrointestinal tract

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