Gastric ulcer. Acute with bleeding (K25.0)

Stomach ulcer(GU) is a multifactorial chronic disease accompanied by the formation of ulcers in the stomach with possible progression and development of complications.

acute ulcer is a deep defect of the mucous membrane, which penetrates to the proper muscular plate of the mucous membrane and deeper. Acute ulcers are more often solitary; have a round or oval shape; on the section they look like a pyramid. The size of acute ulcers is 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: weakly or moderately expressed inflammatory process in 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, a scar is formed within 7-14 days (incomplete regeneration). With a rare adverse outcome, a transition to a chronic ulcer is possible.

Ulcer perforation is the occurrence of a through defect in the wall of the stomach at the site of the localization of the ulcer.

In the case of a combination of such severe complications, the clinic of a perforated ulcer is atypical. In particular, peritoneal symptoms and pain syndrome are less pronounced, and there may be no sharp tension in the abdominal muscles. This is especially noticeable when perforation of the ulcer occurs against the background of ongoing profuse Profuse - plentiful, strong (about bleeding, diarrhea).
bleeding in a weakened, exsanguinated patient. Ulcer perforations in such patients are often diagnosed late, as a result of which the risk of surgery increases significantly and postoperative mortality increases several times (20-25% higher than with a perforated or only bleeding ulcer).
A rare case of a combination of bleeding with perforation is perforation of an ulcer of the anterior wall of an organ and bleeding from a second ulcer located on the back wall ("kissing" ulcers) and penetrating into the underlying tissues and organs. Recognition of such a source of bleeding is difficult.

Flow period

Minimum flow period (days): 1

Maximum flow period (days): not specified

Classification

There is no clear classification of gastric ulcer with bleeding and perforation. In this regard, it is advisable to use the classification of the prevailing symptoms or morphological features.

Bleeding
Classification Forrest(1974) plays an important role in assessing the risk of rebleeding and patient death. Based on the endoscopic picture, it is possible to determine the scope of endoscopic manipulations to achieve hemostasis. Hemostasis - 1) in surgery - stop bleeding; 2) in pathology (syn. blood stasis) - stoppage of blood flow in the vessels of a section of an organ or tissue.
or determine indications for surgery.

- F1A- jet bleeding from an ulcer;

- F1B- drip bleeding from an ulcer;

-FIIA- thrombosed vessels at the bottom of the ulcer;

-FIIB- a blood clot covering the ulcer;

- FIIC- an ulcer without signs of bleeding or inclusion of hydrochloric acid hematin at the bottom of the ulcer;

- FIII- sources of bleeding are not found or an ulcer without signs of bleeding.

In terms of diagnosis and the significance of recurrence prognosis, type IIA (visible vessel) is the most controversial. A visible vessel at the bottom of the ulcer can be represented by a "watch" thrombus or "pearl" tubercle.

"Sentry" thrombus is a thrombus that clogs a defect in an eroded vessel, and looks like a red or black tubercle protruding above the yellow bottom of the ulcer. In some cases, a part of the preserved vessel wall in the form of a pearl rim can be seen around the "watch" thrombus.

"Pearl" tubercle is an eroded vessel, the defect in the wall of which is closed due to its spasm, and not by a thrombus. The tubercle has a pearly whitish color and rises above the bottom of the ulcer.

The presence or absence of a visible vessel, a number of researchers recommend reflecting in the protocol with signs " v+" And" v-". Thus, the presence of a "pearl" tubercle or "watch" thrombus with a pearl rim will be interpreted as a type FIIA v+(the risk of recurrent bleeding in this case is especially high). Type FIIA v- is diagnosed in the presence of a "hour" thrombus without a pearl rim.

A comparative study of the endoscopic picture and morphological studies found that if a pearl-colored tubercle or a red tubercle with a pearl rim (type FIIA v +) is found in the bottom of the ulcer during EGDS, then during the morphological study, the vascular wall protrudes above the bottom of the ulcer and there is more severe damage to the vascular wall, than when EGDS reveals a "clock" thrombus without a pearl rim (type FIIA v-) (Chen et al., 1997).

In the studies of J.W. Law et al. (1998) showed that in most patients the eroded vessel is covered with a fixed thrombus-clot.

The risk of rebleeding is considered low with an FIIC (flat black spot) endoscopic picture.

In a morphological study in 20% of patients with a clean (white) bottom (type FIII), an eroded vessel is found in the bottom of the ulcer. Apparently, the white color of the vessel is not visible during endoscopic examination due to masking by fibrin. In this situation, the clinical picture and laboratory data are of particular importance to the endoscopist, since certain limitations of the usual visual assessment create prerequisites for erroneously determining the risk of rebleeding as minimal. The use of a video endoscope and Doppler studies increases the possibility of detecting a vessel in the bottom of the ulcer.

The issue of further management of the patient is decided after a visual assessment of the source of bleeding.

perforation

By clinical course:

A typical form is the leakage of contents into the free abdominal cavity;

Atypical form - the defect is covered by an omentum or a neighboring organ.

Etiology and pathogenesis

Etiology - acute stomach ulcer.
Pathogenesis - erosion of all layers of the stomach wall by gastric juice in combination with an increase in intragastric pressure and with processes leading to erosive bleeding from an ulcer.

Epidemiology

Age: Predominantly elderly

Sign of prevalence: Extremely rare

Sex ratio (m/f): 5

It is extremely rare.

Clinical picture

Clinical Criteria for Diagnosis

Acute abdominal pain, abdominal muscle tension, nausea, hematemesis, coffee grounds vomiting, melena, pallor, tachycardia, dizziness

Symptoms, course

1. Pain syndrome - extremely intense, "dagger" pain in the epigastric region, which occurs suddenly, without "harbingers" (sometimes after eating). The pain is initially localized in the pit of the stomach or in the right upper quadrant, but quickly becomes diffuse.
When pain occurs, the patient tries to move as little as possible and seeks to take a comfortable position of the body, in which the pain is felt somewhat weaker.
The tension of the abdominal muscles quickly increases and from localized in the right upper quadrant passes to diffuse, and then the stomach becomes hard as a board. The respiratory movements of the abdominal muscles at the same time become superficial, weaken and gradually stop.

In the diagnosis, the disappearance of hepatic dullness during percussion is important. When the patient turns on his right side, he has pain in the left shoulder, on the left - pain in the right shoulder.
The patient's condition is rapidly deteriorating and after 6-8 hours he has signs of diffuse peritonitis. Peritonitis is inflammation of the peritoneum.
often pneumoperitoneum Pneumoperitoneum - 1. The presence of gas in the peritoneal cavity. 2. Gas filling of the retroperitoneal space
(disappearance of hepatic dullness during percussion, visualization of gas under the diaphragm during plain fluoroscopy). The patient also develops vascular collapse, dry tongue and fever.
When examining blood, neutrophilic leukocytosis is determined with a shift of the formula to the left, acceleration of ESR.
Mortality from diffuse fibrinous-purulent peritonitis remains significant.

Delimited, covered perforation, which occurs with the development of limited peritonitis, is characterized by less pronounced symptoms:
- gradual extinction of the inflammatory process;
- slight local pain;
- leukocytosis;
- subfebrile temperature;
- mild symptoms of peritoneal irritation.
However, even with such a course, there is always a risk of developing acute peritonitis and the formation of an abscess in the abdominal cavity, liver, under the diaphragm.

2. penetration Penetration - a complication of peptic ulcer in the form of the spread of an infiltrative-destructive process (penetration with destruction) from the stomach or duodenum into the thickness of a neighboring organ - the liver, pancreas, omentum
is a consequence of progressive destruction of the wall of the stomach or duodenum. It is accompanied by the formation of an adhesive process, which fixes the bottom of the ulcer to the adjacent organ, preventing the ulcer from breaking into the free abdominal cavity. During penetration, an inflammatory infiltrate, adhesions, and sometimes a delimited abscess develop.
Penetrating ulcers of the duodenum are more common than those of the stomach. The pancreas most often undergoes penetration, followed by the hepatoduodenal ligament, liver, lesser omentum, gallbladder and bile ducts, transverse colon, etc.

When diagnosing penetration, the following factors should be kept in mind(Radbil O. S.):
1. Penetrations most often occur in obviously ulcerative patients with an old, sluggish process, in middle and older age groups.
2. Penetration is characterized by exacerbation of pain, which becomes permanent, often this exacerbation is repeated at short intervals ("stepped" penetration), vomiting often joins the pain.
3. Penetration is characterized by local (symptoms of peritoneal irritation, inflammatory infiltrate) and general changes (inflammatory changes in the blood - leukocytosis, shift of the leukocyte formula to the left, increased ESR).
4. During penetration, symptoms develop that characterize the lesion of the organ in which it occurs.
When the ulcer penetrates into the pancreas, the level of serum amylase and lipase markedly increases after stimulation of the pancreas with secretin. It should be borne in mind that an increase in enzyme activity is also possible with concomitant pancreatitis without penetration.

In the case of penetration of ulcers into the bile ducts and gallbladder, internal fistulas appear, which cause severe cholangitis Cholangitis is inflammation of the bile ducts.
and sometimes malignancy Malignancy is the acquisition by cells of a normal or pathologically altered tissue (for example, a benign tumor) of the properties of malignant tumor cells.
penetrating organ.
An x-ray examination often reveals an infiltrative shaft and disturbances in peristalsis in the "niche" area.

Penetration may be associated with gastric bleeding.

3. Bleeding.
A patient with peptic ulcer may experience two types of bleeding:
- sudden massive bleeding(is a sign of a new exacerbation);
- slight bleeding(most often occurs due to the use of an excessive amount of contraindicated medicines).

A small ulcer can bleed daily, as a result, the patient loses blood in the feces (does not have a black color). In this case, the only manifestation of the state may be unmotivated fatigue.

With massive ulcerative bleeding, a characteristic clinical picture is observed: black loose stools, nausea, chilling, sometimes fainting occurs during or after defecation.
Black stools are more common in patients with duodenal ulcers. In patients with stomach ulcers, bloody vomiting or vomiting of "coffee grounds" predominates.
Ulcerative bleeding can be both the first and early sign of the disease. In some cases, the first sign is hypochromic, microcytic anemia.
If the patient loses more than 350 ml of blood, his blood volume decreases markedly and the following symptoms occur: compensatory reactions:
- vascular spasm, manifested by pallor;
- progressive drop in blood pressure;
- decrease in the amount of circulating blood;
- electrocardiographic study fixes myocardial hypoxia.
With massive bleeding, subfebrile temperature appears in patients, pain stops (possible anti-inflammatory effect of blood loss).

4. When combinations of perforation and bleeding from an ulcer one of these complications is most often not identified. This is due to the fact that in a patient weakened by bleeding, perforation of the ulcer proceeds atypically. When bleeding appears against the background of a rapidly pronounced clinical picture of perforation, it can also go unnoticed.

In some cases, against the background of profuse gastroduodenal bleeding in the epigastric region, the patient develops a sharp “dagger” pain typical of ulcer perforation; there is tension in the muscles of the anterior abdominal wall (“board-shaped abdomen”), lack of peristalsis, pain on palpation of the abdomen. These symptoms are not observed with gastroduodenal bleeding without simultaneous perforation.
Gastroduodenal bleeding, as a rule, is painless (pain that occurs before bleeding disappears).

Know what stomach bleeding is. Several milliliters of blood can be shed from wounds daily. And this phenomenon is considered the norm. But it happens that the situation deteriorates, bleeding with a stomach ulcer becomes uncontrollable. At home, it becomes impossible to stop it on your own.

Often, even in a hospital setting, there are problems with stopping heavy gastric bleeding. How to prevent the occurrence of pathology, and what measures should be taken when it occurs? We tell further.

A bleeding ulcer of the stomach and duodenum is a complication of peptic ulcer, in which blood begins to flow into the organ cavity from wounds. This phenomenon occurs in patients very often. This complication of peptic ulcer is divided into:

open;
hidden.

With hidden blood loss, the symptoms are almost invisible. The causes of bleeding in peptic ulcers are often very difficult to determine. It is not associated with physical exertion, injury to internal organs. The process most often begins unexpectedly due to a violation of the integrity of the veins.

Most often, bleeding from a stomach ulcer begins in people suffering from cardiovascular diseases.

Pathology can be caused by the use of excessively hot foods. A sharp change in temperature damages the gastric mucosa and provokes the development of bleeding.

With a stomach ulcer, long-term use of certain types of medications can cause blood loss.

Symptoms

When occult bleeding occurs, there are practically no symptoms. The person does not feel any change in well-being. If blood loss continues for a long time, patients begin to worry about dizziness, severe fatigue. Patients become pale. You can suspect ulcer bleeding by lowering blood pressure.

In order not to miss the onset of the development of pathology and the onset of severe consequences, it is necessary to regularly take tests for the Gregersen reaction. It helps to detect even the smallest particles of blood in the gastric juice.

In chronic peptic ulcer bleeding itself will not stop even for a short period. This is due to the fact that a scar is formed at the site of the lesion, which itself cannot heal. Wounds remain open until surgery is performed.

Acute gastric ulcers, like those of the duodenum, are characterized by intermittent bleeding. But the appeal to specialists cannot be postponed. The lack of medical intervention will lead to a large loss of blood, often a person can only be saved in an advanced state of the disease in intensive care.

The most striking symptom of bleeding in the stomach is vomiting blood. As a rule, the reaction appears immediately. With severe bleeding, the blood in the vomit will be scarlet.

Excessive bleeding can be seen in the feces, it becomes black, sticky and liquid. If the pathology develops in a mild form, the following signs will be observed:

pallor of the skin;
low pressure;
cold extremities;
pulse quickens.

Bleeding of medium volume will manifest itself as follows:

The acute form of the disease, when severe bleeding opens, manifests itself as follows:

chills, weakness, loss of consciousness;
black chair;
there is practically no pressure;
sticky sweat;
nausea and vomiting with blood.

Very dangerous regular repetition of bleeding for 1.5 weeks. Large blood loss can be fatal. First aid and treatment in such cases must be carried out as soon as possible. The further life of the patient and his general condition depend on the correct actions of specialists with a duodenal ulcer with bleeding. Similarly, with a stomach ulcer with bleeding.

Complications

Anemia is the most basic complication that can cause duodenal bleeding and bleeding stomach ulcers. They always lower the hemoglobin level.

The patient's general well-being worsens, it darkens in the eyes, pale skin appears.

Despite the high level of medicine, cases of death from ulcer bleeding are very common. Most often this occurs in older people with severe blood loss, accompanied by other pathologies. Also, deaths can occur due to delayed treatment or failure to provide first aid.

Note! Gastric bleeding is a very dangerous phenomenon. It can not be ignored and treated with folk remedies.

Diagnosis and treatment

In the event of bleeding, first aid actions must be carried out as soon as possible. Only under this condition will it be possible to save the life of the patient. If there is a stomach ulcer and symptoms of bleeding, it is necessary to competently help the patient.

If an open ulcer bleeds, an ambulance should be called urgently.
The patient should be placed on his back and not allowed to move.
Ice can be applied to the abdomen.
The patient is forbidden to drink liquid and food, you can not even drink water. The patient can only lie still, he is transferred to the ambulance on a stretcher.

First aid is to stop a bleeding ulcer. This can be done medically or physically.

An ulcer can be cauterized using a laser, thermal or electrical method. Hemostatic agents are used to stop bleeding. Stopping bleeding surgically is used only if the drugs failed to do this.

If there is a stomach ulcer, bleeding, and then the symptoms disappear, you should not calm down. Be sure to consult a doctor for advice and treatment. Most often, a new exacerbation occurs soon.

Patients who experience severe and moderate bleeding are admitted to the intensive care unit. This is necessary in order to compensate for the loss of blood.

For the elderly, blood transfusion is carried out with the control of blood pressure. There are cases when the heart is not able to cope with the intake of such an amount of fluid into the body. With such a reaction of the body, doctors prescribe drugs that stimulate the heart.

The following drugs are prescribed as treatment:

hemostatic agents;
drugs to improve blood clotting;
hemostatic agents.

For the treatment of bleeding from a duodenal ulcer are prescribed:

remedies for helicobacter;
medications to stabilize acidity in the stomach;
strict diet.

If the bleeding can be stopped with medication, the operation is not performed. The possibility of resuming bleeding is monitored by laboratory tests. Surgical intervention is always considered as an extreme option to stop blood loss with ulcers in the intestines and stomach.

The method of surgical intervention is determined by doctors, taking into account the severity of the disease. The simplest operation is gastrectomy. This is an organ-preserving operation.

In severely weakened patients, the defect is sutured. Both types of surgery do not have technical difficulties, but it is necessary to accurately determine the anatomical location of large vessels in order to avoid injury.

A duodenal ulcer with blood loss is treated with laser therapy. Very rarely, the area from which bleeding is observed is removed.

Prevention and diet

In acute stomach and duodenal ulcers, you need to be attentive to your health and not aggravate the situation. Treatment should be combined with preventive measures.

First of all, you need to give up bad habits. The abuse of alcohol and cigarettes adversely affects the condition of the stomach and duodenal ulcers.

It is necessary to reconsider your diet, it should consist only of "healthy" foods with lots of vitamins.

Patients need:

kefir, cottage cheese;
sweet potatoes, apricots, apples, eggs, cheese, carrots;
ascorbic acid, which is found in cabbage, milk, pork, beef, seafood, yogurt, melon, beans;
vitamin E, which is found in peanuts, mango, kiwi, spinach, egg yolk.

Black tea;
coffee;
bitter chocolate;
fried and fatty.

Maintaining a healthy lifestyle, giving up bad habits and being attentive to your health will be the key to eliminating the risk of developing dangerous pathologies. Timely detection of the first symptoms will help to start treatment already at the initial stage of the disease.

With a closed hemorrhage, the primary symptoms are almost invisible. This type of hemorrhage is divided into the following subspecies:

spicy;
chronic;
symptomatic.

The hemorrhage itself suggests that such a pathology as a stomach ulcer has passed into an aggressive form. Most often, the patient begins to experience severe pain after eating, because of which he may refuse to eat at all. The body, already exhausted in the fight against peptic ulcer, begins to leave the last strength. There is a strong loss in weight, chronic fatigue, drowsiness.

In the absence of treatment and ignoring medical prescriptions, prolonged ulcer bleeding can lead to serious complications, including death. The ulcer itself tends to malignancy (malignancy), so the risk of developing oncology is high. Other consequences of a complicated peptic ulcer include:

acute heart failure;
cerebral edema;
arterial hypotension;
liver failure;
intoxication of the body with decay products of one's own blood;
hemorrhagic shock.

If the patient is not provided with medical care on time, there is a high probability of developing multiple organ failure syndrome (MOS), which is essentially a stress response of the body to severe injury and prolonged blood loss. Clinical death occurs in 80% of MODS cases.

Like any open bleeding, this complication is dangerous because the body loses blood without being able to replenish it. If losses exceed the permissible norm, the patient may die, so it is necessary to provide the patient with assistance and prescribe treatment as soon as possible.

From the correctness of the actions of doctors aimed at eliminating the symptoms of bleeding in gastric and duodenal ulcers, the further life of the patient and his general condition depend.

Like any other bleeding, such a pathology is very dangerous because the body loses a lot of blood, not being able to replenish it. With significant blood loss, above the permissible norm, the patient may die, so it is important to provide him with first aid and prescribe treatment as soon as possible.

Especially dangerous is bleeding provoked by damage to large vessels, which leads to complications such as:

swelling of the brain;
heart failure;
intoxication of the body with toxins and blood decomposition products.

As a result of bleeding, organ failure syndrome can develop, when many organs and systems are affected.

Causes

Most often, ulcerative bleeding provokes the progression of the erosive process in the stomach, high capillary permeability or low blood clotting. Most often, an arrosted artery bleeds, a bleeding vein is somewhat less common, and several small capillaries can also be damaged.

A. Ulcerative lesions of the digestive tract (55-87%)1. Diseases of the esophagus:

Gastroesophageal reflux disease

2. Peptic ulcer of the stomach and / or 12 duodenal ulcer

3. Acute ulcers of the digestive tract:

Medical(after prolonged use of medications: glucocorticoid hormones, salicylates, non-steroidal anti-inflammatory drugs, reserpine, etc.)
Stress (caused by various severe injuries as: mechanical trauma, burn shock, myocardial infarction, sepsis, etc. or emotional overstrain, after a traumatic brain injury, neurosurgical operation, etc.).
Endocrine (Zollinger-Ellison syndrome, decreased parathyroid function)
Against the background of diseases of internal organs (liver, pancreas)

4. Ulcers of the gastrointestinal junctions after previous operations

5. Erosive hemorrhagic gastritis

6. Lesions of the colon:

Nonspecific ulcerative colitis
Crohn's disease

1. Varicose veins of the esophagus and stomach (usually against the background of cirrhosis of the liver and increased pressure in the portal system).

2. Tumors of the gastrointestinal tract:

Benign (lipomas, polyps, leiomyomas, neuromas, etc.);
Malignant (cancer, carcinoid, sarcoma);

3. Mallory-Weiss syndrome

4. Diverticula of the gastrointestinal tract

5. Fissures of the rectum

Blood diseases:
- Hemophilia
- Idiopathic thrombocytopenic purpura
- von Willebrand disease, etc.
Vascular diseases:

Rondu-Osler disease
Schonlein-Henoch disease
Nodular periarteritis

Cardiovascular diseases:

Heart disease with the development of heart failure
Hypertonic disease
General atherosclerosis

Cholelithiasis, injuries, tumors of the liver, gallbladder.

An exacerbation of a stomach ulcer usually occurs when the patient does not experience pain and, so to speak, relaxes, allows himself excess food and makes indulgences in the daily routine. The patient begins to consume alcoholic products, soda, does not monitor the amount of coffee drunk and ignores the manifestations of stress. Other causes of exacerbation of stomach ulcers:

too cold and hot food;
coffee on an empty stomach, or smoking;
infectious manifestations;

In the presence of such reasons, there is a possibility that an opening of a stomach ulcer will occur.

There are enough reasons for opening bleeding with a stomach ulcer, the most common ones should be listed:

non-compliance with recommendations regarding nutrition;
incorrect therapy;
associated inflammatory processes;
excessive physical activity;
alcohol consumption;
lack of timely treatment of the acute form of the disease.

Light bleeding is quite difficult to diagnose, in some cases the patient does not go to the doctor for years.

Initially, the patient has mild symptoms that can be confused with manifestations of other diseases.

Acute blood loss is not difficult to identify, but this does not make it less dangerous.

Acute bleeding can open suddenly, in such cases, you should immediately consult a doctor. Any home treatments will only aggravate the patient's condition.

Ulcerative bleeding opens for the following reasons:

Infection. Viruses spread through an open stomach ulcer, affecting the vessels.
Injury to the surface of the ulcer during medical manipulations (with FGDS).
Strong physical activity. The pressure in the vessels increases, they burst, ulcer bleeding opens. It can be minor or strong if a large vessel is damaged.
Non-compliance with the diet, drinking alcohol. Spicy, fatty foods, alcohol irritate the already damaged mucosa. After eating, bloody vomiting may open.
The use of medical preparations. Some drugs are prohibited for use in ulcers, as they irritate the mucous membrane. After taking such drugs, an exacerbation occurs, an open ulcer begins to bleed.

Complications with this type of ailment can be very diverse, but the most common is bleeding. There are the following types of bleeding:

Open.
Hidden.

Most often, bleeding is complicated by chronic callous, acute stomach ulcers in the presence of a pathology of the cardiovascular system in the patient, as well as ulcerative defects that develop against the background of the use of glucocorticosteroids.

The main reasons for the development of this complication are the progression of inflammatory and destructive processes in the area of the defect, increased capillary permeability, as well as a violation of blood coagulation.

Usually, an artery bleeds, less often a vein or a large number of small vessels localized in the bottom of the ulcer (in this case, latent diapedetic bleeding develops). The formation of a bleeding ulcer can be facilitated by mechanical or chemical injuries of the mucosa, physical or psycho-emotional stress, neurotrophic and thromboembolic lesions of the stomach wall and hypovitaminosis.

The cause of the serious condition of patients is blood loss. With a loss of less than 15% of the blood volume, there are no significant violations of systemic hemodynamics, since protective mechanisms are activated: vasospasm of the skin and abdominal organs, opening of arteriovenous shunts, and an increase in heart rate.

The blood flow in the vital organs is preserved, and in the conditions of the cessation of blood loss, the volume of circulating blood is restored due to natural depots. With a loss of more than 15% of BCC, a generalized spasm of blood vessels, a significant increase in the frequency of heart contractions and the transition of interstitial fluid into the vascular bed are initially compensatory in nature, and then pathological.

Systemic blood flow is disturbed, microcirculation suffers, including in the heart, brain, kidneys, arterial hypotension develops, compensation mechanisms are depleted. Perhaps the development of hepatic, renal failure, cerebral edema, myocardial infarction and hypovolemic shock.

Forms and degrees

According to the stages, bleeding ulcers are divided into medium and massive bleeding. With an average blood loss of about 16-20%, patients become pale, they have cold extremities, diuresis is reduced, and the heartbeat is increased even at rest.

Disturbed by dizziness and tremor, low body temperature and photophobia;
Blood may be present in saliva, traces of blood are also observed in vomit;
Symptoms of dehydration are observed, patients sweat profusely, and the sweat is cold and clammy.

Such hemorrhage with an ulcer is distinguished by the presence of blood impurities in the vomit and the dark, almost black color of the feces.

A stomach ulcer is a defect in the mucous membrane of an organ, which is formed due to the aggressive effects of hydrochloric acid.

According to statistics, bleeding with a stomach ulcer occurs in 10-15% of patients. It happens when a vessel bursts in the area of damage to the mucosa. Distinguish between open and hidden bleeding. When hidden, there are no external manifestations. A complication can only be detected using the Gregersen reaction (gastric juice, urine or feces are treated with special reagents to detect traces of blood).

Open bleeding with a stomach ulcer is manifested by the following symptoms:

Vomiting with blood. The vomit may be brown in color due to the color of the blood with hydrochloric acid. With massive bleeding, scarlet blood is released.
The stool is tarry and dark in color.
Signs of blood loss.

Depending on the degree of blood loss, there are 3 types of bleeding:

Small blood loss (up to 10%). It is manifested by mild symptoms: weakness, dry mouth, slight nausea and dizziness, slight decrease in blood pressure.
Average blood loss (up to 20%). The patient develops hemorrhagic shock of the 1st stage, while the patient is conscious. The main symptoms of moderate bleeding with a stomach ulcer:

nausea, dizziness;
trembling of the limbs;
pallor of the skin;
increased heart rate up to 100 beats per minute;
slight pressure drop.

tachycardia, shortness of breath;
severe pallor of the skin and dry mucous membranes;
thready pulse (up to 140 beats per minute);
a sharp drop in blood pressure (below 90/50);
loss of consciousness.

With a stomach ulcer, bleeding can lead to hemorrhagic shock, which can be:

compensated;
subcompensated;
decompensated;
very heavy.

The pathological condition can be latent and explicit. Hidden bleeding in the initial stages does not cause a deterioration in well-being. An explicit form is observed when a large vessel is damaged, while it is accompanied by nausea, vomiting with blood splashes.

In addition, distinguish between arterial and venous bleeding. Arterial bleeding is characterized by the spread of erosion on the walls of blood vessels, and venous bleeding may be due to thrombosis.

Symptoms

The symptoms of a bleeding stomach ulcer are the same as those observed with any internal hemorrhage - weakness, dizziness, blanching of the skin, nausea and vomiting. In this case, the color of the vomit may be a specific shade of "coffee with milk", as a result of mixing blood with gastric juice.

The main and most striking sign of gastric ulcer bleeding is vomiting with impurities of blood clots, and the vomit can be either scarlet or dark cherry or brown. The bright color of the blood indicates that an open ulcer is bleeding heavily.

Another sign of such that a stomach ulcer has opened is melena. With melena, the stool acquires a characteristic color and texture, the feces become thick, shiny and tar-like, usually a symptom of duodenal bleeding. The black color of the feces indicates a significant blood loss of up to 800 ml of blood. With a more massive hemorrhage, the stool becomes scarlet.

General symptoms:

Unreasonable weakness, malaise
Dizziness
Possible fainting
Changes in consciousness (confusion, lethargy, agitation, etc.)
Cold sweat
Unreasonable thirst
Paleness of the skin and mucous membranes
Blue lips, fingertips
Fast, weak pulse
Lowering blood pressure

All of the above symptoms depend on the rate and volume of blood loss. With slow, non-intensive blood loss during the day, the symptoms can be very scarce - slight pallor. Slight increase in heart rate against the background of normal blood pressure. This phenomenon is explained by the fact that the body manages to compensate for the loss of blood due to the activation of specific mechanisms.

In addition, the absence of general symptoms of blood loss does not exclude the possibility of gastrointestinal bleeding.

External manifestations of gastrointestinal bleeding, the main symptoms:

A change in the color of feces, from a brown dense consistency to black, tarry liquid-like, the so-called melena. However, if up to 100 ml of blood enters the gastrointestinal tract during the day, no changes in feces are visible to the eye. To do this, use specific laboratory diagnostics (Gregdersen test for occult blood). It is positive if blood loss exceeds 15 ml/day.

The main and very first symptom indicating bleeding of a stomach ulcer is vomiting with an admixture of blood. The vomit is distinguished by its color (scarlet, dark brown). This manifestation is not observed immediately. The presence of red blood in the vomit indicates heavy bleeding.

Melena is another sign of gastric bleeding. She has tarry stools. Its appearance indicates the presence of a duodenal bleeding ulcer. Similar feces appear with very heavy bleeding. The chair has its own characteristics. It is black, liquid, shiny. If the bleeding is very heavy, there may be scarlet blood in the stool.

With minor bleeding with a stomach ulcer, symptoms are almost absent. Basically, a person feels satisfactory, nothing interferes with his normal life.

Latent bleeding is manifested through weakness, dizziness, pallor of the face. Many notice dyspeptic disorders a few days before the onset of bleeding and a decrease in all symptoms with the onset of bleeding from the stomach.

However, as blood loss increases, the symptoms of an open stomach ulcer become apparent.

Symptoms of an open stomach ulcer

Anemia is the most basic complication that can cause duodenal bleeding and bleeding stomach ulcers. They always lower the hemoglobin level.

Note! Gastric bleeding is a very dangerous phenomenon. It can not be ignored and treated with folk remedies.

Which doctor should be consulted in case of stomach bleeding?

In chronic gastric bleeding, the patient often does not suspect that he has this pathological condition. Patients turn to specialized specialists about the symptoms of the underlying disease:

for pain and discomfort in the upper abdomen, nausea, indigestion - see a general practitioner, gastroenterologist;
with increased bleeding, the appearance of a large number of bruises on the body - to the therapist, hematologist.

The specialist prescribes an examination, during which gastric bleeding is detected.

The only symptom that can indicate the presence of chronic bleeding in the stomach is black, tarry stools. In this case, you should immediately contact the surgeon.

When do you need to call an ambulance?

With intense acute gastric bleeding, the patient's condition worsens very quickly. In such cases, you need to call the ambulance brigade:

Sharp weakness, pallor, lethargy, rapid deterioration.
Loss of consciousness.
Vomiting "coffee grounds".

If, with intense acute gastric bleeding, medical care is not provided on time, the patient may die from large blood loss!

The ambulance doctor will quickly examine the patient, take the necessary measures to stabilize his condition and take him to the hospital.

What questions can the doctor ask?

During the conversation and examination of the patient, the doctor has two tasks: to establish the presence and intensity of gastric bleeding, to make sure that the bleeding comes from the stomach, and not from other organs.

The severity of the symptoms of such a pathological condition directly depends on the degree of blood loss and the duration of the hemorrhage. With a small or latent hemorrhage, the manifestation of the clinical picture is almost always absent, and the patient's condition and well-being do not worsen.

In cases of heavy bleeding of the stomach, signs such as:

dizziness, which can range from mild to severe;
increased fatigue;
pale skin;
decrease in blood pressure values;
bouts of nausea and vomiting. The vomit at the same time have the color and texture of coffee grounds;
change in the shade of feces - they become black;
decrease in the amount of urine excreted per day;
increased heart rate and shortness of breath, even at rest when the person is sitting or lying down;
increased anxiety and irritability.

With a loss of blood in volumes of 30–50%, the above symptoms are joined by episodes of loss of consciousness, the release of a large amount of cold and sticky sweat, a thready pulse. In such cases, it is almost impossible to measure blood pressure. If you do not carry out emergency qualified assistance, then such a pathology will become irreversible, which, in most cases, causes death.

Consulting a gastroenterologist, with a thorough study of the life history and medical history, analysis of complaints and the presence of specific symptoms, makes it possible for a specialist to suspect the development of gastric bleeding even with minor blood loss.

During the physical examination, the condition of the skin is studied, the presence of pain on palpation of the abdomen is determined, as well as the measurement of blood pressure, pulse and temperature.

Laboratory research should include:

a general blood test - which will show the degree of anemia, a change in composition and the ability to coagulate;
microscopic examination of fecal masses for occult blood, which will objectively make it clear that a person has a hemorrhage.

An obligatory instrumental diagnostic technique is the performance of endoscopy. This is a diagnostic endoscopic procedure, which is carried out using special equipment, aimed at studying the inner surface of all organs of the gastrointestinal tract. Such an examination reveals the location of the focus of bleeding.

Diagnostic measures are aimed not only at establishing the correct diagnosis, but also at conducting a differential diagnosis of an open gastric ulcer with disorders such as the formation of a malignant neoplasm, the formation of polyps, Mallory-Weiss syndrome.

If symptoms are ignored or therapy is not started in time, there is a possibility of developing such consequences of a bleeding ulcer:

hypovolemic shock state;
development of heart failure;
orthostatic hypotension is a condition in which there are low blood pressure;
the formation of acute liver failure;
swelling of the brain;
poisoning with blood decomposition products;
development of MODS - a syndrome of multiple organ failure, in which there is a violation of the functioning of all internal organs and systems.

A typical form of the course of the disease is accompanied by the ingestion of the contents of the stomach into the free abdominal region.

There are three periods of development:

Period of chemical peritonitis. The duration of the flow in time is from 3 to 6 hours. Depends on the diameter of the hole and the volume of secretions from the stomach. Accompanied by acute pain in the stomach. Severe pain is possible in the umbilical segment and in the right hypochondrium. Subsequently, they cover the entire abdomen. Perforation of the anterior wall of the stomach can manifest itself in pain in the region of the left side of the abdomen and left forearm. Pain sensations are characterized by duration of manifestation. Vomiting is rare. Arterial pressure reduced, but the pulse is usually within normal limits. Breathing becomes shallow and rapid. The skin turns pale increased sweating. The muscles of the anterior part of the abdomen are tense, an accumulation of gases is observed in the abdominal cavity.

period of bacterial peritonitis. Begins 6 hours after perforation. The abdominal muscles relax, breathing becomes deeper and sharp pains disappear. The person feels relieved. In this phase, there is an increase in temperature, an increase in heart rate and a further change in blood pressure. A period of increasing toxicity begins, which leads to an increase in the volume of gases, paralysis of peristalsis. The tongue becomes dry, with a gray coating on the anterior and lateral surfaces. The general behavior of the patient changes. He experiences euphoria and relief, becomes uncritical to his condition, does not want to be disturbed. If during the period of increased intoxication no emergency medical care is provided, then the person goes to the third, most severe stage of the disease.

The period of acute intoxication. It begins, as a rule, after 12 hours from the moment of illness. The main manifestation is indomitable vomiting, leading to dehydration. Visually, changes in the skin can be noted. They become dry. There is a sharp drop in body temperature. Elevation up to 38°-40° is replaced by a decrease to 36.6 °. The pulse reaches 120 beats per minute. Upper arterial pressure drops to 100 mm Hg. The general condition of the patient is characterized by lethargy, indifference, delayed reaction to external stimuli. There is an increase in the abdomen due to the accumulation of free gas and liquid. The process of urination is disturbed, eventually stops completely. If a person has reached this phase of development of peritonitis, then it is almost impossible to save his life.

Perforation is characterized by an attack of sharp, sudden pain. If there is a history of peptic ulcer, gastritis, etc., then the task is facilitated. As a rule, a differential method is used for diagnosis.

Light form

Due to the constant hypoxia of the tissues of the internal organs, as well as a decrease in the level of hemoglobin in the blood, the following symptoms appear:

lethargy;
dizziness;
slight decrease in performance.

The patient should pay attention to regular headaches and shortness of breath with signs of a short tachycardia.

Middle form

At this stage, the state of health begins to deteriorate rapidly, specific symptoms of the disease appear, which are acute in nature:

trembling of the limbs;
pallor of the skin;
photophobia;
severe tachycardia;
increased sweating;
pre-fainting states;
vomiting clotted blood (color of coffee grounds);
darkening of stool color.

These symptoms signal regular and profuse internal bleeding, which is a serious threat to the life of the patient. Immediate hospitalization is required with all necessary diagnostic procedures and subsequent treatment in a hospital.

Severe form

A stomach ulcer with massive bleeding is usually accompanied by severe symptoms of hemorrhagic shock, inhibition of the functions of all body systems is observed, which leads to irreversible destruction of internal organs. The main symptoms of severe form include:

increased heartbeat;
dyspnea;
confusion (aggression, apathy, irritation, panic attack);
severe cyanosis;
a sharp drop in blood pressure;
sticky and cold sweat;
thready pulse;
repeated gagging;
liquid black stool;
oligo-anuria syndrome (lack of diuresis).

With timely medical care, there is a chance to save the patient, but according to statistics, the survival rate of patients with extensive blood loss does not exceed 50%.

In general, the manifestations of a bleeding ulcer are reduced to the following symptoms:

Migraines, cephalgia, dizziness, shortness of breath;
Tremor of limbs, hypothermia, cold feet and hands;
Paleness of the skin, palpitations and photophobia;
Manifestations of dehydration such as decreased diuresis, etc.;
After belching, blood may be present in the saliva, the feces become tarry, and impurities of coagulated or fresh blood are observed in the vomit.

If the blood loss is massive, then multiple organ failure rapidly develops, the symptoms of which include cerebral edema, a critical decrease in pressure, a weakening of cardiac, renal, hepatic activity, a state of shock and intoxication, and an unconscious state.

For diagnosis, you will need a consultation with a qualified gastroenterologist, who will study in detail the history and complaints of the patient. As a result of a general clinical blood test, a decrease in erythrocyte mass and hemoglobin is detected.

Bleeding is caused by damage to the arteries or veins. In such a case, the symptoms will be quite bright.

The most common manifestations include:

vomiting blood;
dark (almost black) feces;
acute pain;
photophobia;
tremor;
increase in body temperature;
dehydration;
weakness, possible loss of consciousness.

Hematemesis is a characteristic manifestation of a bleeding stomach ulcer. The vomiting process can begin immediately and after some time, the vomit becomes blood-brown. Dark-colored stool is formed in a patient when blood loss reaches 200 ml, it is important to note that this is a significant amount of loss. With intense bleeding, the patient's stool becomes scarlet.

For an accurate diagnosis, laboratory tests are necessary:

A blood test shows the presence of occult bleeding.
An analysis of gastric juice is carried out, determining its acidity, feces are examined for the presence of blood inclusions.
With the help of fibrogastroscopy, a defect in the walls of the stomach can be detected: this procedure is indicated for all patients with suspected bleeding. Often, a biopsy is taken at the time of this study to rule out the possibility of cancer.

With small blood loss, therapy consists in following a strict diet prescribed by a doctor. The purpose of therapeutic nutrition is to reduce the load on the gastrointestinal tract and increase the regenerative abilities of the body.

The patient must be completely excluded from the diet:

acute;
roast;
smoked;
alcohol.

A sparing diet does not always help; in such cases, surgical intervention is necessary.

After the operation, the patient is shown bed rest, feeding through a tube and full-fledged drug therapy.

Surgical intervention includes the following types of operations:

Suturing the bleeding area.
Removal of part of the stomach.
A puncture through which bleeding vessels overlap.

Diagnosis is not difficult for a gastroenterologist. A gastric ulcer with bleeding is a significant symptom in itself.

The doctor is based on the patient's complaints. The doctor asks the patient about the symptoms, the duration of bleeding, the duration of the disease.

Important information is what circumstances preceded the problem, what treatment the patient underwent. Then the gastroenterologist examines the patient, during palpation the patient experiences severe pain in the stomach.

To clarify the diagnosis, a general blood test is prescribed, where a decrease in hemoglobin and red blood cells is detected. Next, the doctor performs fibrogastroduodenoscopy. With its help, the condition of the mucosa, the size and number of ulcers are studied. It is possible to take a biopsy if there is a suspicion of an oncological process.

Ulcerative bleeding can be both overt and covert. In the first situation, the cause of the condition is the broken integrity of the artery, in the second - a small vessel. Venous involvement is much less common.

A bleeding ulcer with stomach disease has the following symptoms associated with the severity of blood loss:

dizziness;
muscle weakness;
darkening in the eyes;
hypotension;
tachycardia;
pallor of the face;
vomiting of dark masses;
blood clots in the stool;
oliguria.

Gastric ulcer with duodenal bleeding is characterized by the appearance of tarry stools and the manifestation of an anemic condition. In this case, painful sensations can stop against the background of increased leukocytosis. A little later, hyperthermia develops.

In the presence of callous disease in the case when the ulcer has opened, the bleeding does not stop on its own, since there is no regenerative capacity in the affected mucous membranes containing scar tissue. In such cases, blood is shed from the ulcer until surgery is performed.

The acute form of peptic ulcer is characterized by intermittent bleeding, but even in this case, an appeal to a specialist is required, since only resuscitation measures can save the patient in case of serious blood loss.

Examination for a suspected perforated ulcer is complex and should be carried out as soon as possible. Specialists in whose competence the diagnosis of pathology is a gastroenterologist and a surgeon. Difficulties in diagnosis are caused by the similarity of the symptoms of a perforated ulcer and other acute pathologies of the abdominal cavity, so it is important to differentiate from:

attack of appendicitis;
cholecystitis in the stage of relapse;
an attack of acute renal, hepatic colic;
dissection of the aneurysm in the aorta of the peritoneum;
pancreatitis in the acute phase;
myocardial infarction;
thrombosis;
pneumonia of the lower parts of the lungs;
pleurisy;
pneumothorax.

If there is a history of gastric and duodenal ulcers, the task is simplified. The main purpose of the examination is to determine the presence of fluid and gases in the peritoneum, to identify ulcerative defects and through perforations. A set of diagnostic measures that must be carried out:

initial examination with palpation of the abdominal wall;
complete blood count as an indicator of the intensity of the inflammatory process, when the ulcer is perforated, the readings of ESR, stab neutrophils, leukocytes reach an absolute maximum above the norm;
survey radiography is necessary to detect the presence of free gas in the abdominal cavity; reliability of the method over 80%;
CT of the peritoneal organs allows you to visually establish not only the accumulation of gases, but also the presence of fluid, hypertrophy of the gastric ligaments and the ulcer itself; informativeness of CT more than 98%;
endoscopic examination is indicated to clarify the diagnosis, if there is doubt after other diagnostic procedures; endoscopy helps to establish the exact localization of ulcerative defects;
echography of the peritoneal organs, as an accurate and affordable method, allows you to identify the accumulation of gases, fluids and hypertrophy of the gastric walls;
esophagogastroduodenoscopy is indicated to confirm the diagnosis in the absence of gas in the peritoneal space and the impossibility of radiography; Endoscopy visualizes the location and size of perforated defects, the presence of hemorrhages, helps to choose the best tactics for subsequent treatment;
laparoscopy is performed for qualitative and quantitative analysis of effusion in the peritoneum; but it has a lot of contraindications - overweight, the presence of adhesions, low blood clotting, volumetric hernia on the anterior wall of the peritoneum, the patient's serious condition;
An ECG is necessary to assess the functioning of the cardiovascular system, to identify dysfunctions in the rhythm.

When a stomach ulcer is complicated by blood loss, then in such cases, the manifestations of the disease can manifest themselves quite brightly and intensely. If we talk about the latent state, then in this case the symptoms can be blurred. The main symptoms are:

Vomiting with blood.
Change in feces. This symptom is manifested due to the fact that blood enters the intestine.
Sensation of acute loss of blood.
Painful sensations.

At the initial stages, when the blood gradually begins to stand out from the ulcerative formation, obvious signs may not appear. Tellingly, the pain can manifest itself and increase as the disease progresses.

As a rule, the pain has paroxysmal characteristics. It is these properties of pain that confuse many patients.

Because in moments of lull in the symptoms of the disease, patients believe that the danger has passed.

Consequently, there is a loss of precious time and, as a result, the patient's condition becomes critical. As evidenced by numerous reviews of experts, if this complication is not detected for a long period of time, then this can be fatal.

General signs that may indicate that a stomach ulcer has opened can conditionally be divided into obvious and hidden. Undisputed signs include:

Spontaneous pain in the abdomen. Because of the direct manifestation of this kind of symptomatology, pain is referred to as "dagger pain syndrome." When the ulcer has already perforated the shell of the organ, the gastric juice does not stop being secreted, and the hydrochloric acid it contains plays the role of an irritant.
Increasing pain in the intervals between meals.
Nausea.
Vomit.
Paleness of the skin.
A clear drop in temperature.
The patient loses the ability to move. With the manifestation of bright pain, the patient takes a forced position of the body, in which the painful sensation is not so bright.

If the first signs of bleeding with a stomach ulcer appear, it is imperative to conduct a diagnosis to accurately determine the presence of a problem. The main diagnostic method is endoscopy, which should be performed as soon as possible. Endoscopy is performed under general anesthesia.

In addition, special tests are prescribed to determine the presence of latent blood in the stool. Laboratory diagnostics is required to determine hemoglobin, the number of red blood cells, platelets, blood clotting time. In some cases, differential diagnosis may be required to exclude damage to other internal organs.

Anemia

Ulcerative bleeding contributes to a decrease in hemoglobin and is almost always the root cause of life-threatening anemia. Darkening in the eyes, pallor, and increased fatigue are often misunderstood by the patient, while the pathological process in his body is gaining momentum: instead of transporting oxygen and nutrients to the internal tissues and vital organs, there is an intra-abdominal accumulation of blood.

Death

Despite many advances in the field of endoscopy, resuscitation and surgery, the mortality rate from ulcerative bleeding is high. Basically, this tragic consequence occurs in people with massive blood loss, especially in the case of advanced age or against the background of another pathology, as well as in case of delayed medical care.

We must not forget that bleeding with a stomach ulcer is insidious and dangerous: it cannot be ignored, and even more so try to treat traditional medicine recipes, neglecting to go to the hospital.

If the patient's condition allows, then first of all, an endoscopic examination is performed (no later than within 24 hours from the moment of admission to the surgical or intensive care unit).

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, pallor of the skin. Hemoglobin in the acidic environment of the stomach is metabolized, acquiring a dark color, and in the case of vomiting, staining of the vomit in the color of "coffee with milk" is characteristic.

In the case of profuse bleeding, the main symptom is hematemesis, which can be single or repeated. The vomit has a characteristic "coffee grounds" color. In rare cases of massive bleeding from an artery, vomiting of scarlet blood with clots is possible.

A consultation with a gastroenterologist with a detailed study of the history of the disease, 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 the pallor of the skin, a decrease in skin turgor, pain on palpation of the abdomen in the epigastric region is possible.

In the general blood test, a decrease in hemoglobin and red blood cells is determined.

Diagnostic studies

Diagnostic methods of examination when opening a stomach ulcer are as follows:

general analysis of blood and urine;
analysis of feces for occult blood;
abdominal x-ray to detect free gas in it during perforation;
fibrogastroduodenoscopy(FGDS);
biopsy, performed with FGDS for further histological examination;
diagnostic tests to detect Helicobacter pylori i.

The treatment is carried out with medical methods, in case of complications, surgery may be required.

First aid

If you suspect that the patient has started bleeding, you should immediately provide first aid to him. The actions in this case should be similar to those prescribed for any internal hemorrhage.

Lay the patient on a flat, hard surface, place a roller under their feet to ensure a rush of blood to the head and avoid oxygen starvation of the brain. The patient at this time needs complete rest, any physical activity can provoke increased bleeding.

Give the patient food or water should not be, as it can stimulate the digestive processes. But you can put a heating pad with ice or a bottle of cold water on his stomach. Every fifteen minutes, the cold should be removed for three minutes, and then applied again. So you can achieve vasoconstriction in the affected area and a temporary cessation of ulcerative bleeding.

In no case do not wash the victim's stomach and do not give any medications. A bleeding ulcer should be treated by a qualified physician.

Keep the patient conscious until the ambulance arrives. If you notice that he is ready to faint, moisten a piece of cotton wool with a small amount of ammonia and bring it to the patient's nose.

Giving a sniff of ammonia directly from the bottle is strictly prohibited.

After the arrival of the ambulance team, examination of the victim and confirmation of symptoms of ulcerative bleeding, the first aid procedure continues. To begin with, the patient is given two tablespoons of an ice-cold solution of aminocaproic acid, a good hemostatic drug. After a while - a teaspoon of calcium chloride and two crushed dietary tablets.

If, for one reason or another, the patient cannot take these drugs, he may be offered to swallow pieces of ice. However, the effectiveness of this tool is ambiguous. On the one hand, cold compresses blood vessels, but, on the other hand, swallowing movements can further damage the gastric mucosa and increase bleeding.

Do I need to call an ambulance?

Even a suspicion of bleeding from the digestive tract is a reason for hospitalization and intensive examination and treatment. Of course, at the first sign of bleeding, you should call an ambulance, here every minute is sometimes precious.

Walkthrough

First of all, if the patient has symptoms of an ulcer, he should be prohibited from moving. It will be better to lay the patient in a horizontal position on his back. As part of the assistance, before the doctors arrive, it is recommended to put an ice pack on the patient's stomach. You can give a piece of ice so that the patient swallows it, as the cold helps to stop bleeding from a stomach ulcer.

Prohibited before the arrival of doctors:

give the patient food;
drink liquid;
move independently.

Doctors who come to the patient determine what to do next if he has a stomach ulcer that bleeds. Doctors provide first aid and decide whether to hospitalize the patient. Almost always, the patient is assigned to the hospital, and in some cases to the intensive care unit. Already in a hospital setting, further treatment actions are determined:

medication;
physical.

Terrible signs of bleeding in the stomach require emergency care. For this purpose, the following algorithm of actions must be performed with the victim:

ensure complete peace;
lay on a flat surface;
exclude feeding or drinking;
apply cold to the stomach;
refuse gastric lavage and the use of medicines;
keep the patient awake. For this, ammonia is suitable.

When formidable signs appear, it is necessary to take measures to eliminate bleeding as quickly as possible in order to prevent sad consequences. Since the main function of restoring a satisfactory condition is assumed by doctors, it is possible to help the patient only temporarily. To do this, it is important to do the following:

provide the patient with complete rest;
it is desirable to lay the patient on a flat surface;
in no case do not feed or give liquid;
with symptoms of bleeding on the abdomen, it is recommended to put a cold;
you can not wash the stomach and give any medicine;
try to keep the patient conscious until the ambulance arrives (to do this, moisten a cotton swab with ammonia).

If the patient has bleeding, it is urgent to take measures to stop the blood loss.

The appearance of symptoms of gastric bleeding requires immediate medical attention. The patient is called an ambulance.

During this period, the following activities should be carried out:

Provide immobility to the patient.
Lay it on a horizontal hard surface. Roller, pillow, blanket put under the feet. This position will increase blood flow to the head, prevent loss of consciousness.
Water, food completely excluded.
Put a cold heating pad on the epigastric region. She is kept for 15 minutes. After a three-minute break, the procedure is repeated. Cold reduces bleeding.
Prepare a cotton swab with ammonia. It will help restore the consciousness of the patient.

Ambulance

If a person has signs of internal bleeding, help is needed. First of all, you need to call the medical team. The patient should lie on his back and try not to move. If possible, experts advise applying ice to the stomach to reduce the effects of blood loss. At this time, it is forbidden to drink and eat food, medicines, wash the stomach.

If possible, the patient should be kept conscious, ammonia is used for this. Getting to the hospital on your own is also not recommended, this can lead to increased bleeding.

It is forbidden to treat an open ulcer at home, it can be extremely dangerous. It is important to know that even with the improvement of health and the cessation of blood loss, the disease should be treated under the supervision of doctors. It is necessary to call emergency care when hematemesis, feces with bloody components, acute pain in the stomach, development of shortness of breath, tachycardia, and a sharp decrease in pressure appear.

Many people have no idea what to do when an ulcer opens and bleeds. First of all, experts recommend that when such signs of the disease appear, in order to avoid negative consequences, take measures to maximize the elimination of blood loss.

Since the doctor takes on the main burden regarding the elimination of complications and manifestations of the disease, one can try to help the patient only a little. To do this, you need to do the following manipulations:

The patient must first of all ensure peace.
It is also recommended to lay the patient on his back.
During this period, the patient is forbidden to consume anything, including water.
If there are signs of internal bleeding, the patient should apply cold to the abdomen.
It is forbidden to stuff the patient with medications and perform gastric lavage.
By all means try to keep the person from losing consciousness.

Patients whose bleeding is classified as moderate or severe must be hospitalized without fail. The hospital will make the necessary manipulations to compensate for the lost blood.

If the medical method fails to stop internal bleeding, then surgery will be used. The direct methods of such intervention depend on the severity of the patient and the location of the ulcerative crater.

If there are signs of bleeding with a stomach ulcer, then it is imperative to call an ambulance, and the patient should be given first aid before her arrival. First of all, you need to forbid him to move. It is best to put the patient in a horizontal position on his back and put an ice pack on his stomach before the doctors arrive.

You can additionally give a piece of ice to swallow, as the cold helps to stop the bleeding. It is strictly forbidden to give the patient food and water. In the presence of an acute or chronic ulcer with bleeding, the patient is transported only on a stretcher by experienced paramedics.

In almost all cases, the patient is hospitalized in a hospital, and in some cases in an intensive care unit.

Treatment

As such, there are no folk remedies for a bleeding stomach ulcer - this is a very dangerous disease and primary treatment should be carried out exclusively in a hospital with the use of medicines.

What to do if a stomach ulcer has opened? Be sure to get treated! Do not wait for this disease to go away on its own. Usually treatment occurs by classical methods. The choice of treatment depends on the location of the ulcer. The main scheme for the treatment of open peptic ulcer:

Recently, endoscopic therapy in the treatment of ulcers has gained popularity. This is a method of treatment in which applications occur, irrigation of the ulcer itself with the help of medicines. This method reduces the time of treatment of gastric ulcers.

Do not forget about the importance of dietary nutrition during exacerbations of stomach ulcers. There is an opinion that diets for diseases of the stomach lead to additional stress for the body and provokes the further development of the disease. However, contrary to such statements, it has been proven that dietary nutrition not only does not harm, but also helps to speed up the healing process of the ulcer.

Nutrition for bleeding peptic ulcer

Proper nutrition after an attack of a bleeding stomach ulcer is the key to successful rehabilitation. In the first two or three days after an attack, a person should completely refuse to eat and drink. Thirst is usually quenched with an ice cube, which the patient dissolves in the mouth. After the expiration of the period, the patient begins to give food and drink in small quantities.

What can and should be eaten with ulcer bleeding

low-fat milk;
cream in small quantities;
scrambled eggs;
jelly, but not thick;
jelly;
juices, but not sour;
soufflé from meat or cottage cheese;
grated soups;
grated porridge (best of all enveloping oatmeal);
steamed meatballs or meatballs;
mashed potatoes;
herbal decoctions;
butter of the lowest fat content;
in a limited amount of teas and coffee drinks, only after the removal of an acute condition.

This kind of balanced diet will allow you to maintain the vital activity of the body with a sufficient amount of fats, proteins and carbohydrates. If the body will receive all the vitamins, this will contribute to raising the immune system and accelerate the healing of the ulcer.

Any food with a bleeding ulcer should be in liquid form.

What not to do with a stomach ulcer

alcohol in any form;
spices;
roast;
acute;
sweets;
canned food, even vegetables.

A bleeding peptic ulcer is not a sentence in which it is strictly forbidden to eat what you love. It is important to coordinate the diet with your doctor and strictly adhere to it. After recovery, the list of foods that you can eat will definitely expand.

Diet after exacerbation

With an uncomplicated ulcer, treatment is aimed at creating favorable conditions for restoring the mucosa and eliminating the source of infection. For this, drugs are prescribed:

reducing the acidity of the contents of the stomach (antacids);
reducing the production of hydrochloric acid, these are proton pump inhibitors, blockers of histamine receptors of the second type;
gastroprotectors that protect the mucosa from aggressive substances;
antibacterial, protozoal.

If necessary, prescribe vitamins that stimulate the immune system drugs. Alternative methods for an open ulcer can be used only after consultation with your doctor.

Surgical treatment is indicated for the development of complications: perforation, penetration, bleeding that cannot be stopped by endoscopic methods. It is usually possible to stop bleeding into the stomach cavity with the help of FGDS. The vessel is cauterized or coagulated. Perforation requires laparotomy and closure of the hole. In some cases, the area with the ulcerative defect is excised.

With complications such as malignancy or cicatricial stenosis, extended surgical interventions are indicated.

In most cases, therapy is carried out using conservative methods. Do not rely on self-medication, as the wrong approach can cause dangerous consequences and a relapse of the disease.

With a bleeding ulcer, a person is placed in stationary conditions. He will need to comply with bed rest, therapeutic fasting. In addition, the patient is injected with the drug Vikasol and prescribed droppers with epsilon-aminocaproic acid. This treatment helps stop blood loss. With heavy bleeding, a blood transfusion with an erythrocyte mass is performed.

If the lower esophagus is affected, it may be necessary to insert a special catheter with a balloon through the mouth, which is inflated to create pressure in the area of the broken vessel. In some cases, the damaged tissue is affected by special means. Often carry out cauterization of gastric ulcers with bleeding using electric current.

Surgical treatment

With the ineffectiveness of conservative methods of therapy for bleeding in the stomach, surgery is prescribed:

resection of the stomach - partial or complete removal of the affected part of the organ;
total gastrectomy - complete removal of the stomach;
suturing the ulcer by applying serous-muscular sutures;
suturing the vessels of the bottom of the ulcer that bleed;
excision within undeformed tissues with further longitudinal suturing of the defect.

In addition to such surgical techniques, others are also used, for example, clipping of a damaged vessel, the use of a special biological gel that glues the edges of the wound, irrigation of the ulcer with hemostatic drugs.

A patient with gastric bleeding should be immediately admitted to the hospital.

There are two tactics for treating stomach bleeding:

without surgery (conservative);
operation.

Only a doctor can make the right decision. He conducts an examination and examination, establishes the cause and place of bleeding, determines the degree of its severity. Based on this, a further course of action is selected.

Treatment without surgery

Event	Description	How is it carried out?
Strict bed rest	Rest helps to subside bleeding, and during movement it can intensify.
Cold in the epigastric region		The most commonly used is an ice pack wrapped in a cloth.
Gastric lavage with cold water	Under the influence of cold, vasoconstriction occurs, which helps to stop bleeding.	Gastric lavage is carried out using a probe - a tube that is inserted into the stomach through the mouth or through the nose.
Introduction to the stomach through a tube of adrenaline or norepinephrine	Adrenaline and noradrenaline are “stress hormones”. They cause vasospasm and stop bleeding.	A probe is inserted into the patient's stomach through which medications can be administered.
Intravenous administration of hemostatic solutions	Special hemostatic solutions contain substances that increase blood clotting.	Medicines are administered intravenously using a dropper.
donated blood; blood substitutes; frozen plasma.	Transfusion of blood and blood substitutes is carried out in cases where the patient has lost a lot of blood as a result of gastric bleeding.
Other drugs designed to combat existing disorders in the body

Endoscopic treatment

Sometimes stomach bleeding can be stopped during endoscopy. To do this, special endoscopic instruments are inserted into the stomach through the mouth.

Methods of endoscopic treatment:

Injection of a bleeding stomach ulcer with solutions of adrenaline and norepinephrine which cause vasospasm and stop bleeding.
Electrocoagulation- cauterization of small bleeding areas of the mucous membrane.
Laser coagulation- cauterization with a laser.
Stitching with threads or metal clips.
Application of special medical glue.

These methods are mainly used for minor bleeding.

Surgery for stomach bleeding

attempts to stop bleeding without surgery do not work;
severe bleeding and a significant decrease in blood pressure;
severe disorders in the patient's body, which can lead to deterioration of the condition: cardiac ischemia, violation of blood flow in the brain;
repeated bleeding after they have already been stopped.

Sewing up the bleeding area.
Removal of part of the stomach (or the entire organ, depending on the cause of bleeding).
Plastic surgery of the transition site of the stomach into the duodenum.
Surgery on the vagus nerve, which stimulates the secretion of gastric juice. As a result, the condition of the patient with peptic ulcer improves, the risk of recurrence decreases.
Endovascular operations. The doctor makes a puncture in the inguinal region, inserts a probe through the femoral artery, reaches the bleeding loan and closes its lumen.

In most cases, the treatment of bleeding stomach ulcers is performed by conservative methods that do not require surgical intervention. Therapy is carried out in a hospital with the maintenance of complete hunger until the bleeding stops.

At the initial stage, resort to the following therapeutic measures:

injection of Vikasol;
droppers of aminocaproic acid.

If the bleeding is of high intensity, then red blood cells are transfused, which avoids an excessive increase in the volume of circulating blood.

Sometimes the method of treatment corresponds to the location of the bleeding ulcer:

when it is located in the lower parts of the esophagus, a balloon catheter is inserted into the digestive organ through the oral cavity, which is subsequently inflated to create pressure in the area of the damaged vessel;
in the case of a different localization, the focus of bleeding is affected by a special chemical composition that provokes fibrosis and inflammation of the vein.

Recently, endoscopic therapy has been widely used in the treatment of bleeding ulcers, the essence of which is to cauterize the damaged vessel with an electric current. Sometimes a substance is injected into a vein that promotes blood clotting.

In the absence of a positive therapeutic effect, conservative methods are prescribed surgical treatment.

Suspicion of an open ulcer is an indication for immediate hospitalization. While waiting for an ambulance, it is necessary to provide first aid to the victim. The emergency rules are:

ensuring complete rest for a person and a horizontal position of the body on a flat and hard surface;
complete exclusion of food and liquid;
the application of a cold compress to the projection of the stomach, i.e., the upper abdomen;
complete rejection of gastric lavage or the consumption of any medications;
keeping the patient conscious until the arrival of specialists.

Upon arrival at the medical facility, strict bed rest and complete starvation are prescribed. The basis of the treatment of a bleeding stomach ulcer is the provision of hemostasis - the preservation of blood in a liquid state. This can be achieved in several ways:

conservatively - it uses transfusion of blood and plasma products, intravenous administration of medicinal substances, as well as oral administration of aminocaproic acid. Indications for conservative therapy are - a high-risk group of patients, for example, advanced age or the presence of concomitant pathology, as well as the occurrence of gastric ulcers with bleeding at the initial stage of development;
Operably - in most cases, therapeutic endoscopy is prescribed. Hemostasis is carried out in several ways: thermally - this is laser and electrocoagulation, injection - the introduction of drugs such as novocaine, adrenaline and saline solution, mechanically - stopping bleeding by clipping or ligating bleeding vessels. In addition, hemostatic materials such as biological glue or hemostatic powder can be used. Indications for this method of therapy are severe forms of pathology and the addition of complications.

Extensive medical interventions are carried out extremely rarely, often with the ineffectiveness of the above methods. Such operations include complete or partial resection of the stomach, suturing of an open ulcer and suturing of blood vessels.

After such a violation has been eliminated, patients are shown to follow a diet for stomach ulcers, which implies a complete rejection of:

fatty and fried foods;
pickles and smoked meats;
acidic varieties of fruits and vegetables, as well as their consumption in raw form;
legumes and peas;
confectionery and bakery products;
alcoholic and carbonated drinks.

However, a sparing diet does not prohibit the use of:

dietary meats, poultry and fish, steamed, boiled or baked;
vegetable purees;
mucous first courses and cereals;
soft-boiled eggs;
kissels and compotes;
weak tea without sugar.

Compliance with such nutrition will help the patient recover quickly.

Perforated ulcers are treated surgically. Preoperative preparation consists in the removal of gastric contents and the restoration of blood pressure. A study is also being carried out to select further actions.

Evaluated:

Time elapsed since the onset of the disease;

Nature of origin, size and localization of the ulcer;

The severity of peritonitis and the area of its distribution;

Age characteristics of the patient;

Presence/absence of additional pathologies;

Technical features of the hospital and the level of professionalism of doctors;

Separate organ-preserving operations (suturing) and radical (resection, excision of ulcers, etc.).

There are two main types of treatment for gastric bleeding: conservative and surgical. The first is used if the patient belongs to a high risk group (old age or the presence of other serious diseases), as well as with mild and moderate blood loss. The conservative method includes a number of the following therapeutic measures:

transfusion of blood or its individual components (for example, plasma or red blood cells);
intravenous administration of aminocaproic acid, atropine, fibrinogen, calcium chloride;
intramuscular injections of vikasol.

In the first three days of hospitalization, a complete fast is prescribed to stop the bleeding. Further in the course of treatment, doctors recommend sticking to the Meilengracht diet.

A surgical operation is performed in the case of:

extensive blood loss;
ulcer penetration;
rapid deterioration of the patient's condition.

Resection of the stomach

This operation involves the partial removal of the affected area of the upper or lower stomach with the possibility of restoring the normal functioning of the gastrointestinal tract. If there is a need for complete removal of the organ, a total gastrectomy is performed.

Stitching of a stomach ulcer

Bleeding stomach ulcer is an indication for hospitalization of the patient. With moderate and severe bleeding, it is necessary to call an ambulance and provide first aid to the patient.

First aid

Before the arrival of the ambulance, the patient should be laid on the bed, the legs should be slightly higher than the torso to ensure blood flow to the head. Put ice on the stomach area for no longer than 15 minutes.

It is strictly forbidden to give the patient water, food, medications, so as not to provoke gastric motility and increase bleeding. So that the patient does not lose consciousness, he needs to be periodically allowed to sniff ammonia.

Arriving paramedics also provide emergency care to the patient. To do this, they give him a drink of 1 tbsp. l. solutions of aminocaproic acid and calcium chloride.

Further therapy

The algorithm of actions of doctors in the treatment of gastric ulcers with bleeding:

Urgent stop bleeding.
Normalization of pressure, heart rate, restoration of blood volume in case of massive bleeding.
Treatment of the underlying disease.
Consolidation of the result.

To stop blood loss, the following methods are used:

Tamponade. It is carried out in case of localization of the ulcer in the lower esophagus. To do this, a balloon catheter is inserted through the patient's mouth, when inflated with air, it compresses the vessel and the bleeding stops.
Endoscopic hemostasis. Recently, this type of therapy has been used as an alternative to major surgery. Endoscopic hemostasis is of the following types:

Mechanical. A special clip is applied to the damaged vessel.
Injectable. Apply sclerotic preparations that stick together bleeding vessels.
Thermal. The vessel is cauterized using a laser, current, liquid nitrogen, or radio frequency waves.

Drug therapy

Hemostatic agents are prescribed to stop bleeding.

Other Methods

With extensive bleeding, perforation of the ulcer, the absence of the effect of other types of therapy, surgical intervention is indicated. Perform the following types of operations:

Partial resection of the stomach. Remove the upper or lower part of the damaged organ.
Ulcer closure. Ulcers are sutured with a special material.
Vascular closure. With this method, there is a risk of recurrent bleeding.
Ulcer excision. Affected tissue is removed and sutured.

The patient is hospitalized in the surgical department. This is where the disease is diagnosed. In case of large blood loss, a serious condition of the patient is sent to the intensive care unit or intensive care unit.

Urgent measures

Emergency therapy, stop bleeding are carried out immediately after the patient enters the hospital. The following activities are carried out:

Intramuscular injection of Vikasol.
Calcium chloride, aminocaproic acid is injected into a vein.

Activities help stop bleeding, prevent the formation of a blood clot.

First stage

Internal bleeding is stopped with an inflatable balloon catheter. It is introduced into the patient's mouth. The balloon is inflated with air. He squeezes the vessel. Chemical sclerosing stops bleeding.

Endoscopic Therapy

During the procedure, cauterization of an ulcer that bleeds is performed. To do this, a special substance is injected into the patient's vein, which increases blood clotting.

The operation is performed in cases where therapeutic measures have not given a positive result.

mechanical therapy

Extensive bleeding is eliminated in the following ways:

Suturing of the ulcer and the affected vessel.
Clipping. The site of bleeding is determined using an endoscope. Special clips are placed on the vessel. The method is used for bleeding from varicose veins.
Angiographic embolization. Microscopic spirals are introduced into the lumen of the affected vessel.
Resection of the stomach. The operation is performed in cases where previous methods do not work. The ulcerative lesion is excised to the boundaries of healthy tissues. The stomach is sutured.

Surgery requires a long recovery. The patient is on strict bed rest.

After discharge, the patient is placed on a dispensary record. The gastroenterologist monitors the patient's condition. He conducts periodic courses of therapeutic treatment.

People who first encountered a stomach ulcer try to cure it without medical help. Folk recipes help to avoid such complications as an acute ulcer with bleeding:

Take cabbage juice daily. A glass of juice should be drunk three times a day.
Scroll aloe leaves in a meat grinder, add a teaspoon of honey. Leave the composition in a dark place for 3 days. Take 3 times a day before meals.
Mix 20% alcohol tincture of propolis with 200 ml of water. Take 3 weeks, half an hour before meals.

If a bleeding ulcer is suspected, the patient should be immediately hospitalized. Examination on an outpatient basis is not permissible. Until the bleeding stops, complete hunger and strict bed rest are prescribed. Dietary nutrition is allowed only after a complete examination and conservative hemostasis.

If a stomach ulcer with bleeding has opened, then you should immediately consult a doctor for treatment. The main therapy is carried out in the hospital. Immediately after hospitalization, the patient is prescribed drugs that help reduce the risk of severe blood loss. For treatment, the administration of Vikasol is indicated.

If the bleeding is severe enough, then the patient may be prescribed a blood transfusion. After the required volume is restored, additional therapy is required, aimed at the subsequent elimination of symptoms and the risk of subsequent bleeding.

In some cases, endoscopy is used for treatment. This method involves cauterization of a damaged vessel with an electric current. A substance may also be injected into the vein to help blood clot and help prevent future bleeding.

Treatment of a gastric ulcer with bleeding with the help of conservative therapy involves the use of colloid and crystalloid solutions. To compensate for the lost blood, an infusion of the required volume of rheopolyglucin and polyglucin is required.

Also, agents are required to improve blood clotting, in particular, such as platelet mass, fibrinogen, plasma, aminocaproic acid. Doctors also prescribe antibacterial agents, in particular, such as Tetracycline, Metranidazole, Clarithromycin.

Then you need to take proton pump blockers ("Omeprazole") and histamine receptors ("Diazolin"). Additionally, antispasmodics are prescribed, for example, Spazmolgon, No-Shpa.

This treatment is designed for 2 weeks.

In many cases, with a stomach ulcer with bleeding, surgery is the only way to save the patient's life. The method of surgical intervention largely depends on the severity of the patient's condition and the location of the ulcer crater. The most popular method of the operation is gastric resection. This type of operation refers to organ-preserving, and is also quite simple and safe.

In debilitated patients, an alternative method of surgical intervention is suturing the defect with vagotomy, as well as subsequent drainage of the wound. It should be noted that all these techniques are not difficult and do not pose a particular risk, since there is no danger of injury to the vessels during their implementation.

Bleeding in gastric ulcer is a critical phenomenon: when performing therapeutic tactics, organizational issues are certainly important, which act as a basis for effective endoscopic hemostasis (round-the-clock duty of competent specialists, the availability of modern equipment and medicines for hemostasis; adequate pain relief).

Patients whose bleeding qualifies as moderate to severe are hospitalized in the intensive care unit, where they are replenished with the amount of blood lost. The elimination of the phenomenon of hemorrhagic shock will be carried out simultaneously with the clarification of the location of ulcerative bleeding, while the operation should be performed at the optimum time.

The decision to replenish the amount of circulating blood by infusion of red blood cells or plasma substitutes is based on signs of bleeding. In elderly patients with a pathology of the functioning of the heart, as well as in the case of massive bleeding, hemotransfusion (blood transfusion) is carried out in parallel with blood pressure monitoring.

Important indicators of the success of the measures taken are the hourly measurement of diuresis and venous pressure indicators, which, at a level above 16 cm of water. Art. indicate the inability of the heart to cope with the incoming amount of fluid.

In such a situation, the rate of administration of infusion drugs is reduced by prescribing stimulants for the activity of the heart muscle. Conservative therapy is carried out by the following pharmacological groups:

Colloidal and crystalloid solutions. To compensate for the lost blood and normalize the water and electrolyte balance, the primary goal is to infuse a sufficient amount of polyglucin and rheopolyglucin.
Means for improving the blood coagulation properties (fibrinogen, plasma, platelet mass, aminocaproic acid).
Hemostatic drugs of prolonged action (Vikasol).

Patients whose ulcerative bleeding was stopped medically, there are no grounds for urgent surgery. It is possible to predict the likelihood of resumption of bleeding, previously stopped by a conservative method, based on the results of endoscopy and laboratory tests.

If medical therapy fails, surgery is considered as the last option to stop blood loss, while the choice of surgical method depends on the severity of the patient and the location of the ulcer crater.

Resection of the stomach is topical - this is a type of organ-preserving operation, the convenience of which lies in the ease of implementation. In debilitated patients, an alternative option is closure of the defect, with or without vagotomy (dissection of the vagus nerve trunk), and subsequent drainage of the wound.

It should be noted that these methods do not have significant technical difficulties, but require detailed knowledge of the anatomical location of large blood vessels in this area in order to avoid injury.

Suspicion of a bleeding stomach ulcer is a direct indication for emergency hospitalization of patients in the surgical department. Examination on an outpatient basis is strictly unacceptable.

All patients are prescribed strict bed rest, complete hunger (after stopping the bleeding - the Meilengracht diet). Conservative hemostasis includes transfusion of blood products, plasma, the introduction of fibrinogen, aminocaproic acid, calcium chloride, vikasol, atropine, as well as oral administration of aminocaproic acid.

Conservative treatment can be performed in high-risk patients (elderly, severe comorbidities), as well as in mild to moderate bleeding.

Indications for 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 localization of the ulcer and individual characteristics. Can be performed resection of the stomach according to Billroth I or II, excision, suturing of the stomach ulcer, suturing the vessels of the bottom of the ulcer, possibly combined with vagotomy.

Forecast and prevention

The prognosis is determined by the volume of blood loss and the timeliness of specialized care. At present, active surgical tactics of treatment (in the absence of contraindications) is considered the only correct one.

In addition to the rate of bleeding arrest, the prognosis depends on the safety of the patient's compensatory mechanisms, adequate replenishment of the circulating blood volume. With profuse bleeding, a high percentage of mortality is recorded.

Prevention of a bleeding stomach ulcer consists in a timely appeal to a gastroenterologist in the presence of complaints from the stomach, adequate treatment of peptic ulcer according to current standards, medical examination of patients and regular examination.

Therapy Methods

To ensure that a bleeding ulcer does not have a place in your life, follow these recommendations:

Eliminate alcohol from your diet
Quit smoking
Minimize your caffeine intake
Take anti-inflammatory drugs very carefully,
Stick to a diet
Use antacids to reduce stomach acid
Apply covering agents
Get examined regularly.

Peptic ulcer of the stomach is a dangerous disease in which formidable complications are possible, one of which is bleeding. By following preventive measures and taking measures to combat Helicobacter pylori infection, the disease can be avoided.

A patient with peptic ulcer must clearly remember the symptoms of a complication of his disease in order to start treatment on time. Modern medicine has many proven methods of dealing with them.

At the first signs of this type of bleeding, it is necessary to consult a gastroenterologist for a detailed examination and treatment in a hospital. Firstly, the patient is immediately prescribed hemostatic drugs, for example, a course of injections of Vikasol medicines. If a bleeding stomach ulcer has caused severe blood loss, then in this case the patient is given a blood transfusion.

If the damage is located in the lower part of the esophagus, then a balloon catheter is inserted into this area, inside the catheter is inflated, squeezing the bleeding area. Also, a solution is used for treatment to prevent fibrosis and inflammation.

Sometimes in the treatment of ulcerative bleeding, the method of endoscopy is used, this procedure consists in cauterizing the affected area with an electric current.

If the above methods of treatment do not help, then the method of surgical intervention is used - gastric resection.

After the operation, the patient stays in the hospital for some time, and for the rest of his life he adheres to the strictest diet.

Remember, bleeding is an extremely dangerous complication of a stomach ulcer, in order to prevent the development of such a situation, you must strictly monitor your health, and at the first sign you should immediately consult a doctor.

Treatment for a confirmed perforated ulcer is surgical. The main goals of therapy are the preservation of the patient's life, the elimination of ulcerative defects, and the fight against peritonitis.

In the future, treatment is aimed at eliminating the underlying disease that led to the perforation. The operation for a perforated ulcer is carried out after careful preparation of the patient - purification (drainage) of the gastric cavity from the contents, stabilization of blood pressure.

Diet

After the bleeding is stopped, a special diet must be followed for 10-12 days. Eating during this period should be every 2-3 hours, the size of one serving should not exceed 150 ml.

Food should be pureed, steamed, boiled or stewed. Rough, fatty, spicy and acidic foods should be avoided. In the diet of a patient with peptic ulcer, you can include the following products:

Milk, non-sour curd,
Low-fat varieties of fish and meat,
Soft-boiled eggs (no more than 2 per day),
Puree soups,
Semi-liquid rice, oatmeal, buckwheat porridge.

After a patient with a bleeding stomach ulcer is discharged from the hospital, it is necessary to provide him with proper nutrition.

First, it is necessary to exclude from the diet all foods that can somehow contribute to the resumption of bleeding. These include alcohol, salt, sugar, wheat flour products, and milk. Tea and coffee can be drunk, but in limited quantities. You should also completely stop smoking and medicines based on aspirin - they can cause re-bleeding.

The convalescent diet should include:

eggs - soft-boiled or in the form of an omelette;
lean meats or poultry;
a variety of soups with milk, chicken or vegetable broth;
semi-liquid cereals in milk or water (semolina, oatmeal, rice) with a spoonful of butter;
a large number of various stewed vegetables - carrots, zucchini, potatoes, beets;
sweet fruits and berries;
low-fat dairy products;
weak sweet tea (possible with milk);
still mineral water.

Diet therapy is one of the main methods of treatment for peptic ulcer disease. Food should not irritate the mucous membrane, be easily digestible and be nutritious enough to promote rapid healing of the ulcer.

You need to eat fractionally, in small portions, with an exacerbation, the number of meals is 5-8 per day. The temperature of the dishes should be 25-33 degrees.

Be sure to observe the drinking regimen of 30 ml / kg per day.

In acute stomach and duodenal ulcers, you need to be attentive to your health and not aggravate the situation. Treatment should be combined with preventive measures.

First of all, you need to give up bad habits. The abuse of alcohol and cigarettes adversely affects the condition of the stomach and duodenal ulcers.

Patients need:

kefir, cottage cheese;
sweet potatoes, apricots, apples, eggs, cheese, carrots;
ascorbic acid, which is found in cabbage, milk, pork, beef, seafood, yogurt, melon, beans;
vitamin E, which is found in peanuts, mango, kiwi, spinach, egg yolk.

Black tea;
coffee;
bitter chocolate;
fried and fatty.

Maintaining a healthy lifestyle, giving up bad habits and being attentive to your health will be the key to eliminating the risk of developing dangerous pathologies. Timely detection of the first symptoms will help to start treatment already at the initial stage of the disease.

Successful treatment is largely due to proper nutrition. During the first day, a complete refusal of food and drink is expected.

Thirst is quenched with a few teaspoons of water or a piece of ice that dissolves in the mouth. After a couple of days, you can eat food in liquid form.

Acceptable products include lactic acid products, fish or minced meat, juices.

It is important to avoid roughage, gassy drinks, and foods that can cause more bleeding.

The first rule for recovery and reducing the risk of relapse is strict adherence to the doctor's instructions. The exception to the rule “if you can’t, but really want to” does not work. In the postoperative period, a strict diet is established. It can last from 3 to 6 months. The diet becomes more difficult gradually.

The basic principles of the diet:

The daily number of meals is up to 6 times, in small portions.

All products taken should be puree or semi-liquid.

Cooking food should be steamed or boiled

Salt should be taken in limited quantities

You should also limit the intake of simple carbohydrates (sugar, chocolate, pastries) and liquids.

On the 2nd day after the operation, mineral water, fruit jelly, weak, slightly sweetened tea are allowed to be taken.

One of the components of effective therapy is nutrition, which involves the strictest restrictions. A diet for a bleeding stomach ulcer involves an absolute rejection of fluids and food on the first day. With a strong thirst, the patient is given water (several teaspoons) or ice for resorption. Further nutrition includes raw eggs, milk, jelly, liquid jelly.

Experts came to the conclusion that if there is an open process with bleeding, prolonged hunger is contraindicated, since the secreted gastric juice worsens the condition of the mucosa. The body must receive the required number of calories, mineral salts, vitamins, proteins. In this case, the food should be liquid.

What diet should be followed in the following days? A little later, you can add soufflé from cottage cheese, meat, vegetable purees, chopped cereals, steam cutlets, butter to the diet. When the patient has an ulcer and bleeding opens, all spicy dishes, alcoholic drinks, smoked meats, and fried foods fall under a complete ban.

In the postoperative period, it is important for patients to follow a diet, the purpose of which is to protect the stomach from increased stress, accelerate the process of recovery and restore gastrointestinal motility, and prevent recurrence of perforation. A strict diet for a perforated stomach ulcer in the postoperative period can last up to six months. The diet expands very slowly.

Diet principles:

the total number of meals per day is at least 5–6, portions are modest in volume (200–250 g);
the consistency of the dishes is semi-liquid, in the form of a homogeneous puree;
the best ways to cook dishes are boiling in water or steamed;
salt is sharply limited;
intake of carbohydrate foods and liquids is subject to restriction.

The rate of recovery from stomach ulcers largely depends on nutrition. The more accurately the patient will follow the doctor's recommendations in terms of diet, the faster the healing process of the ulcer will occur. About the features of nutrition during exacerbation of stomach ulcers and will be discussed in our article.

Why do you need a diet for peptic ulcer

In the issue of recovery, an important role is assigned to diet therapy: the diet should be as vitaminized as possible and suggest the use of the following products by the patient:

Zinc: kefir, cottage cheese;
Retinol: apricots, cheese, carrots, eggs, sweet potatoes;
Ascorbic acid: melons, beans, non-sour orange, cabbage, milk, berries, potatoes, yogurt, pork, beef, liver, seafood;
Vitamin E: spinach and other greens, egg yolk, peanuts, mango and kiwi.

Products and food processing, the use of which is strictly prohibited:

Pepper;
Coffee;
Fried and fatty foods;
Bitter kind of chocolate.

Bleeding in peptic ulcer occurs in 18-25% of cases, accounting for 60-75% of all cases of gastrointestinal blood loss. Most often, the source of bleeding in peptic ulcer is arrosted arteries located in the area of the ulcer, less often veins and capillaries. It can be obvious (acute), arising suddenly, or latent, manifesting itself gradually. In most cases, ulcers of the lesser curvature of the stomach bleed (bleeding occurs from the system of the left and right gastric arteries) and duodenum, penetrating into the head of the pancreas or into the hepatoduodenal ligament (bleeding from the system of the gastroduodenal and upper duodenal-pancreatic arteries).
Pathogenesis of hemodynamic disorders in ulcerative bleeding.

First of all, blood loss is accompanied by a decrease in BCC and hypovolemic shock. Developing hypovolemia adversely affects the blood supply, primarily to the brain and heart. Under such conditions, the vital activity of the organism is ensured by the activation of autoregulatory neurohumoral mechanisms of adaptation and protection. Thus, a deficiency of ODC up to 10-15% does not lead to significant hemodynamic disturbances and is compensated by a decrease in the capacity of the vascular bed, spasm of the vessels of the skin, abdominal organs, and opening of arteriovenous shunts.

With blood loss over 15% of the BCC, blood pressure decreases by 15-30%. Compensation for the missing BCC, an increase in cardiac output, and, as a result, normalization of blood pressure and improvement in blood supply to organs and tissues in this category of patients occur due to the greater tension of adaptive-protective mechanisms. BCC deficiency is compensated by a generalized spasm of blood vessels, penetration into the general bloodstream of part of the tissue fluid, blood from natural depots, lymph from the lymphatic vessels. At the same time, the replenishment of the BCC is accompanied by its hemodilution. The heart rate also increases. At the same time, under the influence of corticosteroids, aldosterone, antidiuretic hormone, reabsorption of water and sodium in the renal tubules increases, diuresis decreases.

However, replenishment of BCC adversely affects tissue perfusion. Cell hypoxia develops, which inevitably leads to switching of metabolism to an anaerobic type. Gradually, metabolic acidosis occurs. In the case of depletion of the protective mechanisms of restoration of BCC, blood pressure decreases to a critical level - 50-60 mm Hg. Art. There is an irreversible disorder of microcirculation. The function of the liver (liver failure), kidneys (renal failure), heart (myocardial infarction) is sharply disturbed. In this foyer, patients often die.

The deterioration of the condition of patients with bleeding in peptic ulcer disease is facilitated by intoxication of the body with hydrolysis products of the blood that has poured into the intestine. The leading role in the intoxication process belongs to ammonia. The latter, due to a decrease in the detoxification function of the liver due to systemic hypotension, is not captured by hepatocytes. In combination with a decrease in diuresis, this leads to a significant increase in the concentration of ammonia and other toxic substances in the blood.

Classification of bleeding in peptic ulcer disease. Gastroduodenal bleeding is subdivided: I) according to etiology - from a chronic ulcer, from an acute ulcer, from a symptomatic ulcer; 2) by localization - from a stomach ulcer: a) cardia, b) body of the stomach, c) antrum, d) pyloric canal (lesser curvature, anterior wall, posterior wall); from a duodenal ulcer: a) bulbous, b) postbulbar, c) descending section (walls: anterior, posterior, upper, lower, transitional and combined); 3) by nature: continuing: a) jet (profuse), b) laminar, c) capillary, d) recurrent, e) unstable hemostasis; held: a) stable hemostasis, b) posthemorrhagic anemia; 4) according to the severity of bleeding or blood loss.

E. L. Berezov distinguishes three degrees of severity of gastrointestinal bleeding in peptic ulcer based on the frequency of hematemesis, tarry stools, blood pressure and pulse rates, and the general condition of patients:

Mild degree: single vomiting, tarry stools, blood pressure and pulse are normal, the general condition is satisfactory.
Moderate degree, syncope, repeated hematemesis, weakness, decrease in systolic blood pressure to 90-80 mm Hg. st, increased heart rate up to 100 beats.
Severe degree, profuse repeated vomiting, tarry stools, systolic blood pressure drops to 60-50 mm Hg. Art. pulse 120 or more beats per 1 min, the patient's condition is critical.

Symptoms of bleeding in peptic ulcer. Typical signs of gastrointestinal bleeding are hematemesis, tarry stools, general symptoms. Their severity primarily depends on the severity and duration of bleeding, the amount of blood loss.

Hematemesis occurs in most cases of gastrointestinal bleeding in peptic ulcer disease. It can be single and often recurring, slight and profuse, such as coffee grounds, and less often - scarlet blood with clots. Hematemesis is most typical for bleeding from gastric ulcers. In persons with duodenal ulcer, it is observed when blood is thrown into the stomach through the gaping pylorus. However, with a slow accumulation of blood in the stomach, vomiting may be absent, since the outflowing blood has time to evacuate into the intestines. A similar situation occurs in patients with gastric bleeding due to rapid emptying of the stomach.

Vomiting of blood with clots is noted with massive bleeding with peptic ulcer. The appearance of vomiting at short intervals is a sign of ongoing bleeding, and after a long period of time - indicates its resumption.

Common symptoms of blood loss include weakness, dizziness, pallor of the skin and mucous membranes, cold clammy sweat, acrocyanosis, impaired vision, hearing and mental disorders (cerebral hypoxia), pain in the heart region (myocardial hypoxia).

Diagnosis of bleeding in peptic ulcer. When examining patients with gastrointestinal bleeding, the task is to establish its presence, determine the cause, localization of the source and severity. Of great importance for subsequent tactics is the confirmation of the continuation or stop of bleeding.

First of all, attention is drawn to the nature of complaints, anamnesis, the results of an objective examination and digital rectal examination are analyzed. Often, the disappearance of abdominal pain after bleeding and local pain on percussion in the pyloroduodenal zone are detected. It is extremely important to assess the state of hemodynamics (pulse, blood pressure, CVP, ECG, diuresis), hematological parameters (erythrocytes, hemoglobin, hematocrit, etc.) in order to timely diagnose hemorrhagic shock.

On an emergency basis, fpbroeophagogastroduodenoscopy is performed, including for patients in extremely serious condition, as this allows for simultaneous implementation. If it is impossible to examine the stomach and duodenum due to the large amount of contents, they are washed with cold water through a probe, followed by fibrogastroduodenoscopy.

Gastroduodenal bleeding in peptic ulcer disease is characterized according to endoscopic signs formulated by G. P. Shorokh and V. V. Klimovich (1998). The authors highlight:

Endoscopic signs of ongoing bleeding in peptic ulcer: a) pulsating bleeding; b) the presence of blood in the lumen of the stomach or duodenum, which accumulates despite constant aspiration; c) diffuse capillary bleeding from the bottom or edges of the ulcer; d) south-under bleeding of a loose red clot in the area of the ulcer; e) scarlet blood clots that fill the lumen of the stomach or duodenum and do not allow to see the ulcer;

The bleeding that has taken place in peptic ulcer disease, which is divided into stable (steady) and unstable (unstable) hemostasis.

Endoscopic signs of bleeding in peptic ulcer with unstable hemostasis are as follows: a) the ulcer is covered with a dark blood clot, there is “coffee grounds” in the stomach, there is no fresh blood; b) in the crater of the ulcer there is a vessel closed by a red thrombus; c) a pulsating vessel is visible in the ulcer crater; d) the ulcer is closed by a loose red clot.

Endoscopic signs of ongoing bleeding in peptic ulcer disease with stable hemostasis: a) the bottom of the ulcer is covered with fibrin; b) small thrombosed vessels on the ulcer; c) the bottom of the ulcer is covered with hemosiderin (black color of the bottom), there is no blood in the stomach.

If, on the basis of instrumental diagnostic methods, it is impossible to find the source of bleeding in peptic ulcer disease, and the patient's condition is progressively worsening, an emergency is indicated.

Differential diagnosis of bleeding in peptic ulcer disease. More than 70 diseases are known to be accompanied by gastroduodenal bleeding. Most often, differential diagnosis of bleeding of ulcerative etiology is carried out with gastrointestinal bleeding with decaying, Mallory-Weiss syndrome, hemorrhagic erosive gastritis, varicose veins of the esophagus and stomach, Rendu-Weber-Osler disease, leukemia, hemophilia, Werlhof's disease, Dieulafoy's syndrome.

With a decaying cancerous tumor of the stomach, bleeding is rarely profuse. Usually it is small, like coffee grounds, and is not accompanied by pain. Bleeding is preceded by loss of appetite, body weight, a progressive increase in weakness, fatigue,. The reaction of feces to occult blood after the disappearance of bloody vomiting and tarry stools remains positive for a long time. The diagnosis is specified on the basis of the results of fibrogastroscopy with a biopsy of the tumor tissue and X-ray examination.

Mallory-Weiss syndrome is manifested by bleeding from a rupture of the mucous membrane of the cardioesophageal region. There may be several breaks. They are located longitudinally. The syndrome occurs predominantly at a young age. Bleeding occurs suddenly with severe vomiting and is accompanied by the appearance of retrosternal pain. With fibrogastroscopy in the esophageal-cardiac zone, linear ruptures of the mucosa of various lengths and depths are found.

Hemorrhagic erosive gastritis is characterized by varying degrees of intensity of bleeding from single and multiple erosions of the gastric mucosa, representing superficial ulcers. Erosions are localized in any part of the stomach, but more often in the body and in the prepyloric section. The development of erosive gastritis is promoted by burn disease, drug overdose, myocardial infarction, acute cerebrovascular accident, and traumatic brain injury. The only method for diagnosing erosive gastritis is fibrogastroscopy.

Bleeding from varicose veins of the esophagus and stomach on the basis of portal hypertension is promoted by portal crises, a violation in the blood coagulation system, ulceration of the mucous membrane of the esophagus and stomach under the influence of the acid-peptic factor. Often, bleeding occurs after a heavy meal, as well as during sleep, when blood flow to the portal vein system increases significantly. When examining patients, they find an increase or, conversely, a decrease in the liver, splenomegaly, often combined with ascites, dilatation of the veins of the anterior abdominal wall.

In Randu-Weber-Osler disease, multiple telangiectasias and mucosal angiomas are the source of bleeding. The disease is hereditary, transmitted by dominant type. Often, along with gastrointestinal bleeding, bleeding from telangiectasia and angiomas are observed, localized on the mucous membranes of the nose, oral cavity, lips, tongue, wings of the nose, ear lobes, bladder, trachea and bronchi.

Gastrointestinal bleeding in patients with leukemia occurs due to increased permeability of the mucosal vascular wall. Bleeding can be either minor or profuse. Diagnosis is based on the results of a blood smear, biopsy, and bone marrow aspirate.

In patients with hemophilia, the occurrence of gastrointestinal bleeding is associated with a drop in the level of antihemophilic globulin in the blood below 30%. The disease is inherited, occurs mainly in men. Anamnesis data indicate increased bleeding from soft tissue wounds, the presence of intra-articular, subcutaneous and intermuscular hematomas. Increased blood clotting time up to 10-30 minutes.

Typical signs of Werlhof's disease, in addition to gastrointestinal bleeding, are increased bleeding of the gums, nasal mucosa, renal and uterine bleeding, subcutaneous bruising and hemorrhage in the submucosal membranes. Thrombocytopenia is found in the blood, a significant increase in clotting time.

Dieulafoy's syndrome was described in 1897. It occurs mainly in men under the age of 50 who do not have any history of ulcers. The syndrome is characterized by the development of massive arterial bleeding, prone to recurrence from single superficial erosions, mainly of the gastric mucosa. In 70-80% of cases, the source of bleeding is located in the stomach along the posterior wall of its upper third, 4-6 cm from the esophageal-gastric junction. However, Dieulafoy ulcers (Dieulafoy ulcers) can also be localized in the proximal esophagus, duodenum, and large intestine. The usual diameter of manifestations is 0.5-0.8 cm. The disease is based on a violation of the formation of vessels of the submucosal layer in the process of embryonic development, which, in combination with chronic inflammation of the mucosa, leads to thrombosis of the artery and necrosis of its wall. At the bottom of the erosion there is always an arrosed aneurysmically altered small artery of the submucosal layer. The development of bleeding is facilitated by the acid-peptic factor, mechanical damage to the mucous membrane, endotoxicosis, disruption of hormonal homeostasis, circulation of aggressive autoimmune complexes, atherosclerosis, and hypertension. During fibrogastroscopy in patients with Dieulafoy's syndrome, a large amount of blood is found in the stomach, often in the form of a cast.

More rare sources of gastrointestinal bleeding are gastrointestinal diverticula, hiatal hernias, liver ruptures, and hepatic artery aneurysms (manifested by hemobilia).

Treatment of bleeding in peptic ulcer disease. Patients with gastrointestinal bleeding and compensated hemodynamics are hospitalized in the intensive care unit of the surgical department or in the intensive care unit. In case of life-threatening bleeding, accompanied by hemorrhagic collapse and (or) shock, they are delivered to the operating room, where measures are taken to stabilize hemodynamics (catheterization of the central vein or several peripheral veins for intensive infusion-transfusion therapy and control of CVP). Against the background of ongoing treatment, an emergency with endoscopic hemostasis is performed. In case of its ineffectiveness and if the patient tolerates surgical intervention, a laparotomy is performed. Patients with a high degree of risk are not offered, and they are transferred for further treatment to the intensive care unit. Patients with stopped bleeding after normalization of hemodynamics are admitted to the intensive care unit or intensive care units of the surgical department.

Conservative treatment of patients with gastrointestinal bleeding in peptic ulcer disease involves hemostatic therapy and replenishment of BCC in order to normalize central hemodynamics, microcirculation, trans capillary exchange and respiratory function of the blood.

Hemostatic therapy is divided into local and general. The methods of local hemostatic therapy include endoscopic hemostasis; the use of agents that reduce fibrinolytic activity; hypothermia of the stomach.

Several methods of endoscopic hemostasis have been developed. Among them, the most common are chipping the source of bleeding with drugs (), diathermocoagulation, targeted irrigation of a bleeding ulcer with hemostatic drugs, clipping of arrosed vessels, cryotherapy on the source of bleeding, etc.

The method of instillation of the source of bleeding with drugs is based on the achievement of hemostasis both due to mechanical compression of the vessels with a solution of the injected fluid (filtration tamponade of the vessels), and the local effect of drugs that cause vasospasm, increase platelet aggregation with thrombus formation in an arrosed vessel, and inhibit increased local fibrinolysis . Ethoxysclerol, MK-6 glue dissolved in 70-96 ° ethyl alcohol, MIRK-10, MIRK-15 glue, norepinephrine, adrenaline, oil preparations (iodolipol, mayodil, aevit, etc.) are used for chipping ulcers. The drugs are injected into the ulcer, under the vessel or under the clot from 2-3 points in a volume of 1-2 ml at each point.

When using the method, it should be borne in mind that after the injection of alcohol into the tissues of the wall of the stomach or duodenum, the size of the ulcer may increase due to superficial necrosis of the mucosa.

The treatment of a bleeding ulcer with a diathermic probe begins around the arrosed vessel, which leads to its gradual compression by sealing tissues. In patients with a hanging thrombus located in the source of bleeding or leakage of blood from under it, diathermocoagulation begins from the upper edge of the thrombus downwards. As a result, a white scab forms at the site of the bleeding ulcer,

As a rule, for thermal arrest of gastroduodenal bleeding, bipolar electrocoagulation is used, which is accompanied by a smaller depth of tissue damage and is not complicated by perforation of the wall of the coagulated organs,

Laser photocoagulation (video endoscopic laser photocoagulation) of bleeding ulcers refers to methods of non-contact exposure to the source of bleeding. It is more expedient to use high-intensity laser radiation (YAG - neodymium laser, argon laser), which is not absorbed by hemoglobin and water, and therefore penetrates deep into the steak of the stomach and duodenum with the formation of a strong whitish scab on the surface of the ulcer.

The effectiveness of low-intensity laser radiation in a bleeding ulcer is disputed, since it can increase hyperemia and vulnerability of surrounding tissues with the appearance in some cases of flat erosions on the mucous membrane. Their formation increases the likelihood of recurrent bleeding. Based on the available data on the effect of low-intensity laser radiation, a number of authors (P. M. Nazarenko et al., 1999 and others) suggest that it be prescribed to patients with bleeding ulcers only when a hemostatic effect is achieved within 4-5 days.

The disadvantage of laser photocoagulation is the impossibility of stopping the ongoing intense bleeding in peptic ulcer disease. More often, quantum coagulation is used in combination with other methods of endoscopic hemostasis.

For targeted irrigation of a bleeding ulcer, caprofer, 10% calcium chloride solution, thrombin, fibrinogen, aminocaproic acid, norepinephrine, mezaton, etc. are used. Of the listed medicines, only irrigation of the ulcer with caprofer leads to a stop of intense bleeding. All other drugs are used for hemostasis in patients with small, mainly capillary bleeding. The composition of caprofer includes iron carbonyl complex and aminocaproic acid. The hemostatic effect of the drug occurs immediately after its application to the surface of a bleeding ulcer with the formation of a dense black clot, well fixed to the mucous membrane of the stomach and duodenum. The clot is well retained for 12-16 hours.

The method of endoscopic clipping of bleeding vessels in an ulcer is based on the imposition of metal clips with a special clipper on the base of the vessel or along its length on both sides of the bleeding site,

The use of agents that reduce fibrinolytic activity and open arteriovenous shunts. To reduce the fibrinolytic activity of the mucosa, a mixture was proposed consisting of 10 g of epsilon-aminocaproic acid, 200 mg of thrombin and 100 ml of water, which the patient takes orally every 15 minutes for 2 hours, and then 3 times a day. The opening of arteriovenous shunts, which leads to bleeding of the mucous membrane, is facilitated by the introduction into the stomach (including through a nasogastric tube) of 4 ml of a 0.1% solution of noradrenaline in 150 ml of isotonic sodium chloride solution. In the absence of a hemostatic effect, norepinephrine is prescribed again, but at a half dose.

Hypothermia of the stomach (cold on the epigastric region) is used in a complex of methods of local hemostatic therapy. Gastric lavage with cold (up to +4 °C) water is used if it is impossible to use more modern methods of local hemostasis in patients with ongoing bleeding from peptic ulcer. The formation of blood clots during gastric lavage is accelerated by the addition of silver nitrate and thrombin to the water.

For the purpose of general hemostatic therapy, 10 ml of a 10% solution of calcium chloride (gluconate) is administered intravenously; every 4-6 hours - 5% solution of fibrinolysis inhibitor epsilon-aminocaproic acid - 100-200 ml and native fresh frozen plasma. Intramuscularly, a 1% solution of vikasol is prescribed up to 3 ml per day, dicynone, etamsylate - 1-2 ml every 6-8 hours, and in severe cases - intravenously trasilol (100 thousand units) or counterncal (25-30 thousand units) . A good hemostatic effect is given by secretin, which is administered intravenously at a dose of 100 mg per 50 ml of isotonic sodium chloride solution.

If successful, the achievement of hemostasis from a bleeding ulcer allows a set of measures to normalize the hemodynamics of patients and stabilize their general condition. This makes it possible to either achieve healing of the ulcer with the help of therapeutic methods, or to perform surgery in more favorable conditions for patients.

The elimination of volemic disorders is primarily in the replenishment of the BCC. Since the most favorable conditions for ensuring adequate hemodynamics and gas exchange in tissues occur during hypervolemic hemodilution, the volume of transfusion media administered in patients with gastrointestinal bleeding with peptic ulcer should be three times the blood loss due to blood substitutes and blood in a rational combination. In patients with hypovolemia of 25-30% BCC, the ratio between colloid and crystalloid preparations is 1:1.5, and BCC deficiency of 30% or more is 1:2. Indications for blood transfusion occur in the case of a decrease in hemoglobin concentration below 80 g / l and a hematocrit number of up to 0.25, So, with mild blood loss (up to 1000 ml), 1.5-2 liters of glucose-salt solutions are intravenously administered in combination with plasma substitutes (5-10% glucose solution, acesol, disol, chlosol, gelatinol, etc.). Bleeding of moderate severity (up to 2000 ml) serves as an indication for the transfusion of 4500 ml of infusion-transfusion media, of which 1500 ml (no more than 1/3 of the total infusion volume) are glucose-salt solutions (1: 1), 1500 ml are colloids ( of which 50% is fresh frozen plasma) and 500-800 ml of donor erythrocytes.

Reimbursement of BCC is carried out under the strict control of CVP blood pressure, heart rate, hourly diuresis, erythrocytes, hemoglobin and hematocrit.

Replenishment of blood loss is considered relatively adequate when the number of erythrocytes reaches 3.0 x 10i/l, hemoglobin 90 g/l, hematocrit number 0.30.

In parallel, modern complex therapy of peptic ulcer is being carried out, including the use of histamine H2 receptor blockers, primarily intravenously, hydrogen pump inhibitors, drugs that destroy HP, antacids, enveloping and adsorbing agents, reparants, anabolic agents, biogenic stimulants, vitamins, etc.

After stopping bleeding with peptic ulcer, the patient follows the Meilengracht diet for 10-12 days: intake of easily digestible food with a daily energy capacity of at least 1000-1200 kcal every 2-3 hours, 100-150 ml. Possessing buffer properties, food in the stomach neutralizes hydrochloric acid and proteolytic enzymes, reduces hungry peristalsis of the stomach and stimulates the regeneration process. If bleeding in this group of patients has not resumed, then, if indicated, they undergo a planned operation after 10-12 days of preoperative preparation. The remaining patients are treated conservatively for peptic ulcer disease.

Operations used in the treatment of patients with bleeding in peptic ulcer, according to indications, are divided into urgent, urgent and delayed.

According to G. P. Shorokh and V. V. Klimovich (1998), urgent operations should be performed; a) with ongoing bleeding with peptic ulcer, which could not be stopped endoscopically; b) the onset of recurrent bleeding in the hospital. Operations of this group are performed: a) in the first 2 hours after the patient's admission with continued bleeding with peptic ulcer and a failed attempt at endoscopic hemostasis; b) in the first 2-5 hours after admission, when there is massive blood loss with unstable endoscopic hemostasis or massive blood loss with endoscopically achieved temporary hemostasis in arterial bleeding; c) in case of recurrence of bleeding with peptic ulcer in a hospital, regardless of the time of the previous bleeding.

Urgent operations are indicated in patients with a high risk of bleeding recurrence in peptic ulcer and are prophylactic in order to prevent a possible recurrence of bleeding. Surgical intervention in this group is performed within 6-36 hours after admission.

Delayed surgeries are performed 12-14 days after bleeding has stopped in case of peptic ulcer in patients who have undergone a complete examination and comprehensive preoperative preparation for surgical intervention (their ulcer did not heal during the treatment).

The volume of the operation performed in patients with bleeding in peptic ulcer disease depends on the timing of its implementation, localization of the ulcer and the general condition of the patients. In persons operated on for urgent and urgent indications and without severe concomitant diseases, with relatively stable hemodynamic parameters, a radical operation is performed. At the same time, in patients with unstable hemodynamics, severe comorbidities, palliative surgery is performed with the sole purpose of stopping bleeding.

During the operation after the revision of the abdominal organs, the localization of the ulcer is clarified. In difficult situations, a wide longitudinal gastrotomy or duodenotomy is performed, followed by a visual examination of the mucous membrane of the stomach and duodenum. After finding the source, they resort to a temporary stop of bleeding (suturing, ligation of the bleeding vessel) and perform the main operation. As radical operations for bleeding mediogastric ulcers (type I according to Johnson), resection of 2/3 of the stomach according to Billroth-2, Billroth-1, pylorus-preserving resections of the stomach, ladder (step) resection of the stomach are used.

In patients with type II bleeding ulcer, the operation of choice is resection of 2/3 of the stomach according to Billroth-2, Billroth-1. Less commonly, they perform pyloroantrum-preserving resection of the stomach and vagotomy.

In case of bleeding from type III ulcers, resection of the stomach is performed according to Billroth-1, Billroth-2, pylorus-preserving, antrumectomy with selective vagotomy.

As palliative operations in patients with bleeding stomach ulcers, the following are used: a) gastrotomy and suturing of the vessel in the ulcer; b) sectoral excision of the ulcer, pyloroplasty and vagotomy; c) excision of the ulcer, removal of its crater outside the stomach with ligation of the bleeding vessel and suturing of the wall defect.

In patients with bleeding ulcers of the duodenum and pyloric stomach, the following types of operations are performed:

When the ulcer is localized on the anterior wall: a) hemipyloroduodenoresection according to Bely; b) excision of the ulcer and pyloroplasty according to Judd-Horsley; c) excision of the ulcer and duodenoplasty with vagotomy (often stem vagotomy as the most quickly feasible), Duodenoplasty is performed when the upper edge of the ulcer is removed at a distance of at least 0.8 cm from the pylorus;

With ulcers of the posterior wall, having a diameter of 0.8-1 cm, it is shown: a) suturing the arrosed vessel in the bottom of the ulcer with suturing the mucosal defect above it, performing a stomach-draining operation and vagotomy; b) suturing of an arrosed vessel with tamponade of the bottom of the ulcer with the posterior lip of duodenoplasty (according to Finney), pyloroplasty according to Finney and vagotomy; c) in patients with a bleeding penetrating ulcer of the posterior wall of the duodenum, which is sutured with difficulty and often gives recurrence of bleeding, it is more expedient to remove it outside the intestine with suturing of the resulting wall defect (extraduodenization of the ulcer), to perform an operation draining the stomach and vagotomy.

In case of bleeding from large (more than 1 cm in diameter) penetrating ulcers of the pyloric stomach and duodenum, distal resection of the stomach is performed.

In patients with unremovable bleeding ulcers of the posterior wall of the duodenum (low, postbulbar), the stomach is resected for exclusion, the bleeding vessel is sutured with an operation draining the stomach and vagotomy.

Mortality after resections of the stomach, performed for bleeding ulcers, is 4-8%, and at the height of bleeding - 10-28%. After vagotomy, deaths are observed 5-10 times less frequently.

The article was prepared and edited by: surgeon

In some patients with erosive lesions of the stomach, ulcerative bleeding is possible, the severity of which depends on how large the vessel is damaged. It can open unexpectedly, regardless of the size and location of the defect.

Sometimes vessel damage is detected for the first time, and in some cases the cause is an ineffectively treated bleeding ulcer.

Hemorrhage with an ulcer is always life-threatening, so medical assistance is needed to eliminate it. Even if the bleeding spontaneously stops, after a certain period of time it can resume.

Symptoms of open bleeding

With hidden hemorrhage, signs are almost completely absent. The patient's state of health practically does not suffer, there may be a slight decrease in working capacity and weakness.

With prolonged bleeding, symptoms of oxygen starvation of tissues may occur: dizziness, pallor, headache, shortness of breath, palpitations. It is possible to lower blood pressure in a sitting and standing position.

In order for the disease to be detected in a timely manner and not to progress to a more severe stage, vomit and feces, as well as gastric juice, should be taken from time to time to carry out the Gregersen reaction, which makes it possible to detect traces of blood in the samples.

Average blood loss

With moderate blood loss (from 16 to 20%), the patient's extremities become cold, the face becomes pale, diuresis decreases, and the heart rate increases even at rest.

In addition, the following symptoms are noted:

tremor and dizziness;
blood in saliva after reflux or vomiting;
increased sweating;
hypothermia;
photophobia;
signs of dehydration.

For obvious bleeding from a stomach ulcer, pronounced signs are characteristic. Such hemorrhage can be recognized by hematomesis (vomiting blood) and melena (black feces).

massive bleeding

With a large blood loss (from 21 to 30%), the symptoms of a bleeding stomach ulcer can be identified by a strong heartbeat, shortness of breath and a sharp drop in pressure. In this case, the body is not able to replenish the blood loss on its own, but the consequences of severe hemorrhagic shock are still reversible. Patients with these signs of bleeding ulcers usually become unhealthy agitated, irritable and restless.

A bleeding ulcer has a very high mortality rate, up to half of the cases. Symptoms of massive bleeding (more than 30%) are characterized by a sharp pallor of the skin, unconsciousness, thready pulse and increased sweating. The pressure is often impossible to determine. If the patient is not provided with emergency medical care, then the patient's condition worsens and becomes irreversible.

Causes of ulcer bleeding

There are many reasons for bleeding from stomach ulcers.

The following negative factors are of greatest importance:

Associated infection.
Mechanical damage to the surface of the ulcer, for example, during FGDS.
Excessive physical activity during an acute process.
Insufficient therapeutic effect of therapy, incorrectly chosen tactics.
Taking illegal foods, alcohol, or drugs, such as NSAIDs.
Not provided first aid for exacerbation.

It is important to adhere to a properly selected diet, because due to its absence or nutritional errors, hemorrhage can also open.

Danger of ulcers with hemorrhage

Any hemorrhage, massive or light, is extremely life-threatening for the patient. Profuse bleeding can cause the death of the patient in a few hours, and an ulcer that bleeds slightly for a long time imperceptibly leads to the extinction of the patient.

Hemorrhage is a typical complication of stomach ulcers. In this case, the erased form of the disease passes into the active stage. The patient suffers severe pain after eating, so he begins to avoid eating any food, which leads to exhaustion of the body. In addition, blood loss further weakens the patient, causing weight loss, poor health and weakness.

With an ulcer with profuse bleeding, damage to large vessels occurs, so the patient can lose most of the blood in the first half hour.

This condition can cause multiple organ failure syndrome:

swelling of the meninges;
hypovolemic shock;
pressure drop;
heart and liver failure;
intoxication with decomposed blood.

A bleeding stomach ulcer can cause a condition that is practically incompatible with life. In this case, the probability of death is high, therefore, if signs of hemorrhage appear, you should immediately seek medical help.

Health food

The most important component of effective therapy is a diet for bleeding stomach ulcers. It provides for abstinence from eating and drinking for the first 2-3 days. You can periodically slightly quench your thirst with a piece of ice or a spoonful of water. After this period of time, the patient is allowed to give some food of a liquid consistency.

Nutrition for a stomach ulcer with bleeding should include:

raw and soft-boiled eggs;
milk and cream;
oatmeal or milk jelly;
not too thick jelly;
sweet diluted juices.

Proper nutrition does not welcome fasting for more than 3 days. Even if the ulcer is acute with bleeding, it is necessary to ensure that the patient receives enough calories, as well as proteins, fats, carbohydrates, minerals and vitamins. In addition, mechanical, chemical and thermal protection of the mucosa is necessary, so the consistency of the food should be semi-liquid, the taste is neutral, and the temperature is warm.

Gradually, the diet expands and includes:

mashed potatoes and carrots;
meat and curd souffles;
mucous pureed soups;
steam meat and fish meatballs;
boiled pureed porridge;
butter;
cocoa and tea with milk;
decoction of rose hips and compote.

With this form of the disease, alcohol, coffee, spicy and sour foods are categorically excluded. The dietary diet should be discussed and agreed with a specialist who is aware of all the intricacies of therapy. He will advise the optimal set of products that will contribute to effective treatment.

If medical treatment and diet do not help or are inappropriate, surgery is necessary. Resection or suturing of the stomach, which in this case is treated only under general anesthesia, is carried out using endoscopic equipment.

Sometimes there is a need for open surgery with a longitudinal incision of the abdominal wall. After surgery, the patient is shown strict bed rest, massive maintenance therapy and parenteral nutrition.

Therapy of ulcers with hemorrhage

The assumption that a patient develops a bleeding stomach ulcer excludes examination in a polyclinic, since it is a reason for urgent hospitalization in a surgical hospital. In this case, there is a huge risk of increased blood loss, so the patient should be in bed and refrain from eating in the first days (hereinafter referred to as the diet).

Compensation for blood loss and the appointment of drugs that help stop hemorrhage are shown:

blood and plasma preparations;
aminocaproic acid;
vicasola;
calcium chloride;
atropine.

Conservative treatment is indicated for older people with general diseases. It is also carried out with hemorrhages of mild and moderate severity.

There are methods of endoscopic hemorrhage arrest:

Mechanical - the imposition of a clip, alloying, as well as the use of gluing.
Injection - the introduction of sclerosants, adrenaline, novocaine, saline.
Thermal - laser coagulation, thermocoagulation, radiofrequency coagulation and thermoprobe.

An indication for surgical treatment is an open defect with massive blood loss, regardless of the type of ulcer, recurrent and incessant bleeding with conventional treatment, and the addition of other complications of the disease. The choice of operation is determined by the localization of the defect and the severity of the pathology. The doctor may recommend excision or suturing of the vessels of the bottom of the ulcer.

With hemorrhage, it consists in a careful attitude to one's health and contacting a specialist if the slightest symptoms of stomach damage occur. And also in the medical examination on the recommendation of a doctor and examination with the appointment of adequate treatment.