Bleeding from gastric and duodenal ulcers

A peptic ulcer is complicated by bleeding in about one in ten patients. According to the research, obvious bleeding occurs in 10-15% of patients with peptic ulcer, and hidden bleeding, detected only with the help of Gregersen's reaction and not manifested clinically, accompany the exacerbation of the disease. Ulcers of the duodenal ulcer bleed 4-5 times more often than ulcers of the stomach. Often, bleeding is the first sign of the disease.

The mechanism of development of bleeding lies in the fact that in the area of the ulcer there is damage to the vessel, and it begins to bleed. If a small vessel is damaged, the bleeding is very insignificant, without clinical manifestations and is only detected with the help of Gregersen's reaction.

Explicit bleeding from an ulcer is characterized by three main syndromes:

• bloody vomiting;
• tarry stools;
• symptoms of acute hemorrhage.

Bloody vomiting is most typical for bleeding from a stomach ulcer and is much less common in an ulcer of the duodenum. In the latter case, bloody vomiting is observed because the contents of the duodenum with blood are thrown into the stomach. Gastric contents with bloody vomiting usually has the form of a coffee grounds (dark brown color), which is caused by the transformation of hemoglobin of the outflow of blood under the influence of hydrochloric acid into hydrochloric acid hematin having a dark color. Bloody vomiting occurs soon after bleeding, and sometimes after some time after it. If the bleeding develops very quickly and the amount of blood poured out is large, vomiting is possible with scarlet blood

Tarry stool, melena (melena) - the most important sign of hemorrhage from the duodenal ulcer, is usually observed after the loss of more than 80-200 ml of blood.

Melena is characterized by a liquid or mushy consistency of stool and its black color. Under the influence of the intestinal flora, hemioglobin is formed from the outflowing blood of ferrous sulfide, which has a black color. A typical chair with melena - black, like tar, unformed (liquid, mushy), shiny, sticky. It is necessary to distinguish melena from pseudomelenia, i.e. Black decorated chair, associated with the reception of blueberries, bismuth, bird cherry, blackberry, iron preparations. Unlike true melena, when pseudo-delicate, the stool has a normal consistency and shape.

Melena can also be observed with massive bleeding from a stomach ulcer. In this case, the blood not only erupts from the stomach in the form of "coffee grounds", but can also get into the 12-colon.

It should be noted that with intensive bleeding, the stool may not be tarry and acquire a reddish color.

It must be emphasized that in case of bleeding from the ulcer of the duodenum, the black tar-like stool appears not at the time of bleeding, but after several hours or even a day after it. Melena is observed after a single blood loss usually 3-5 more days.

A characteristic sign of ulcer bleeding is the sudden disappearance of the pain syndrome - a symptom of Bergman. 

[1], [2], [3], [4], [5], [6], [7], [8],

Common symptoms of acute hemorrhage

The severity of the general symptoms of acute blood loss depends on its magnitude and speed. The faster the bleeding occurs and the more massive the loss of blood, the more common the violations.

The volume of circulating blood (BCC) is 2.4 l / m ^{2 of} the body surface in women and 2.8 l / m ^{2 of} the body surface in men or 70 ml / kg of body weight in men and 65 ml / kg in women. The average BCC of an adult with a body weight of 70 kg is 5 liters, of which 2 liters are cell elements (erythrocytes, leukocytes, platelets), 3 liters - for plasma.

Blood loss of about 10% of BCC (400-500 ml) either does not cause general symptoms (ie, shock phenomena, BP fall, disturbances of consciousness and other symptoms), or general disorders will be mild (mild nausea, cognition, dryness and salty taste in the mouth, general weakness, a slight tendency to decrease blood pressure).

Blood loss of about 10-15% BCC is well and quickly compensated by the body through the release into the bloodstream of the deposited blood.

Blood loss of about 15-25% BCC (700-1300 ml) causes the development of stage I hemorrhagic shock (compensated, reversible shock). This stage of shock is well compensated by activation of the sympathoadrenal system, high release of catecholamines, peripheral vasoconstriction. In this phase, the following symptoms appear:

• the patient in consciousness is calm or sometimes somewhat aroused (agitated);
• the skin is pale, the hands and feet are cold;
• subcutaneous veins on the hands in a collapsed condition;
• pulse is increased to 90-100 in 1 min, weak filling;
• BP remains normal or tends to decrease;
• oliguria is observed, the amount of urine released decreases by half (at a rate of 1-1.2 ml / min or 60-70 ml / h).

Blood loss is about 25-45% BCC (1300-1800 ml). With this magnitude of hemorrhage, decompensated reversible hemorrhagic shock develops. At the same time, activation of the sympathoadrenal system and high peripheral resistance can not compensate for the cardiac output that has decreased dramatically due to blood loss, which leads to a decrease in systemic BP and the development of the following symptomatology:

• pallor of the skin is expressed significantly;
• cyanosis of visible mucous membranes (lips, nose);
• dyspnea;
• tachycardia, dull heart tones;
• pulse of very weak filling, pulse rate up to 120-140 per minute;
• BP systolic is below 100 mm Hg. Low blood pressure;
• oliguria (diuresis less than 20 ml / h);
• Consciousness is preserved, but the sick are restless, excited.

Shortness of breath is caused by worsening of the blood flow of the brain, as well as by the development of a different degree of expression of the "shock lung" due to impaired vascular permeability of the small circle and overflow of the lungs with blood due to shunting of blood. Symptomatic of the shock lung develops gradually, after 24-48 h and in addition to dyspnea manifests itself as a cough, scattered by dry wheezing in the lungs, and in severe cases (in the terminal phase) a picture of pulmonary edema. 

Blood loss of 50% bcc and more (2000-2500 ml) causes the development of severe hemorrhagic shock (some authors call it decompensated, irreversible). The latter term is to some extent conditional, since timely and correctly conducted therapy even at this stage can lead to improvement of the patient's condition.

Main clinical symptoms:

• the patient is unconscious;
• the skin is very pale, covered with cold sticky sweat;
• dyspnea;
• the pulse is threadlike, its frequency is more than 140 per minute;
• systolic blood pressure is sometimes not determined;
• characteristic of oligoanuria.

Laboratory and instrumental data for acute bleeding from a stomach ulcer or duodenal ulcer

1. General blood analysis. Posthemorrhagic anemia develops. However, the degree of anemia is not an indication of the amount of blood lost, since the volume of the vascular bed decreases with acute blood loss. In the first few hours with a large loss of blood, a moderate decrease in hemoglobin and the number of red blood cells can be observed. After 1-2 days after the bleeding stops, normochromic or hypochromic anemia develops (due to hemodilution - the transition of fluid from the interstitial spaces to the vascular bed in order to increase the volume of the bcc). It is also possible to reduce the number of leukocytes and platelets.
2. ECG. There is a sinus tachycardia, sometimes various types of extrasystoles. Characteristic diffuse changes in the myocardium as a decrease in the ST interval down the isoline and a significant decrease in the amplitude of the T wave in the thoracic and standard leads. In elderly people, a negative symmetrical T wave may appear, as a manifestation of ischemic changes in the myocardium.
3. Radiography of the lungs with a severe degree of hemorrhagic shock reveals a picture of pulmonary edema (a decrease in the transparency of lung tissue, the emergence of foci of infiltration, a radical dimming in the form of a "butterfly").
4. Fibrogastroduodenoscopy. If there is a suspicion of ulcerative bleeding, and even more so with ulcer bleeding, an emergency FGD with a diagnostic and therapeutic purpose must be conducted. If a bleeding vessel is found in the EHF, it should, if possible, be coagulated by diathermo- and laser coagulation to stop bleeding. 

[9], [10], [11], [12], [13], [14]

Determination of the degree of blood loss

To determine the degree of blood loss, various methods have been proposed. Most of them estimate the degree of blood loss in relation to BCC.

Calculation of the shock index of Algovera

The Algovera shock index is the ratio of the pulse rate to the level of systolic blood pressure.

Determination of the degree of hemorrhage in the shock index of Algovera

Indicators of shock index	The volume of blood loss
0.8 and less	10% BCC
0.9-1.2	20% BCC
1.3-1.4	30% BCC
1.5 and more	40% BCC
About 0.6-0.5	Normal BCC

Determination of the degree of blood loss by Bryusov PG (1986)

The method is based on the following indicators:

• general condition of the patient;
• the value of blood pressure;
• heart rate;
• the amount of hemoglobin and hematocrit.

There are four degrees of severity of bleeding.

Mild bleeding:

• the deficit of BCC does not exceed 20%;
• the patient's condition is satisfactory;
• may have weakness, dizziness;
• pulse rate up to 90 in 1 minute;
• Blood pressure is normal or there is a tendency to a slight decrease;
• the hemoglobin content is higher than 100 g / l;
• hematocrit more than 0.30.

Average severity of hemorrhage:

• shortage of BCC in the range of 20-30%;
• a patient with a moderate severity;
• pronounced general weakness, dizziness, darkening before the eyes;
• pulse rate up to 100 per 1 minute;
• moderate arterial hypotension;
• the hemoglobin content is 100-70 g / l;
• hematocrit 0.30-0.35.

Severe degree of hemorrhage:

• shortage of BCC 30-40%;
• the patient's condition is severe;
• severe weakness, severe dizziness, shortness of breath, pain in the region of the heart (mainly in the elderly and patients with ischemic heart disease);
• pulse rate of 100-150 per minute;
• BP systolic decreases to 60 mm Hg;
• the hemoglobin content is 70-50 g / l;
• hematocrit less than 0.25.

Extremely severe degree of hemorrhage:

• a BCC deficit of over 40%;
• the patient's condition is extremely difficult;
• patient unconscious, covered with cold sweat, pale skin, cyanosis of mucous membranes, dyspnea;
• pulse and blood pressure are not determined;
• hemoglobin below 50 g / l;
• hematocrit less than 0.25-0.20.

[15], [16], [17], [18], [19], [20]

Determination of the degree of hemorrhage by GA Barashkov (1956)

The method of GA Barashkov is based on the determination of the relative density of blood using a series of solutions of copper sulfate with a relative density of 1.034 kg / l to 1.075 kg / l.

A drop of venous heparinized blood is dropped into vials with solutions of copper sulfate. If the blood density is lower than the density of the given solution, the drop immediately floats, if higher - it sinks. If a drop of blood remains suspended for 3-4 seconds, this indicates a consistent density.

Bleeding from gastric and duodenal ulcers must be differentiated from bleeding from the esophagus, stomach and intestines of another etiology.