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When bleeding from the upper gastrointestinal tract, accompanied by vomiting with blood, it is necessary to use a nasogastric tube to assess blood loss. If there is a suspicion of bleeding from the upper gastrointestinal tract in patients with melanoma and with a clinic of epigastric pain, a history of aspiration of the contents is carried out through a nasogastric tube. Detection of blood in an aspirate indicates the presence of bleeding. With bleeding
Fig. 9-5. (A)
An endoscope with a device for suctioning a varicose node and its local dressing
. (B) Putting a rubber loop on the base of the varicose vein. (B) The endoscope was removed. (By: Yamada T., Alpers D. I., Owyang S., Powell DW, Silverstein F. E., eds. Textbook of Gastroenterology, 2nd ed. Philadelphia:.!. B. Lippincott, 1995; 1: 679. )
The pyloric sphincter prevents blood from entering the stomach from the duodenum, and there is no blood in the nasogastric aspirate. An objective examination of such patients determines melena. Therefore, the lack of blood in the aspirate does not make it possible to completely eliminate the presence of bleeding. Melena usually appears with bleeding from the upper gastrointestinal tract (above the Treitz ligament), but can also occur with bleeding from the small intestine and proximal colon. Melena occurs due to the conversion of hemoglobin to hematin and other hemochromes under the influence of the bacterial flora of the intestine. Experimentally, melena can be obtained if you drink 100-200 ml of blood. When bleeding from the small intestine, proximal part of the colon, the amount of blood entering the intestinal lumen is usually insufficient for unchanged blood to appear in the stool, but it is enough for melena to appear.
Bleeding from the small intestine is quite rare. With small bleeding from the colon, feces usually have a positive reaction to blood, and with severe bleeding, hematoschia is noted (the appearance of blood in the stool). Another marker of bleeding from the upper gastrointestinal tract is an increase in blood urea nitrogen. Such azotemia cannot be explained only by the absorption of blood, since it has been experimentally proved that blood intake per os is accompanied by an increase in nitrogen level to a much lesser extent than with bleeding. It is assumed that azotemia appears secondary to hypovolemia. In nasogastric aspirates, blood is usually determined visually, so there is no need for any tests. However, it must be borne in mind that some foods may produce aspirate in the form of "coffee grounds". Sometimes traces of blood in the aspirate appear due to trauma to the nasogastric tube. When using standard tests for occult blood, it is necessary to take into account the likelihood of false negative results in an acidic environment.
The presence of hepatoschia usually indicates that the source of bleeding is localized in the lower gastrointestinal tract. However, in 11% of patients with severe bleeding from the upper gastrointestinal tract, fresh blood in the rectal discharge may appear against the background of a quick passage of blood through the intestines. As a result of this, the use of a nasogastric tube and / or endoscopic treatment methods is required to localize the source of bleeding in patients with hematoschia.
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