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Examination and treatment of a patient with gastrointestinal bleeding

The approach to the examination of a patient with bleeding depends on the place of its localization, vastness and intensity. With bloody vomiting, there is usually more blood loss (often more than 1000 ml) than with melena (usually 500 ml or less), and the mortality rate in the first case is about twice as high as in the second. For the first time, a doctor can be called to a patient in a state of shock. Before proceeding to the collection of an anamnesis and a thorough physical examination of the patient, attention should be paid to the indicators of the function of vital organs, blood should be sent for examination to determine its group and cross-compatibility, and a system should be established for intravenous infusion of saline and other solutions that increase plasma volume. The doctor who begins the examination of a patient with bleeding should clearly understand that in the process of conducting diagnostic tests. First of all, it is necessary to ensure the maintenance of an adequate volume of intravascular fluid and stable hemodynamics.

Anamnesis. Anamnesis or symptoms suggesting a primary peptic ulcer may provide useful information for diagnosis. Similarly, alcohol abuse or the use of anti-inflammatory drugs in the recent past should suggest that erosive gastritis is more likely. If alcohol abuse has continued for a long time, then a varicose vein of the esophagus may be a more likely source of bleeding. Acetylsalicylic acid can also cause gastroduodenitis, ulceration, and bleeding. Data on previously occurring gastrointestinal bleeding help in the diagnosis, as well as data on a family history of intestinal diseases or hemorrhagic diathesis. The vomiting urges that had bothered him in the recent past, followed by bloody vomiting, suggest the likelihood of Mallory-Weiss syndrome. The acute onset of bloody diarrhea may indicate inflammatory bowel disease or infectious colitis. It is also important to exclude concomitant systemic diseases or recent trauma, since bleeding due to erosive gastritis often accompanies these conditions.

Physical examination. After determining the orthostatic changes in heart rate and blood pressure, as well as restoring the volume of circulating blood, the patient should be examined to identify the symptoms of the underlying disease. An extraintestinal source of bleeding should be excluded by a thorough examination of the oral cavity and nasopharynx. Examination by a dermatologist helps to identify telangiectasias characteristic of Osler-Randu-Weber syndrome (although they are not visible with severe anemia), pigmentation around the mouth characteristic of Peitz-Jägers syndrome, dermatofibroma characteristic of neurofibromatosis, and often occur in Gardner’s syndrome and osteoma, and osteomaschia purpura or diffuse pigmentation with hemochromatosis. Characteristic signs of chronic liver disease, such as arachnoid hemangiomas, gynecomastia, testicular atrophy, jaundice, ascites, and hepatosplenomegaly, should be suspected of portal hypertension causing bleeding from varicose veins of the esophagus or stomach. A marked increase in lymph nodes or the identification of palpable formations in the abdominal cavity can be a reflection of a latent malignant process in it. A thorough examination of the rectum is important both to exclude local pathology and to determine the color of feces.

Laboratory research methods. Initial studies should include determining the hematocrit, hemoglobin level, assessing the morphology of red blood cells (hypochromic, microcytic red blood cells suggest chronic bleeding), counting the number of leukocytes and determining the leukocyte formula, as well as counting the platelet count. In order to exclude primary or secondary coagulation disorders, prothrombin time, partial thromboplastin time, and other studies to evaluate the blood coagulation system can be determined. An X-ray examination of the abdominal organs rarely helps to establish a diagnosis, unless perforation of any organ is intended. Despite the fact that the data of the initial laboratory studies are very valuable and necessary, it is important to re-conduct them in the process of monitoring the clinical condition of the patient.

Diagnosis and treatment. The diagnostic approach to a patient with gastrointestinal bleeding should be individualized. At first, the patient may be under the supervision of a general practitioner, but if surgical intervention is necessary, he should be consulted by a surgeon.

If there is a history of melena or bloody vomiting, or if bleeding from the upper gastrointestinal tract is suspected, the patient should insert a probe through the nose into the stomach and aspirate its contents to determine whether the bleeding actually occurs from the upper gastrointestinal tract. If the first portion of the aspirated contents of the stomach is clear, the probe should be left in it for several hours, because, despite this, active bleeding from the duodenum can occur. If there is no blood in the contents aspirated from the stomach during the period of active bleeding, then it is reasonable to assume that it does not come from the stomach and duodenum, so the probe can be removed. However, if there are no signs of active bleeding while the probe is in the stomach, it cannot be argued that the bleeding does not occur from the stomach or duodenum, therefore endoscopy may be required.

If the stomach contents that are aspirated using a probe are stained with red blood or have the color of coffee grounds, immediately rinse the stomach with saline. It has two goals: it allows the clinician to cordon off the intensity of bleeding and cleanses the stomach of blood clots accumulated in it before a possible endoscopy. Subsequent diagnostic measures will depend on whether the bleeding continues or not; this can be assessed by changes in vital signs, by the need for blood transfusion, and by the number of bowel movements and the consistency of feces. Most medical centers are now equipped with experienced specialists in endoscopy and radiology, as well as appropriate equipment for conducting selective arteriography, and therefore urgent endoscopic or angiographic studies can be carried out in the first hours after hospitalization. It is necessary to emphasize the need to obtain evidence that the identified lesion is the source of bleeding (Fig. 37-1).

Fig. 37.1. Photograph obtained by endoscopy in a patient suffering from bloody vomiting.

You can see the stomach ulcer (a) along its lesser curvature (arrows); suddenly developed bleeding in an ulcer (b) from a damaged artery (arrows).

If the bleeding has stopped and the patient's condition has stabilized, one can proceed either to an esophagogastroduodenoscopy or to an X-ray examination of the upper gastrointestinal tract using barium. Despite the fact that endoscopy provides greater diagnostic accuracy, there is no convincing evidence that its implementation in the early stages increases the survival of patients.
A study using barium helps to identify a potential source of bleeding, but there are significant limitations in conducting x-ray studies. Firstly, processes such as erosive gastritis and mucosal ruptures in Mallory-Weiss syndrome are not visualized during x-ray examination. Secondly, with repeated bleeding after radiography with barium, its residues impede subsequent endoscopy, while angiography becomes impossible. It is clear that the approach in this situation should be individualized. The solution to the issue of esophagogastroduodenoscopy or radiography with barium contrast will depend on several circumstances, including the presence of an experienced endoscopist in the hospital and the patient's condition. Although emergency endoscopy and rapid diagnosis usually do not reduce morbidity or mortality, emergency endoscopy may play an important role in planning treatment for some patients with cirrhosis or undergoing surgery on the stomach. If other patients with visible vessels and, therefore, with a high risk of developing repeated bleeding are identified, the nature of possible complications can be foreseen. The development of new methods for coagulation of bleeding ulcers or sclerotherapy of varicose veins through an endoscope may expand in the future indications for endoscopy in the early stages.

Persistent bleeding from the upper gastrointestinal tract should be considered from different points of view, and most clinicians prefer to immediately carry out esophagogastroduodenoscopy. Determining the location and cause of bleeding is very important for planning appropriate treatment, especially if varicose veins are expected. Thus, during the examination, the question of the need for surgery or angiography, as well as suspected bleeding from varicose veins, are direct indications for esophagogastroduodenoscopy. In contrast, the decision to conduct an esophagogastroduodenoscopy is more difficult to make when examining a patient with massive bleeding, since a large amount of blood prevents the pathology of the mucous membrane from being seen, and in addition to endoscopy, angiography may be required in this case.

If the bleeding continues, and with endoscopy it is not possible to identify its source, then the latter can be localized behind the Treitz fascia. In this case, angiography is often of great value for the diagnosis. To identify the site of bleeding using angiography, it is necessary that its intensity is at least 0.5 ml / min. Clinical parameters reflecting the degree of blood loss include postural hypotension and the need for a blood transfusion to maintain the stability of vital functions. By means of emergency angiography, the site of bleeding can be localized, but its cause may not be determined in the absence of varicose veins, vascular malformations or aneurysms.

Therapeutic angiography is useful for controlling persistent bleeding. Prolonged intra-arterial infusion of vasoconstrictors (such as vasopressin) often allows you to successfully cope with bleeding caused by a stomach ulcer or rupture of the mucous membrane in Mallory-Weiss syndrome. In addition to this, embolic material can be introduced directly into the artery perfusing the site of bleeding. However, for stopping it from varicose veins, intravenous infusions of vasopressin and endoscopic sclerotherapy are more effective than angiographic methods.

If bleeding from varicose veins of the esophagus is detected during endoscopy of the upper gastrointestinal tract, it can be stopped by injecting vasopressin into the peripheral vessels. The response to this treatment depends on the general condition of the patient, assessed by clinical and laboratory parameters. It was established that for stopping bleeding from varicose veins, intra-arterial administration of vasopressin is no more effective than intravenous administration. This bleeding can also be stopped using pneumatic tamponade using a catheter proposed by Sengstaken — Blakemore. Unlike the introduction of vasopressin, this method is usually used for preoperative stabilization of the condition, after which (no later than .48 hours, if possible) an operation should be performed. Endoscopic sclerosis of varicose veins is an effective method of stopping bleeding from the veins of the esophagus, therefore, in all cases when possible, it should be used before surgery.

When evaluating bleeding from the lower gastrointestinal tract, the most important procedures are digital rectal examination, anoscopy, and sigmoidoscopy. With the help of the latter, it is possible to establish the site of bleeding or to confirm bleeding from a focus localized outside the reach of the device. Colonoscopy is a valuable technique for assessing the condition of patients with minor or moderate bleeding from the lower gastrointestinal tract. Preparation of the colon by washing it with saline allows you to evaluate its condition during colonoscopy for several hours. Most of the pathological changes in it, including angiodysplasia, can be detected and cured by a patient using polypectomy or electrocoagulation. If active bleeding continues, then arteriography can be performed to localize the site of bleeding and local administration of vasoconstrictors.

Since arteriography can detect actively bleeding lesions only in cases where the intensity of blood loss exceeds 0.5 ml / min, and gastrointestinal bleeding is intermittent in nature, it is rarely useful for making a diagnosis. Scanning with radioactive red blood cells is a more sensitive research method than arteriography to determine blood loss with an intensity of 0.1 ml / min and can be used to examine patients with less severe bleeding. However, scanning for bleeding is a less specific method than arteriography, and usually it can be used to localize the lesion, but it is rarely possible to make an accurate diagnosis. Scanning is most useful for active minor or intermittent bleeding to determine the most appropriate time for arteriography and to obtain maximum information. And finally, the role of X-ray with barium contrast is limited in assessing acute rectal bleeding. Despite the fact that with its help a potential source of bleeding can be localized, it does not allow to identify the place of bleeding. In addition, if active bleeding resumes, then subsequent colonoscopy or angiography data will be difficult to interpret due to remnants of the contrast medium in the gut. In this regard, it is reasonable to postpone X-ray studies with barium contrast in both the upper and lower parts of the gastrointestinal tract for at least 48 hours after the cessation of active bleeding
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Examination and treatment of a patient with gastrointestinal bleeding

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