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Prognosis for bleeding from the upper gastrointestinal tract

There are several criteria for poor prognosis for bleeding from the upper gastrointestinal tract. The most important is the cause of the bleeding. So, for bleeding from varicose veins, the highest frequency of repeated bleeding (relapses) and deaths is characteristic. In primary hospitalization, mortality in this type of bleeding is 30%, with repeated - 50-70%. Bleeding of such a localization accounts for 10% of all bleeding from the upper gastrointestinal tract. Therefore, a decrease in mortality due to bleeding from varicose veins could significantly reduce the total number of deaths from bleeding from the upper gastrointestinal tract.

An important prognostic sign for gastric ulcer is an endoscopic examination of the site of recent bleeding (the presence of fresh and old blood clots, active arterial bleeding, oozing blood, a naked vessel) (Table 9-1). A naked vessel is described as the formation of a dark red, cyanotic or gray color raised above the surface of the ulcer, resistant to washing with saline. Surgical treatment of peptic ulcer is considered desirable for patients with a naked vessel, although this naked vessel may actually turn out to be a blood clot covering the defect in the wall of the bleeding artery, which is located below the surface of the bottom of the vessel's ulcer. When thrombosing a naked (visible) vessel, a large red thrombus is first formed, which gradually darkens and decreases in size. Over time, it loses platelets and is replaced by a white plaque consisting of fibrin. The presence of a small dark sentimental thrombus, as well as traces of previous bleeding (dark scar, white thrombus) indicates a small risk of repeated bleeding. The presence of a naked vessel in the ulcer crater in FGDS (fibrogastroduodenoscopy), regardless of the endoscopic picture, in most cases indicates the need to use surgical methods of treatment and a high risk of death. In such patients, the risk of repeated bleeding is 50% higher than in patients without a naked vessel.



Table 9-1.

CAUSES OF BLEEDING, RISK OF REPEATED BLEEDING





By: Johnson JH Endoscopic risk factors for bleeding peptic ulcer. Gastrointest. Endosc. 36: S 16.1990

During FGDS during the first days of hospitalization in 20-50% of patients with ulcerative bleeding reveal a naked vessel. For the implementation of preventive measures aimed at reducing mortality, it is necessary to determine the factors predisposing to repeated bleeding. More than 30 randomized trials were conducted to identify which manifestations of previous bleeding require treatment aimed at preventing relapse. Despite a slight discrepancy in the results, treatment was recommended for patients with active bleeding (strong or slightly oozing blood) in the presence of an indelible formation protruding above the bottom of the ulcer. At the clinic, large blood loss (hypotension, vomiting of blood, the need for transfusion of more than two units of blood) requires the immediate removal of a blood clot from the bottom of the ulcer to detect a bleeding vessel.

Other prognostic factors are:

1. The presence of severe bleeding, requiring blood transfusion, the presence of fresh blood in the nasogastric aspirate, hypotension.

2. Age of patients (people over 60 years of age have a higher percentage of probability of death). The presence of concomitant diseases should always be considered.

3. The presence of concomitant pathology (chronic renal failure).

4. Bleeding that occurred during hospitalization: the risk of death is 33–44%, in contrast to 7-12% in patients with bleeding that began before hospitalization.

5. The size of the ulcer. In patients with very large ulcers (> 2 cm), mortality is about 40%.

6. The urgency of surgery. When performing surgery according to emergency indicators, mortality is 30% (with planned surgery - 10%).
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Prognosis for bleeding from the upper gastrointestinal tract

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