– complication peptic ulcer, which consists in the leakage of blood into the stomach cavity from damaged vessels (arrozed arteries, veins or capillaries). Symptoms are determined by the severity of bleeding; the main manifestations are vomiting “coffee grounds”, “tarry” stools, signs of hypovolemia and systemic violations hemodynamics. The most important diagnostic method is esophagogastroduodenoscopy, during which hemostasis can be performed. Treatment in most cases is surgical; with a small amount of blood loss, as well as in high-risk patients, conservative bleeding control is performed.

The cause of the serious condition of patients is blood loss. With a loss of less than 15% of blood volume, there are no significant disturbances in systemic hemodynamics, since protective mechanisms are activated: spasm of blood vessels in the skin and organs abdominal cavity, opening of arteriovenous shunts, increased heart rate. Blood flow in vital organs is maintained, and when blood loss stops, the volume of circulating blood is restored due to natural depots. With a loss of more than 15% of the bcc, a generalized spasm of blood vessels, a significant increase in heart rate and the transition of interstitial fluid into the vascular bed are initially compensatory in nature, and then pathological. Systemic blood flow is disrupted, microcirculation suffers, including in the heart, brain, kidneys, arterial hypotension develops, and compensation mechanisms are depleted. Possible development of liver and kidney failure, cerebral edema, myocardial infarction and hypovolemic shock.

Symptoms of a bleeding stomach ulcer

The symptoms of this pathological condition are determined by the degree of blood loss and the duration of bleeding. Hidden bleeding ulcers are manifested by general weakness, dizziness, and pale skin. Hemoglobin in the acidic environment of the stomach is metabolized, acquiring a dark color, and in the case of vomiting, the vomit is typically colored “café au lait.”

In the case of profuse bleeding, the main symptom is bloody vomiting, which can be one-time or repeated. Vomit has a characteristic “coffee grounds” color. In rare cases of massive bleeding from the artery, vomiting of scarlet blood with clots is possible.

A mandatory sign of a bleeding stomach ulcer with a loss of more than 50 ml of blood is “tarry” stool that occurs after a few hours or the next day. For bleeding, the volume of which does not exceed 50 ml, feces of normal consistency and dark in color.

Many patients note an increase in the intensity of the symptoms of a peptic ulcer (stomach pain, dyspepsia) over several days, as well as their disappearance with the onset of bleeding (Bergmann's symptom). Signs such as thirst, dry skin, decreased diuresis, and pain on palpation of the abdomen are also possible.

The general symptoms of a bleeding ulcer are determined by the degree of blood loss. With a deficit of circulating blood volume of less than 5 percent (grade 1), minor disturbances in systemic hemodynamics occur; The patient’s health remains satisfactory, blood pressure is within normal limits, and the pulse is slightly increased. With a deficiency of 5-15 percent of circulating blood volume (grade 2 blood loss), patients experience lethargy, dizziness, possible fainting, and systolic blood pressure below 90 mm Hg. Art., the pulse is significantly increased. With a loss of more than 15-30 percent of the blood volume (grade 3), the patient’s condition is severe, there is marked pallor of the skin and mucous membranes, the pulse is threadlike, frequent, systolic blood pressure is below 60. A deficiency of more than 30 percent of blood volume (grade 4) is accompanied by impaired consciousness, the condition is extremely severe, blood pressure is reduced to a critical level, the pulse is not detected.

Diagnosis of bleeding stomach ulcers

A consultation with a gastroenterologist with a detailed study of the disease history, patient complaints and objective data suggests the presence of this pathology even with a small amount of blood loss. During an objective examination of the patient, attention is drawn to pallor of the skin, decreased skin turgor, and possible pain on palpation of the abdomen in the epigastric region. A general blood test determines a decrease in hemoglobin and red blood cells.

A mandatory diagnostic method for gastric bleeding is esophagogastroduodenoscopy. Diagnostic endoscopy is performed in all cases where there is reasonable suspicion of ulcer bleeding. The only contraindication is the patient's agonal state, when the results of the study cannot affect the outcome of the disease. Endoscopy allows you to visualize the source of bleeding and differentiate a bleeding ulcer from other causes of gastrointestinal bleeding. In most cases diagnostic procedure goes into treatment. It has been proven that early endoscopic hemostasis significantly reduces the incidence of relapses, the need for surgical interventions, and mortality.

Differential diagnosis is carried out with gastric bleeding of another etiology: malignant tumors, gastric polyps, Mallory-Weiss syndrome, pathology of the blood coagulation system, cardiovascular system.

Treatment of bleeding stomach ulcers

Suspicion of a bleeding gastric ulcer is a direct indication for emergency hospitalization of patients in surgical department. Examination in outpatient setting. All patients are prescribed strict bed rest and complete fasting (after stopping the bleeding - the Meulengracht diet). Conservative hemostasis includes transfusion of blood products, plasma, administration of fibrinogen, aminocaproic acid, calcium chloride, vikasol, atropine, as well as oral administration of aminocaproic acid. Conservative treatment can be carried out in patients at high risk (old age, severe concomitant pathology), as well as in mild and medium degree severity of bleeding.

Currently, effective methods of endoscopic hemostasis have been developed: thermal (electrocoagulation, thermal probe, laser, radio frequency and argon plasma coagulation), injection (local administration of adrenaline, novocaine, saline and sclerosants), mechanical (stopping gastroduodenal bleeding by clipping or ligating bleeding vessels during gastroduodenoscopy ) and the use of hemostatic materials (biological glue, hemostatic powder).

Indications for carrying out surgical treatment are severe bleeding, regardless of the type of ulcer, combination with other complications of peptic ulcer (penetration, pyloroduodenal stenosis), repeated bleeding that does not stop under the influence of conservative methods of hemostasis. The specific choice of operation is determined by the location of the ulcer and individual characteristics. Gastric resection can be performed according to Billroth I or II, excision, suturing of a gastric ulcer, suturing of the vessels of the bottom of the ulcer, possibly combined with vagotomy.

Prognosis and prevention

The prognosis is determined by the amount of blood loss and the timeliness of specialized care. Currently, active surgical treatment tactics (in the absence of contraindications) are considered the only correct one. In addition to the speed of stopping bleeding, the prognosis depends on the preservation of the patient’s compensatory mechanisms and adequate replenishment of the circulating blood volume. With profuse bleeding, a high mortality rate is recorded.

Prevention of bleeding gastric ulcers consists of timely contacting a gastroenterologist if there are complaints from the stomach, adequate treatment of peptic ulcers in accordance with current standards, medical examination of patients and regular examinations.

Is absolute norm with this disease. The patient leaks several milliliters of blood from the wound every day.

However, there are situations when blood loss is more significant, and it is often possible to stop this internal bleeding Doesn't work at home. Moreover, in some situations, even in a hospital setting, it is not possible to stop blood loss in a timely and effective manner.

In this article, we will talk in detail about what a bleeding ulcer is, how to prevent this disease, and what emergency first aid should be provided when it develops. We will also talk about how bleeding ulcers of the stomach and duodenum are treated.

How and why does bleeding occur with a stomach or duodenal ulcer?

Ulcerative bleeding occurs in approximately 18-30% of all patients with gastrointestinal ulcers. Moreover, of all types of bleeding of the gastrointestinal tract, 60-75% of cases account for the ulcerative type of bleeding.

An open bleeding ulcer usually occurs in the gastric region, with blood loss coming from arrosive arteries. Much less often, blood loss comes from the veins or capillaries (according to PubMed).

Causes for Ulcer Bleeding large number. We list the most common reasons in practice:

1. Incorrectly formulated diet for the patient or lack thereof.
2. Insufficiently effective treatment, attempts by the attending physician to carry out therapy empirically, that is, at random.
3. Ulcer complicated by infection.
4. Damage to the ulcer surface by stomach acid or penetration foreign body(performing FGDS analysis, for example).
5. Overstrain of the abdominal cavity due to exhausting physical activity against the background of an acute ulcerative process.
6. Taking foods or medications that are aggressive to the gastric mucosa and duodenum (alcohol and non-steroidal anti-inflammatory drugs are especially dangerous).
7. Failure to provide first aid for exacerbation or acute form of gastric or duodenal ulcer.

Why is ulcer bleeding dangerous?

Any bleeding, be it profuse (heavy) or light, is life-threatening for the patient. And if profuse bleeding can lead to the death of the patient within a matter of hours, then light and prolonged bleeding quietly kills a person.

It is not uncommon for patients with mild but prolonged bleeding They haven’t seen a doctor for years. The disease makes itself felt only in terminal stage, whereas in the early stages there are no symptoms (including pain).

As a result, the patient first develops chronic fatigue, impaired attention, and sometimes even quite serious problems with sleep. After a few months, the level of circulating blood drops even further, photophobia, dizziness and, in rare cases, attacks of syncope (loss of consciousness) appear.

As a result, the patient turns to the doctor already at the manifestation of the disease, when the saturation of the organs with blood drops to a critical level. Such cases are not uncommon and usually occur in people who neglect their health.

Acute blood loss is not so insidious, but has a high mortality rate even with timely treatment. Thus, acute blood loss due to a perforated ulcer of the stomach and duodenum, even under intensive care conditions, leads to death in 30-50% of cases.

It should be understood that acute blood loss is terrible because it can occur against the background of complete well-being, without previous signs. And first aid in this case is meaningless, since there is no way to directly influence internal bleeding without medical equipment.

Symptoms of Ulcerative Bleeding

In the vast majority of cases, when little blood is released, the symptoms of ulcer bleeding are so scanty that it is almost impossible to identify the disease in the early stages.

In other cases, when the problem progresses, the following symptoms are observed:

• presence of blood in saliva (when stomach contents reflux into oral cavity for heartburn), including the presence of blood in saliva after vomiting;
• pallor of the body, disappearance of superficial veins into the body;
• decrease in body temperature to 36.3-36.4 degrees;
• photophobia (with an accompanying increase in temperature this symptom requires analysis to exclude meningitis);
• dizziness;
• nausea and vomiting of bloody masses;
• black stool with a stomach ulcer and stool with streaks of blood with a duodenal ulcer;
• increased sweating even against the background of calm and normal temperature;
• tremor;
• symptoms of dehydration, including dry mouth and lips.

Classification of ulcer bleeding

There is a medical classification of ulcer bleeding, based on the characteristics of its course. Medical classification subdivides bleeding ulcers according to the following parameters:

• for reason (etiology): from chronic form, acute or symptomatic;
• by location (localization): from the stomach, from the duodenum;
• according to the nature of the course: ongoing bleeding and established bleeding;
• by severity: moderate blood loss and massive blood loss.

Also, the classification of bleeding from gastrointestinal wounds is divided according to severity. Total exists three degrees of disease severity:

1. Mild: single vomiting, black stool (melena), blood pressure and pulse are normal, the patient’s general condition is generally satisfactory.
2. Moderate: presence of fainting, repeated bloody vomiting, weakness, decrease in systolic pressure to 90-80 mm Hg. Art., tachycardia with an increase in pulse to 100 beats.
3. Severe: massive repeated vomiting of blood, tarry stools, systolic pressure reduced to 60-50 mm Hg. Art., tachycardia with an increase in pulse to 120 or more beats, critical condition of the patient.

Forrest classification

In addition to the general classification of ulcer bleeding, there is also a special Forrest classification. It was created by the doctor J. Forrest in 1987. The Forrest classification is needed to assess the likelihood of recurrent bleeding and, accordingly, the likelihood of the patient’s death.

Forrest classification looks like this:

1. Jet gastroduodenal bleeding from an ulcer (F1A).
2. Drip gastroduodenal bleeding from an ulcer (F1B).
3. Thrombosed arteries at the bottom of the ulcer (FIIA).
4. Blood clot tightly sealing an ulcer (FIIB).
5. Ulcer without any signs of bleeding (FIIC).
6. No sources of bleeding were found at all (FIII).

Based on this classification, risks of relapse and death of the patient are calculated as follows:

• F1A: complicated disease, risk of relapse 55-100%, mortality – 11%, symptoms are pronounced;
• F1B: same as F1A, symptoms are severe;
• FIIA: complicated disease, risk of relapse 40-50%, mortality – 11%;
• FIIB: complicated disease, risk of relapse 20-30%, mortality – 7%;
• FIIC: the risk of relapse for this type of disease is 10-20%, mortality is 6%;
• FIII: the risk of relapse for this type of disease is 5%, mortality is 2%.

Gastrointestinal bleeding (video)

Treatment of ulcer bleeding

For light and minor bleeding, treatment consists of the doctor prescribing a special gentle diet. Therapeutic diet is aimed at minimizing the load on the gastrointestinal system and enhancing the regenerative abilities of the body.

Nutrition (you can read the details) is selected with an emphasis on not in any way provoking progression (development). The menu is very modest, since most products are simply prohibited for the patient. Spicy, salted, fried, smoked and other similar products are strictly prohibited. The patient is prohibited from drinking alcohol, caffeine, and stimulants.

When therapeutic nutrition does not help or there is no point in using it, they resort to surgical intervention. Surgical treatment in this case is carried out exclusively under general anesthesia, since the local analgesic effect is not enough, the pain can provoke shock in the patient.

The operation is carried out using medical endoscopic equipment; in rarer cases, they resort to open surgery with a slit along abdominal wall. After the operation, the patient is prescribed strict bed rest, feeding through a tube, and powerful drug therapy.

Upon awakening, patients often experience a strong fear of death, therefore, in order to avoid stressful shock after the patient awakens, a doctor should be with him to reassure him. The patient is not allowed to actively move on the couch for the first days after surgery, as active movements may cause the sutures or clips placed on the ulcer to break.

Acute gastric ulcer with bleeding is the main complication of gastric ulcers (GU) of any etiology.
Acute ulcers by etiology are usually symptomatic and stress ulcers.

Under acute stomach ulcer(AJ) should be understood as a PU of any etiology that has the morphology of an acute ulcer. PG should be distinguished from erosion and chronic gastric ulcer. Some authors also understand by this term the newly diagnosed ulcer or the stage of the course of peptic ulcer of the stomach and duodenum (including Helicobacter pylori etiology).

Erosion- shallow defect, damage to the mucous membrane within the boundaries of the epithelium. The formation of erosion is associated with necrosis of the mucous membrane. As a rule, erosions are multiple and are localized mainly along the lesser curvature of the body and the pyloric part of the stomach, less often in the duodenum. Erosions can have different shapes and range in size from 1-2 mm to several centimeters. The bottom of the defect is covered with fibrinous plaque, the edges are soft, smooth and do not differ in appearance from the surrounding mucous membrane.
Healing of erosion occurs in 3-4 days through epithelization (complete regeneration) without scar formation. If the course is unfavorable, it may develop into an acute ulcer.

Acute ulcer is a deep defect of the mucous membrane, which penetrates to the muscular plate of the mucous membrane and deeper. The reasons for the formation of acute ulcers are similar to those for erosions. Acute ulcers are often solitary; have a round or oval shape; in cross-section they look like a pyramid. The size of acute ulcers ranges from several mm to several cm. They are localized on the lesser curvature. The bottom of the ulcer is covered with fibrinous plaque, it has smooth edges, does not rise above the surrounding mucous membrane and does not differ from it in color. Often the bottom of the ulcer has a dirty gray or black color due to the admixture of hematin hydrochloride.

Microscopically: mild or moderate inflammatory process at the edges of the ulcer; after rejection of necrotic masses at the bottom of the ulcer - thrombosed or gaping vessels. When an acute ulcer heals within 7-14 days, a scar forms (incomplete regeneration). In rare cases, an unfavorable outcome may lead to a chronic ulcer.

Chronic ulcer- characterized by severe inflammation and proliferation of scar (connective) tissue in the area of ​​the bottom, walls and edges of the ulcer. The ulcer has a round or oval (less often linear, slit-like or irregular) shape. Its size and depth may vary. The edges of the ulcer are dense (callous ulcer), smooth; undermined in its proximal part and flat in its distal part.
Morphology of a chronic ulcer during an exacerbation: the size and depth of the ulcer increases.
There are three layers at the bottom of the ulcer:
- top layer- purulent-necrotic zone;
- middle layer- granulation tissue;
- bottom layer- scar tissue penetrating into the muscle membrane.
The purulent-necrotic zone decreases during the period of remission. Granulation tissue, growing, matures and turns into coarse fibrous connective (scar) tissue. In the area of ​​the bottom and edges of the ulcer, the processes of sclerosis intensify; the bottom of the ulcer is epithelialized.
Scarring an ulcer does not lead to a cure for peptic ulcer disease, since an exacerbation of the disease can occur at any time.

An acute ulcer is usually understood as a symptomatic, stress-induced ulcer with a characteristic morphology that is not prone to chronicity (Cushing's ulcer Cushing's ulcer - an ulcer of the stomach or duodenum, sometimes developing when the central nervous system, for example after a traumatic brain injury
, Curling's ulcer Curling's ulcer is an ulcer of the stomach or duodenum that occurs as a result of serious injury or extensive burn of these organs
).
Sometimes an acute gastric ulcer can be understood as a newly diagnosed gastric ulcer without taking into account its morphology. This approach does not seem entirely correct and is permissible only if it is impossible to reliably (visually, histologically, etiologically) determine or assume the morphology or etiology of the identified ulcer.

An acute gastric ulcer is distinguished from a chronic Helicobacter-associated ulcer, in addition to morphological features, by the fact that it is almost always possible to identify a provoking factor, with the exception of which ulcer healing and recovery occurs quite quickly.

Term peptic ulcer, used in foreign literature, allows for a fairly broad interpretation of the etiology of stomach ulcers, including stomach ulcers, for example, with Zollinger-Ellison syndrome, taking NSAIDs, etc., which domestic medicine traditionally classifies as symptomatic ulcers.

Bleeding from an acute gastric ulcer defined as at least one episode of coffee grounds or melena detected during gastric lavage or after an enema (regardless of whether the hematocrit decreased or not). It should be noted that the criteria used to define bleeding in published clinical studies, vary widely (eg, a positive stool guaiac test or the presence of blood in the nasogastric aspirate, hematemesis, melena, or the need for a blood transfusion). Thus, different authors use various criteria for diagnosing this condition.

Examples of diagnoses:
1. Acute calculous cholecystitis, cholecystectomy (date); acute stress multiple erosions and small acute ulcers of the antrum of the stomach, complicated by moderate bleeding.
2. Rheumatoid arthritis; three large acute drug-induced ulcers of the anterior wall of the stomach (taking NSAIDs Non-steroidal anti-inflammatory drugs (non-steroidal anti-inflammatory drugs/agents, NSAIDs, NSAIDs, NSAIDs, NSAIDs) - group medicines, which have analgesic, antipyretic and anti-inflammatory effects, reduce pain, fever and inflammation.
- indomethacin).

Classification

Forrest classification:

Type F I- active bleeding:
-I a- pulsating jet;
- I b- flow.

Type F II- signs of recent bleeding:
- II a- visible (non-bleeding) vessel;
-II b- fixed thrombus clot;
- II s- flat black spot(black bottom of the ulcer).

Type F III- an ulcer with a clean (white) bottom.

Etiology and pathogenesis

General information

All symptomatic gastric ulcers are united by this common feature, as the formation of an ulcerative defect of the gastric mucosa in response to the influence of ulcerogenic factors (factors leading to the formation of ulcers).

1. Symptomatic stomach ulcers(usually stressful)

Stress gastric ulcers are one of the types of diseases of the mucous membrane of the gastrointestinal tract (GIT) associated with stress (the so-called stress-related mucosal disease, SRMD).

SRMD in the gastrointestinal tract manifests itself in two types of mucosal lesions:
- stress-related hypoxic injury, which manifests itself as diffuse superficial damage to the mucous membrane (non-bloody erosions, petechial hemorrhages into the mucosa);
- discrete stress ulcers, which are characterized by deep focal lesions, penetrating into the submucosa, most often in the fundus of the stomach.
Stress-induced mucosal lesions ultimately affect many areas of the upper gastrointestinal tract.

The occurrence of symptomatic ulcers has previously been associated with activation of the hypothalamic-pituitary-adrenal axis with a subsequent increase in the production of corticosteroid hormones. The action of the latter causes damage to the protective mucosal barrier, acute ischemia of the mucous membrane of the stomach and duodenum, increased tone of the vagus nerve, and disturbances of gastroduodenal motility.
Modern approaches to the pathophysiology of the process do not exclude this mechanism, but they appear to be multifactorial and are associated primarily with hypoxia of the gastrointestinal mucosa.

The main SRMD factors recognized today are:
- decreased blood flow;
- damage associated with ischemia, hypoperfusion and reperfusion.

IN normal conditions the integrity of the gastric mucosa is maintained by several mechanisms, including normal microcirculation in the mucosa. Good microcirculation nourishes the mucous membrane, eliminates hydrogen ions, free radicals and other potential toxic substances, formed in the intestinal lumen. Secreted mucosal “traps” in the form of bicarbonate ions can neutralize hydrogen ions.
If the barrier formed by the mucous membrane is unable to block the harmful effects of hydrogen ions and oxygen radicals, mucosal damage develops. An increase in the synthesis of nitric oxide, apoptosis and the release of cytokines from damaged cells play a certain role. In addition, there is a slowdown in peristalsis in the upper gastrointestinal tract. Decreased rate of gastric emptying results in prolonged exposure of the mucosa to acid, thereby increasing the risk of ulceration.

An acceptable level of SaO 2 does not indicate adequacy of mucosal perfusion. Most often, in critically ill patients on mechanical ventilation, peripheral saturation does not suffer or suffers moderately, which does not indicate the absence of ischemia of the gastric and duodenal mucosa.

Cushing's ulcers originally described in patients with brain tumors or cerebral trauma, that is, in a group of patients with high intracranial pressure. These are usually single deep ulcers that are prone to perforation and bleeding. They are associated with a high debit of hydrochloric acid in the stomach and are usually located in the duodenum or stomach.
Extensive burns are associated with the so-called " Curling's ulcers".
The factors listed above for the occurrence of stress ulcers are especially relevant in children and elderly patients.

Currently, the list of potential threats to the development of stress acute peptic ulcers (diseases, conditions, conditions) has been expanded.
Main antecedent conditions:
- sepsis;
- multiple organ failure syndrome;
- isolated positive blood culture (even without any clinic);
- endoscopically or radiologically confirmed peptic ulcer of the stomach and duodenum within 6 weeks before admission to the ICU;
- organ transplantation;
- a history of bleeding from the gastrointestinal tract within 48 days before admission to the ICU ICU - intensive care unit
;
- coagulopathy Coagulopathy - dysfunction of the blood coagulation system
(including due to the use of heparin, warfarin, aspirin and other anticoagulants);
- artificial ventilation lasting more than 48 hours;
- surgery on the aorta for aneurysm;
- old age;
- taking systemic corticosteroids GCS (glucocorticoids, glucocorticosteroids) - drugs, one of the leading properties of which is to inhibit the early stages of synthesis of the main participants in the formation inflammatory processes(prostaglandins) in various tissues and organs.
IV or orally more than 40 mg/day. (according to some authors, more than 250 mg in hydrocortisone equivalent);
- acute heart attack myocardium;
- condition after extensive neurosurgical operations;
- any type acute failure(hepatic, renal, pulmonary, cardiovascular).

2.Dieulafoy's ulcer
The theory about Dieulafoy's disease as one of the causes of acute gastric ulcers with bleeding is controversial. A possible cause is an unusually tortuous and dilated artery of the submucosal layer of the stomach. However, even a targeted study, as a rule, does not reveal signs of vasculitis Vasculitis (syn. angiitis) - inflammation of the walls of blood vessels
, atherosclerosis or formed aneurysm Aneurysm - expansion of the lumen blood vessel or heart cavity due to pathological changes their walls or developmental anomalies
. Neighboring veins and medium-sized vessels resemble the picture of arteriovenous anomalies - angiodysplasia.

The cause of ulcerative bleeding is mainly a purely local ulcerative necrotic process during an exacerbation of the disease with damage to the vessel. In some cases, atherosclerotic vascular lesions acquire independent significance as a cause of ulcerative bleeding. In this case, vascular changes such as productive endarteritis are detected, apparently secondary. Endarteritis is an inflammation of the inner lining of an artery, manifested by its growth and narrowing of the lumen of the arteries, thrombosis and disturbances in the blood supply to the corresponding organs or parts of the body.
, endophlebitis Endophlebitis - inflammation of the inner lining of a vein
, sometimes with vascular thrombosis. The development of bleeding is favored by concomitant vitamin deficiency (vitamins C and K).

3.Acute ulcers associated with non-steroidal anti-inflammatory drugs (NSAIDs).
Taking NSAIDs more often leads to the formation of chronic stomach ulcers. Many authors use the term “NSAID-associated gastropathy” in relation to such ulcers and other processes associated with taking NSAIDs. However, in some cases, against the background of severe intercurrent pathology, taking NSAIDs directly provokes the development of stress ulcers and aggravates bleeding from them.

The following are considered as etiopathogenetic factors in the development of NSAID gastropathy:
- local irritation of the gastric mucosa (GMU) and subsequent formation of ulcers;
- inhibition of the synthesis of prostaglandins (PGE2, PGI2) and their metabolites prostacyclin and thromboxane A2 in the coolant, which perform the function of cytoprotection;
- disturbance of blood flow in the mucous membrane due to previous damage to the vascular endothelium after taking NSAIDs.

The topical damaging effect of NSAIDs is manifested by the fact that some time after the administration of these drugs, an increase in the penetration of hydrogen and sodium ions into the mucous membrane is observed. NSAIDs suppress the production of prostaglandins not only in areas of inflammation, but also at the systemic level, so the development of gastropathy is a kind of programmed pharmacological effect of these drugs.

It has been suggested that NSAIDs may induce apoptosis through proinflammatory cytokines. Apoptosis is the programmed death of a cell using internal mechanisms.
epithelial cells. When using these drugs, the hydrophobic layer on the surface of the coolant is affected, the composition of phospholipids is depleted and the secretion of gastric mucus components is reduced.
In the mechanism of the ulcerogenic effect of NSAIDs, changes in lipid peroxidation play an important role. The resulting products of free radical oxidation cause damage to the coolant and destruction of mucopolysaccharides.
In addition, NSAIDs have a certain effect on the synthesis of leukotrienes, a decrease in the number of which leads to a decrease in the amount of mucus, which has cytoprotective properties. A decrease in the synthesis of prostaglandins leads to a decrease in the synthesis of mucus and bicarbonates, which are the main protective barrier of the coolant fluid from aggressive factors. gastric juice.

When taking NSAIDs, the level of prostacyclin and nitric oxide decreases, which adversely affects blood circulation in the submucosal layer of the gastrointestinal tract and creates an additional risk of damage to the coolant and duodenum. Changing the balance of protective and aggressive gastric environments leads to the formation of ulcers and the development of complications: bleeding, perforation, penetration.

4. Other mechanisms and conditions of occurrence.
Acute gastric ulcer, complicated by bleeding, occurs in patients with hypergastrinemia, hypercalcemia (isolated cases).

Epidemiology

Age: except children younger age

Sign of prevalence: Rare

Sex ratio(m/f): 2

According to statistics, stress ulcers are the most common (about 80%). 10-30% of patients have symptomatic ulcers due to cardiovascular disease. The most rare are symptomatic ulcers due to endocrine diseases (Zollinger-Ellison syndrome Zollinger-Ellison syndrome (syn. gastrinoma) - a combination of peptic ulcers of the stomach and duodenum with adenoma of the pancreatic islets, developing from acidophilic insulocytes (alpha cells)
- no more than 4 per 1 million population per year).

Stress stomach ulcers
Stress lesions of the gastric mucosa (not only ulcers, but also submucosal petechiae Petechia is a spot on the skin or mucous membrane with a diameter of 1-2 mm caused by capillary hemorrhage
and non-bleeding erosions) are detected endoscopically in 75-100% of patients in the ICU ICU - intensive care unit
, in the first 24 hours after admission. Only 6-10% of identified lesions of the gastric mucosa (up to 30% of ulcers) are accompanied by bleeding, which is defined as at least one episode of coffee grounds or melena obtained during gastric lavage or after an enema (regardless of whether the hematocrit decreased or not). Only 2-5% of patients with mucosal stress lesions have bleeding requiring transfusion.

Symptomatic drug ulcers:
1. It has been established that about 50% of ulcers associated with taking NSAIDs are complicated by bleeding.
2. About 80% of ulcer bleeding stops spontaneously and about 20% continues or recurs after stopping.
3. About 80% of recurrent bleeding occurs in the first 3-4 days.
4. Up to 10% of recurrent bleedings lead to death (0.5% in people under 60 years of age, 20% in people over 80 years of age).

Symptomatic ulcers in other diseases
Frequency of development of hepatogenic gastropathy Gastropathy is the general name for stomach diseases.
with liver cirrhosis it is 50-60%, gastroduodenal ulcers - from 5.5 to 24%. This is 2.6 times higher than the prevalence of gastric and duodenal ulcers among the rest of the population.

Dieulafoy's disease is a relatively rare cause of upper gastrointestinal bleeding.

Ulcerations, as a source of massive gastrointestinal hemorrhages (bleeding), are observed in 0.3-5.8% of cases.
Bleeding recurs in 18-100% of patients - this is a hallmark of the disease. Severe bleeding is observed in more than a third of patients.

Risk factors and groups

I. For stress stomach ulcers and for stress-induced damage to the mucous membrane of the gastrointestinal tract (GIT), the following risk factors were formulated (according to the ASHP Commission on Therapeutics and approved by the ASHP Board of Directors, 1998, with additions and changes from 2012)

1. Independent risk factors:
- coagulopathy (including those caused medicines) with the following indicators: platelet count<50 000 мм 3 , INR (INR International normalized ratio (INR) is a laboratory indicator determined to assess the extrinsic pathway of blood coagulation
) > 1.5 or PTT (partial thromboplastin time) > 2 normal indicators;
- respiratory failure: mechanical ventilation (MV) ≥ 48 hours.

2. Other risk factors:
- spinal cord damage;
- multiple injuries: injury to more than one area of ​​the body;
- liver failure: level total bilirubin> 5 mg/dL, AST > 150 U/L (or more than 3 times the upper limit of normal values) or ALT > 150 U/L (or more than 3 times the upper limit of normal values);

Thermal burns > 35% body surface area;
- partial resection Resection - surgery by removing part of an organ or anatomical formation, usually with the connection of its preserved parts.
liver;
- traumatic brain injury with coma and a Glasgow scale score ≤10 or with the inability to follow simple commands;
- liver or kidney transplantation;
- history of gastric ulcer or bleeding within a year before admission to the ICU ICU - intensive care unit
;
- sepsis or septic shock, with hemodynamic support with vasopressors and/or positive blood culture or clinically suspected infection;
- stay in the ICU ICU - intensive care unit
more than 1 week;
- hidden or obvious bleeding lasting more than 6 days;
- therapy with corticosteroids, regardless of the route of administration.

Note. Some US researchers indicate other risk factors in the group renal failure(serum creatinine level more than 4 mg/dL).

II. Ulcers associated with NSAID use
According to the recommendations of the American College of Gastroenterology (2009) for the prevention of complications of gastropathy induced by NSAIDs, all patients can be divided into the following groups according to the degree of risk of toxic effects of NSAIDs on digestive tract:

1. High risk:
- there is a history of a complicated ulcer, especially a recent one;
- multiple (more than 2) risk factors.

2. Moderate risk (1-2 risk factors):
- age over 65 years;
- high dose of NSAIDs;
- there is a history of an uncomplicated ulcer;
- simultaneous use of acetylsalicylic acid (including in low doses), corticosteroids or anticoagulants.

3. Low risk: no risk factors.

Taking NSAIDs increases the risk of bleeding by 2.74 times; at the age of more than 50 years - 5.57 times; with previous episodes of bleeding or while taking glucocorticoids - 4.76 times; when combining NSAIDs with anticoagulants - 12.7 times.

Clinical picture

Clinical diagnostic criteria

Hematemesis, melena, epigastric pain, tachycardia, weakness, dizziness, arterial hypotension, orthostatic collapse

Symptoms, course

Patients with acute gastrointestinal bleeding exhibit hematemesis Hematemesis - vomiting of blood or blood mixed with vomit; occurs when there is gastric bleeding.
, melena Melena - discharge of feces in the form of a sticky black mass; usually a sign of gastrointestinal bleeding.
, as well as additionally symptoms and signs of hypovolemia of varying degrees.

Signs of hypovolemia Hypovolemia (syn. oligemia) is a reduced total amount of blood.
:
- reduction blood pressure(systolic or mean) by more than 20 mmHg. Art., lying down, or more than 10 mm Hg. Art., sitting;
- increased heart rate by more than 20/min;
- decrease in hemoglobin by more than 20 g/l.

Coffee grounds, melena Melena - discharge of feces in the form of a sticky black mass; usually a sign of gastrointestinal bleeding.
, an admixture of blood in the aspirate from the stomach through a tube, positive samples blood in the stool confirms bleeding from the upper gastrointestinal tract (GIT).

Hematemesis manifests itself in the form of vomiting blood, either vomiting in an unchanged form, or vomiting in the form of a dark brown granular substance (“coffee grounds”) - formed as a result long stay blood in the stomach and the conversion of hemoglobin into methemoglobin by hydrochloric acid.

Melena(the appearance of altered blood in the rectum) is recognized by black, loose stools, sometimes with a red tint (when the blood is fresh and has a characteristic pungent odor). This is due to heme oxidation by intestinal and bacterial enzymes and indicates that the source of bleeding is likely to be in the upper gastrointestinal tract and definitely proximal to the ileocecal Ileocecal - relating to the area where the ileum and cecum join.
anastomosis. It should be kept in mind that melena Melena - discharge of feces in the form of a sticky black mass; usually a sign of gastrointestinal bleeding.
may continue for several days after active bleeding has stopped. This fact can confuse doctors. In addition, it is necessary to distinguish melena from the results of oral iron supplements, causing the appearance sticky but relatively hard gray-black stool.
With increased gastrointestinal motility (for example, stimulation with proserin) and a decrease in the acid-forming function of the stomach, melena Melena - discharge of feces in the form of a sticky black mass; usually a sign of gastrointestinal bleeding.
may contain an admixture of fresh, unchanged blood, which can also cause a diagnostic error.

Rectal bleeding of unchanged blood directly suggests that the source of bleeding is the colon, rectum or anus. However, it should be remembered that heavy bleeding from the upper gastrointestinal tract can manifest itself in the same way. Therefore, in a patient with massive rectal bleeding with unchanged blood, especially if there are signs of hypovolemia Hypovolemia (syn. oligemia) is a reduced total amount of blood.
, bleeding from the stomach or duodenum should be excluded.
If patients have previously undergone aortic surgery with a graft, the possibility of an aortoenteric fistula should be considered with consultation with a vascular surgeon.

Diagnostics

Pre-insertion of a nasogastric tube to evacuate blood clots and improve the accuracy of endoscopy has not been universally accepted.

The main method is endoscopy (FGDS), which should be completed as early as possible (on the first day after admission). Endoscopic examination is performed under benzodiazepine sedation, but if the patient vomits a large number blood, then it is possible to use general anesthesia with endotracheal intubation with a tube with a cuff.

Endoscopic examination should begin with the patient positioned strictly on the left side, as this ensures the accumulation of blood in the area of ​​the fundus of the stomach, where ulcers rarely occur. If it is necessary to examine the fundus of the stomach, then the patient is turned over on his right side and the head end of the gurney is raised so that the blood moves to the antrum. Once the endoscope has passed through the esophagogastric junction, a seemingly obstructive collection of blood and clots is usually not detected. As long as the stomach is able to distend, a moderate amount of blood will rarely interfere with adequate visualization of the source of bleeding. Most likely, a clot covering the ulcer will be visible. It is important to try to wash it off to determine how tightly it is held in place - this affects prognosis and treatment, and careful washing rarely speeds up bleeding.

If there is too much blood in the stomach for an adequate examination, it is necessary lavage. The 40 Fr lavage tube is ideally inserted into the stomach, where suction is performed directly. This way, enough blood and clots are usually removed to allow inspection. If this does not help, then lavage Lavage is the washing of a body cavity (for example, colon or stomach) with water or medicinal solution
carried out with the introduction of a liter of water through the canal. Thanks to this, the clots will be broken up and can then be easily removed through a tube installed in the appropriate position.

FGDS FGDS - fibrogastroduodenoscopy ( instrumental study esophagus, stomach and duodenum using a fiberoptic endoscope)
should be performed urgently in all patients at risk who have bleeding from the upper gastrointestinal tract, an unexplained drop in hemoglobin (hematocrit in children) or positive tests for occult blood in the stool.

Laboratory diagnostics

Blood tests: hemoglobin, hematocrit, red blood cell count, platelet count, coagulation time, coagulogram, blood group and Rh factor, acid-base balance ABC - acid-base state - balance of acids and bases, i.e. the ratio of hydrogen and hydroxyl ions in the biological media of the body (blood, intercellular and cerebrospinal fluids, etc.)
.

Stool analysis: determination of occult blood.

Differential diagnosis

It should be differentiated from bleeding from other parts of the gastrointestinal tract (esophagus, duodenum, small intestine); with gastric bleeding of other etiology (acute erosive gastritis, varicose veins, vascular malformation, polyp, carcinoma, leiomyoma, lymphoma, etc.).

Complications

Possible complications:
- shock;
- anemia;
- consumption coagulopathy;
- recurrent bleeding.

According to modern ideas, the risk of recurrent bleeding and/or death is associated with the following endoscopic signs:
- detection of an exposed vessel at the bottom of the ulcer (risk 90%);
- exposed vessel at the bottom of the ulcer without visible bleeding (50% risk);
- a large unformed “red” thrombus that covers the defect and does not close when the ulcer is irrigated with isotonic sodium chloride solution (risk 25%).

According to International clinical guidelines on the management of patients with nonvariceal upper gastrointestinal bleeding (consensus meeting held in June 2002 under the auspices of the Canadian Association of Gastroenterologists), the risk of recurrent bleeding can be determined according to the table below.

Statistically significant predictors of recurrent bleeding

Risk factors	Indicators of increased risk
Clinical factors
Age > 65 years	1,3
Age > 70 years	2,3
Shock (syst. BP< 100 мм рт.ст.)	1,2-3,65
General Status (ASA*)	1,94-7,63
Concomitant diseases	1,6-7,63
Unstable level of consciousness	3,21 (1,53-6,74)
Continued bleeding	3,14 (2,4-4,12)
Previous blood transfusion	Not defined
Laboratory factors
Hemoglobin< 100 г/л или hematocrit< 0,3	0,8-2,99
Coagulopathy (prolonged aPTT)	1,96 (1,46-2,64)
Signs of bleeding
Melena	1,6 (1,1-2,4)
Scarlet blood on rectal examination	3,76 (2,26-6,26)
Blood in the stomach or tube	1,1-11,5
Hematemesis	1,2-5,7
Endoscopic factors
Active bleeding during endoscopy	2,5-6,48
Signs of high risk	1,91-4,81
Clot at the bottom of the ulcer	1,72-1,9
Ulcer size > 2 cm	2,29-3,54
Presence of peptic ulcer	2,7 (1,2-4,9)
Ulcer localization
Lesser curvature of the stomach	2,79
Top wall	13,9
Rear wall	9,2

* ASA - American Society of Anesthesiologists

Medical tourism

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment abroad

What is the best way to contact you?

Send an application for medical tourism

Medical tourism

Get advice on medical tourism

People often ignore treatment for gastritis, allowing peptic ulcers to develop. Its dangerous consequence is bleeding from a stomach ulcer. A person with such a complication must receive prompt medical attention to save his life.

For people with gastrointestinal pathologies, it is important to know not only the signs of vascular damage, but also need to regularly prevent the disease.

Bleeding (hemorrhage, hemorrhage) during an ulcer is the destruction of blood vessels and the flow of blood into the stomach with its subsequent spread throughout the gastrointestinal tract. The main signs are a deterioration in the general condition of a person, epigastric pain, blackening of the color of feces and a red-brown mixture in the vomit.

Hemorrhage often opens when acute ulcer, as well as in case of exacerbation of the chronic form. In photographs of macroscopic specimens or endoscopic images, you can see deep grooves in the gastric mucosa with blood clotted inside.

Types of bleeding due to peptic ulcer:

• by type: open (strong, in case of destruction of the artery) and hidden (weakly expressed, in case of damage to small vessels);
• by degree: light or moderate bleeding and massive blood loss;
• by nature: established and ongoing;
• by origin: symptomatic (as a sign of another disease), acute, chronic;
• by localization: from an ulcer located in an organ (body, antrum, cardia, pylorus) or in the duodenum.

Depending on type pathological process in the ICD-10 reference book it is assigned codes K25.0, K25.2, K25.4 or K25.6.

Causes of bleeding from a stomach ulcer

A bleeding ulcer appears inside the stomach due to injury from erosion, scar, or neoplasm. Destruction of the integrity of blood vessels in the wound area also occurs due to thrombosis, atherosclerosis, microcirculation disorders due to diabetes or other diseases. Bleeding also occurs when an ulcer is not treated correctly, an unauthorized change in the treatment regimen, or stopping taking medications prescribed by a doctor.

Intragastric hemorrhage can be caused by mechanical damage to the ulcer during instrumental examination organ or eating rough food, excessive physical activity. Bleeding also occurs due to irritation of the surface of erosions with medications, in particular NSAIDs, hot food, aggressive substances, alcohol, and other thermal and chemical factors.

Symptoms and signs of a bleeding ulcer

Hidden bleeding rarely occurs with a stomach ulcer severe symptoms. A person periodically feels paroxysmal pain in the epigastric region, notes increased fatigue, deterioration in performance. Prolonged hemorrhage is indicated by a decrease in hemoglobin levels, arrhythmia, the development of hypotension, and darkening of the stool.

Symptoms and signs of moderate blood loss (up to 20%):

With massive blood loss, the severity of the symptoms worsens, and the symptoms of multiple organ failure are added. Manifestations of MODS syndrome include swelling of brain tissue, a drop in pressure, weakening of the functions of the heart, liver, kidneys, intoxication due to decomposition of blood in the gastrointestinal tract, and shock. The patient may be unconscious.

Diagnosis of bleeding gastric ulcer

In the absence of contraindications, doctors perform therapeutic gastroscopy. During the examination, the organ cavity may be washed and hemostatic drugs administered inside.

The patient, if possible, donates stool, has gastric juice collected to detect occult blood (Gregersen reaction), and CT angiography. A plain X-ray of the abdominal cavity is performed to confirm the absence of a perforation (through hole) in the wall of the stomach. The patient is also given a blood test to assess hematocrit, the concentration of red blood cells.

First aid for bleeding stomach ulcers

It is impossible to stop intragastric hemorrhage at home using traditional methods: the patient will require emergency drug treatment. Therefore, you should immediately call an ambulance. If bleeding is suspected, a person is prohibited from eating, drinking, or getting to the hospital on their own.

Before the medical team arrives, the patient should lie on his back (without a pillow, with his feet on a raised surface), apply a cold heating pad to the epigastric area and swallow a piece of ice. In case of severe vomiting, it is allowed to give an intramuscular injection of Cerucal (2 ml) or drink a solution of Novocaine (30 ml). You can inject 5 ml of Vikasol intramuscularly to reduce bleeding. Until doctors arrive, the person is kept conscious, using cotton wool soaked in ammonia if necessary.

Drug therapy for intragastric bleeding

Upon arrival, doctors give the patient a hemostatic agent to drink (2 tablespoons of aminocaproic acid, two crushed Dicinone tablets), 1 tsp. calcium chloride to speed up blood clotting or drugs are administered intravenously. The patient is then taken to the hospital. In case of severe hemorrhage, a transfusion of red blood cell mass is given to restore the volume of blood volume.

Methods of conservative treatment:

1. To stop bleeding, IM injections, IV infusions, or endoscopic injections of hemostatic (hemostatic) drugs into the stomach are used. The patient is prescribed Collargol, Gastrosol, Epsilon-amincapronuic acid, Cryoprecipitate, Vikasol, other means.
2. To normalize the water-salt balance and circulating blood volume, it is also prescribed Reopoliglyukin or other colloidal, crystalloid solutions.
3. Plasma is used to improve blood clotting Fibrinogen, platelet mass, Calcium Gluconate, vitamin K.
4. To eliminate the syndromes, symptomatic therapy is carried out with painkillers, spasmodic, antiallergic and other drugs.

After stopping hemorrhage, gastroprotectors are also prescribed to accelerate wound healing, antiulcer, antisecretory and antimicrobials. Use Famotidine,Pariet, De-Nol, Amoxicillin, Metronidazole,Venter, Methyluracil and other medicines.

Therapeutic nutrition for bleeding ulcers

If a stomach ulcer opens with any type of bleeding, it is recommended to use parenteral nutrition(administration of beneficial substances through droppers). Until the hemorrhage is stopped, the patient is advised to go on a strict hunger strike. Then, instead of intravenous feeding, treatment table No. 0 is prescribed with a gradual transition to diet No. 1A, No. 1B and No. 1 according to Pevzner.

All food is boiled in water or steamed, consumed pureed, brought to a liquid consistency with low-fat chicken broth. It is allowed to eat warm mucous soups, dairy products, dietary meat minced in a blender, and fish. Eliminate from the diet any food and drinks that irritate the lining of the stomach.

Surgical treatment for bleeding ulcers

Operations are performed in case of unsuccessful stoppage of bleeding conservative methods. In surgical treatment, minimally invasive methods are used: laser coagulation, endovascular hemostasis, clipping of a damaged vessel or cauterization (diathermocoagulation) of an ulcer. The bleeding wound is also sutured and the stomach is resected.

After the operation it is prescribed drug therapy and diet No. 0 according to Pevzner.

Useful video

How to help with gastrointestinal bleeding can be found in this video.

Complications and consequences of a bleeding ulcer

The main danger of a gastric ulcer with hemorrhage is the threat to the patient’s life. Hidden bleeding leads to intoxication of the body by the breakdown of red blood cells and the gradual decline of a person, and massive bleeding leads to fatal outcome. In addition, even stopped hemorrhage can often recur in the presence of predisposing factors.

Complications of gastric ulcers with chronic bleeding include anemia. Its symptoms are pale skin, fatigue, frequent darkening of the eyes. At the site of deep erosions, adhesions also form with loss of mucosal function. Often diagnosed perforated ulcer and peritonitis due to perforation of the stomach wall.

A dangerous complication is the death of the patient due to significant blood loss. Hidden hemorrhage suddenly becomes abundant (profuse), and a person’s health rapidly deteriorates. In case of massive loss of fluid, he dies in sharp decline BCC, hypovolemic shock, internal organ failure, drop in blood pressure.

Prognosis of bleeding from a gastric ulcer

In 90% of cases, hemorrhage is stopped using conservative methods when receiving medical care at the very beginning of bleeding. If complications arise, doctors give a favorable prognosis only in the case of surgical treatment. With massive blood loss, 5% of patients die.

Prevention of intragastric bleeding

People with stomach ulcers are strictly prohibited from changing the treatment regimen or interrupting the course of treatment prescribed by the gastroenterologist. To avoid bleeding, it is better to stop drinking alcohol and smoking; it is not recommended to break your diet, engage in strength sports, or perform heavy physical work. With the permission of the doctor, you can alternate the treatment of concomitant diseases with medications and herbal remedies. This will reduce irritation of the gastric mucosa with medications.

People with gastrointestinal diseases are recommended to be examined by a gastroenterologist 2–4 times a year and undergo preventive treatment in health resort institutions specializing in pathologies of the digestive system. Such measures will reduce the likelihood of intragastric bleeding and the risk of other complications of the ulcer.

Ulcerative bleeding occurs suddenly and does not depend on the stage of development and nature of the underlying disease. In rare cases, the complication becomes the first symptom of a stomach ulcer. Hemorrhage is life-threatening and, if help is delayed, often ends in the death of the patient.

Reasons

The main cause of bleeding in cases of gastric ulcers is deep ulceration of the walls, when the bottom of the lesion reaches the arteries and vessels. Hemorrhage is most often complicated by acute and chronic callus defects in the presence of predisposing factors.

They may be:

• excessive consumption of coarse foods that injure the walls and bottom of the ulcer;
• preference for very hot or cold food, which irritates the open wound and causes it to bleed;
• drinking alcohol and smoking, especially on an empty stomach;
• abdominal injuries;
• long-term treatment with glucocorticosteroids, NSAIDs, antibiotics;
• poor blood clotting;
• gastrointestinal diseases;
• pathologies of the heart and blood vessels;
• stress, emotional breakdown.

Sometimes gastric bleeding occurs under the influence of excessive physical strain or sudden lifting of weights, prolonged mental stress. Pathology can also be provoked by vitamin deficiency, thrombosis of the veins of the lower extremities, and non-compliance with the work and rest regime.

An open stomach ulcer often bleeds in patients diabetes mellitus, atherosclerosis, patients with high blood pressure. Some clinicians note the hereditary nature of the complication - if the defect is present in one of the parents, the likelihood of its occurrence in children increases markedly.

Symptoms

Signs of a bleeding gastric ulcer are usually divided into hidden, typical for any hemorrhage, and obvious, characteristic of internal hemorrhage.

Hidden symptoms are manifested by weakness, impaired coordination of movements, tachycardia, shortness of breath, darkening of the eyes. Fall in blood pressure, appearance profuse sweating, agitation or loss of consciousness are considered signs of hemorrhagic shock and require urgent replacement therapy.

With intraluminal bleeding from the stomach, the symptoms become obvious:

• sharp pain and burning in the abdomen;
• the appearance of nausea;
• pale skin;
• vomiting blood;

The localization of discomfort depends on the location where the stomach ulcer burst. To alleviate suffering, the patient assumes the fetal position with his knees pulled up to his stomach.

With minor bleeding, the stool becomes dark in color; heavy hemorrhages are characterized by the appearance of melena - tarry stool of a viscous consistency with an unpleasant odor. In case of massive blood loss, there may be no black feces, and scarlet blood begins to be released from the rectum.

Manifestations of ulcerative blood loss can increase over several days or weeks or occur simultaneously.

First aid

If a stomach ulcer has opened and a person has the first symptoms of hemorrhage, it is necessary to act very quickly. The first step in helping the victim should be to call a medical team.

• provide the patient with complete immobility;
• lay it on a horizontal surface, placing a pillow or cushion of folded clothing under your feet;
• cool the stomach area with ice or frozen food;
• talk to the patient without losing consciousness.

What should not be done in case of an acute gastric ulcer with bleeding? It is prohibited to feed or water the victim, give analgesics, or lift or sit him down.

Which doctor treats a bleeding stomach ulcer?

A burst ulcer rarely gives you the opportunity to see a doctor on your own. More often, the patient is taken to the hospital by ambulance, where a gastroenterologist and surgeon take care of his health. If there are concomitant pathologies that cause bleeding, other specialists are involved in treatment.

If the hemorrhage is moderate and the patient is able to go to the clinic, he should contact a gastroenterologist, or, if he is not available, a therapist.

Diagnostics

Initial examination of a patient with characteristic symptoms even with small blood losses suggests rupture of a gastric ulcer. To clarify the diagnosis, the victim is prescribed a number of studies:

• clinical blood test;
• coagulogram;
• bilirubin test;
• Ultrasound of the abdominal cavity.

The main diagnostic method for gastric ulcers with bleeding is esophagogastroduodenoscopy. If hemorrhage persists, a radionuclide test may be prescribed.

When a patient is admitted to a hospital, if their health allows, an endoscopic examination is performed first, followed by other diagnostic measures.

Treatment

An ulcer with open bleeding is always a risk for the patient. Such a patient needs round-the-clock monitoring, modern equipment and competent restoration of hemostasis.

Drug therapy

A bleeding gastric ulcer, the treatment of which requires intravenous infusion of plasma substitutes and red blood cells, is carried out in an intensive care unit.

Hemostatic therapy includes:

• intravenous drugs - Aminocaproic acid, Dicynone, Fibrinogen, Hemophobin, gluconate or calcium chloride;
• therapeutic endoscopy;
• local therapy - bed rest, taking Norepinephrine or Adrenaline, cold applied to the epigastric area;
• vascular embolotherapy through the femoral artery.

Additionally, the patient is prescribed cardiac medications to normalize acid balance Sodium bicarbonate is used. Restoring microcirculation and increasing the volume of fluid in the arteries is carried out with Reopoliglyukin and Trental.

Antiulcer therapy after bleeding has stopped includes taking Pilobact. The issue of stopping hemorrhage is decided using a probe or FGDS.

Operation

If conservative treatment open gastric ulcer does not give the expected result or the patient is in old age, the option of surgical intervention is being considered. There may be other reasons for surgery:

• massive bleeding;
• regular recurrences of hemorrhage;
• the location of the ulcer near large arteries.

Today, gastrectomy is considered the most effective and organ-preserving type of intervention. In older and debilitated patients, suturing can be performed with or without sectioning the vagus nerve. With any method of intervention, the patient must observe strict bed rest and follow all doctor’s instructions.

Proper nutrition

Diet for stomach ulcers is a necessary condition quick recovery. In the first week after bleeding, the patient is prescribed table No. 1, excluding the following products:

• fatty, salty, fried and smoked foods;
• legumes and peas;
• sour vegetables and fruits;
• bread and confectionery;
• sparkling water, coffee, alcohol.

By following a diet, you can not only speed up recovery, but also avoid the risk of repeated relapses.

Complications

Untreated gastric ulcer with bleeding can cause many serious complications:

• cerebral edema;
• liver dysfunction;
• toxic poisoning;
• anemia;
• disruption of body systems.

And these are not all the consequences. Complicated ulcer bleeding often leads to the death of the patient. The urgency of the problem is emphasized by the figures - the mortality rate from hemorrhage is 10–15%, and among patients with massive bleeding it reaches 50–55%.

Prevention

There is no specific prevention of ulcerative blood loss, but compliance certain rules will help preserve the health and sometimes even the life of the patient.

Prevention measures:

• promptly treat all diseases of the stomach and duodenum;
• eat small and often meals;
• avoid stress, mental and physical fatigue;
• undergo regular medical examinations and follow all doctor’s instructions.

For a patient with a stomach ulcer, it is very important to maintain a moderate pace of life, maintain affordable physical activity, follow a strict diet and completely give up alcohol and smoking.

The prognosis of a peptic ulcer with bleeding depends on the timeliness and competence of the assistance provided, as well as the amount of blood loss. Great responsibility lies with the patient himself. You should not wait until the ulceration opens. At any, even the slightest suspicion of bleeding, it is recommended to immediately seek help. This is exactly the case when it is better to play it safe.

Useful video about first aid for gastrointestinal bleeding