How to recognize internal bleeding in a child. internal bleeding

Gastrointestinal bleeding in children is quite common and may result from mechanical damage Gastrointestinal tract accidentally swallowed by sharp objects and aggressive liquids, and can be a symptom of a very serious illness. The health, and often the life of the baby, depends on how quickly the parents take action. Of course, self-medication is unacceptable here, you should immediately consult a doctor.

The causes of such bleeding may be different. In children under three years of age, the reasons may be:

1. intussusception, that's the view intestinal obstruction caused by the ingrowth of one of the sections of the intestine into another;
2. Meckel's diverticulum is a protrusion of the intestine into weak point and the formation of the so-called "abnormal bag";
3. doubling of the large intestine, which may be accompanied by a doubling of other organs;
4. hernia esophageal opening in the diaphragm.

In children under seven years of age, gastrointestinal bleeding can be caused by polyps in the intestines, usually they occur in the rectum and sigmoid colon.

In children older than seven years, the reasons may be:

1. stomach ulcer, duodenum;
2. various types of gastritis;
3. ulcerative colitis;
4. bleeding from varicose veins different departments gastrointestinal tract;
5. thermal ileitis or Crohn's disease, this is an inflammation of the ileum small intestine, accompanied by the appearance of ulcers and polyps and the destruction of the mucosa.

In addition, in children of all ages, bleeding can occur when they swallow some hard and sharp objects as well as aggressive liquids. It is also possible to get dysentery or typhoid fever. Babies may have blood in the stool if the mother has cracked nipples and through them her blood enters the baby's intestines.

There are several blood diseases that are also characterized by bleeding in the gastrointestinal tract. There can be many causes of bleeding and parents themselves should not make a diagnosis. Their task is to notice the bleeding that has begun in time.

Symptoms of stomach bleeding in children

Sometimes harbingers of bleeding are sharp deterioration child's condition. There are all signs of blood loss: lethargy and weakness, the child feels dry mouth and intense thirst, skin and mucous membranes become pale, heart palpitations appear, may decrease arterial pressure.

And if bloody vomiting appears, as well as a stool with blood, or all together, then this is already acute stage illness. Moreover, by the color of the blood, you can understand in which department the bleeding occurred. If hematemesis occurs, the bleeding cannot be below the duodenum. Red blood in the vomit, if the bleeding is in the esophagus or stomach, if it is dark, then the focus of bleeding is further.

If there is blood in the stool, then bleeding has occurred in the lower gastrointestinal tract. Dark blood in feces or even black stools indicate bleeding in the ileum or colon. If the blood in the stool is bright, then this indicates that it has entered the stool from the rectum or from the cracks in the anus.

Emergency care for gastric bleeding in children

When these signs appear, you need to call " ambulance". Before her arrival, it is necessary to put the child to bed, apply ice to the site of the alleged bleeding, you can even let the child swallow pieces of ice. When vomiting, lay the head on one side so that the child does not choke. It is not necessary to water and feed the child, it is also impossible to wash the stomach and put an enema.

Treatment

Treatment of the child is determined by the doctor after complete examination patient, usually it is carried out permanently. Depending on the intensity of bleeding, there may be a therapeutic treatment for mild or surgical for intensive. The operation reveals the focus heavy bleeding and take steps to eliminate it. This can be ligation of veins, and the imposition of a sigmostoma (this is the removal of a segment of the intestine to the outside), and resection of a part of the stomach or intestines. In any case, the treatment is long and serious, restoring the child's health after surgery requires great dedication from the parents.

Conservative treatment is more gentle and consists of a number of therapeutic measures:

1. bleeding from burns chemicals, carry out gastric lavage with neutralizing substances;
2. the introduction of medications that help stop bleeding;
3. removal of blood from the gastrointestinal tract using a probe or, if there is no danger, using enemas;
4. restoration of blood loss, usually performed by transfusion of donor blood;
5. general body support. Since feeding the child on the first day is not recommended, therefore, a mixture of glucose and saline is administered intravenously, starting from the second day, they begin to carefully feed diet food recommended by a doctor;

diagnosis and treatment of the disease. Usually this stage is long in time, treatment continues after the child has been discharged from the hospital. Here, parents are required to strictly adhere to the recommended treatment.

is a condition in which blood is poured either into the body's natural cavity (stomach, bladder, uterus, lungs, joint cavity, etc.), or into the space artificially formed by the outflow of blood (retroperitoneal, intermuscular). Symptoms of internal bleeding depend on its location and the degree of blood loss, usually include dizziness, weakness, drowsiness, loss of consciousness. Pathology is diagnosed on the basis of external examination data, the results of radiography, CT, MRI and endoscopic studies. Treatment - infusion therapy, prompt elimination source of bleeding.

ICD-10

K92.2 S27.1 S06.4 O08.1

General information

internal bleeding- loss of blood, in which blood does not flow out, but into one of the cavities human body. The cause may be an injury or a chronic disease. The massive nature of blood loss, late treatment of patients for help and diagnostic difficulties in identifying this pathology increase the severity of the problem and turn internal bleeding into serious threat for the lives of patients. Treatment is carried out by specialists in the field of clinical traumatology, abdominal and thoracic surgery, neurosurgery, vascular surgery.

The reasons

The cause of internal bleeding can be both trauma and some chronic diseases. Massive, life-threatening post-traumatic bleeding into the abdominal cavity can develop as a result of blunt trauma to the abdomen with damage to the spleen and liver, less often - the pancreas, intestines or mesentery (when struck, falling from a height, car accident, etc.). Bleeding in pleural cavity usually occurs with multiple fractures of the ribs with damage to the intercostal vessels and pleura. AT isolated cases it is caused by fractures of 1-2 ribs.

Bleeding into the cranial cavity is one of the dangerous complications traumatic brain injury. Since the skull, unlike other natural cavities, has a rigidly fixed volume, even a small amount of outflowing blood causes compression of the brain structures and poses a threat to the life of the patient. It should be borne in mind that intracranial bleeding can develop not only immediately after the injury, but also after several hours or even days, sometimes against the background of complete well-being.

Bleeding into the joint cavity can be caused by both intra-articular fracture and contusion. It does not represent an immediate danger to life, but if left untreated, it can lead to serious complications.

A significant proportion of the total number of internal bleeding is bleeding into the cavity of any organ, which develops as a result of chronic diseases. gastrointestinal tract: malignant tumors, peptic ulcer of the stomach and intestines, erosive gastritis, varicose veins of the esophagus with cirrhosis of the liver, etc. In surgical practice, Mallory-Weiss syndrome is also often found - cracks in the esophagus due to alcohol abuse or a single abundant intake food.

Another fairly common cause of internal bleeding is gynecological diseases: ovarian ruptures, ectopic pregnancy, etc. B gynecological practice there are internal bleeding after abortions. There may also be internal bleeding with placenta previa or premature abruption, postpartum bleeding with retained placenta, uterine ruptures and birth canal.

Classification

There are several classifications of internal bleeding:

• Based on the cause: mechanical (due to damage to blood vessels in trauma) and arrosive (due to damage to vascular wall with necrosis, germination and decay of the tumor or destructive process). In addition, diapedetic bleeding is distinguished, which occurs due to an increase in the permeability of the wall. small vessels(for example, with scurvy or sepsis).
• Based on the volume of blood loss: mild (up to 500 ml or 10-15% of the circulating blood volume), moderate (500-1000 ml or 16-20% BCC), severe (1000-1500 ml or 21-30% BCC), massive (more than 1500 ml or more than 30% BCC), fatal (more than 2500-3000 ml or more than 50-60% BCC), absolutely fatal (more than 3000-3500 ml or more than 60% BCC).
• Given the nature of the damaged vessel: arterial, venous, capillary and mixed (for example, from an artery and a vein or from a vein and capillaries). If blood leaks from the capillaries of any parenchymal organ(liver, spleen, etc.), such bleeding is called parenchymal.
• Based on localization: gastrointestinal (into the cavity of the esophagus, stomach or intestines), into the pleural cavity (hemothorax), into the pericardial sac (hemopericardium), into the joint cavity, etc.
• Taking into account the place of accumulation of the spilled blood: abdominal (into the pleural, abdominal, and other cavities) and interstitial (into the thickness of tissues with their impregnation).
• Depending on the presence or absence obvious signs bleeding: explicit, in which the blood, even after some time and in an altered form, “comes out” through natural openings (for example, staining the stool black), and hidden, in which it remains in the body cavity.
• Taking into account the time of occurrence: primary, occurring immediately after traumatic injury vascular wall, and secondary, developing some time after the injury. In turn, secondary bleeding is divided into early (develops on days 1-5 due to slipping of the ligature or expulsion of a blood clot) and late (usually occurs on days 10-15 due to purulent fusion of a thrombus, necrosis of the vessel wall, etc.) .

Symptoms of internal bleeding

General early signs of this pathology are general weakness, drowsiness, pallor of the skin and mucous membranes, dizziness, cold sweat, thirst, darkening in the eyes. Possible fainting. The intensity of blood loss can be judged both by changes in pulse and blood pressure, and by other factors. clinical signs. With a small blood loss, there is a slight increase in heart rate (up to 80 beats / min) and a slight decrease in blood pressure, in some cases there may be no clinical symptoms.

A fall indicates moderate internal bleeding. systolic pressure up to 90-80 mm. rt. Art. and increased heart rate (tachycardia) up to 90-100 beats / min. The skin is pale, there is a coldness of the extremities and a slight increase in breathing. Possible dry mouth, fainting, dizziness, nausea, weakness, severe weakness, slow reaction.

In severe cases, there is a decrease in systolic pressure up to 80 mm. rt. Art. and below, increased heart rate up to 110 and above beats / min. There is a strong acceleration and disturbance of the rhythm of breathing, sticky cold sweat, yawning, pathological drowsiness, tremor of the hands, darkening of the eyes, indifference, apathy, nausea and vomiting, a decrease in the amount of urine excreted, excruciating thirst, darkening of consciousness, a sharp pallor of the skin and mucous membranes, cyanosis limbs, lips and nasolabial triangle.

With massive internal bleeding, the pressure drops to 60 mm Hg. Art., there is an increase in heart rate up to 140-160 beats / min. Characteristically periodic breathing(Cheyne-Stokes), absence or confusion of consciousness, delirium, severe pallor, sometimes with a bluish-gray tint, cold sweat. The look is indifferent, the eyes are sunken, the facial features are pointed.

With fatal blood loss, coma develops. Systolic pressure drops to 60 mm Hg. Art. or not defined. An agonal breathing, sharp bradycardia with a heart rate of 2-10 beats/min., convulsions, dilated pupils, involuntary excretion of feces and urine. The skin is cold, dry, "marbled". Agony and death follow.

Treatment of internal bleeding

It is necessary to ensure the delivery of the patient to the department as soon as possible specialized care. The patient needs to be kept calm. If a hemothorax or pulmonary bleeding is suspected, the patient is given a semi-sitting position, with blood loss in other areas, they are laid on a flat surface. Cold (eg, ice pack) should be applied to the area of ​​the suspected source of bleeding. It is strictly forbidden to heat the affected area, give enemas, give laxatives, or inject drugs into the body that stimulate cardiac activity.

Patients are admitted to the hospital. The choice of department is carried out taking into account the source of internal bleeding. Treatment of traumatic hemothorax is carried out by traumatologists, non-traumatic hemothorax and pulmonary bleeding– thoracic surgeons, intracranial hematomas- neurosurgeons, uterine bleeding - gynecologists. In case of blunt trauma of the abdomen and gastrointestinal bleeding, hospitalization is carried out in the department of general surgery.

The main tasks in this case are an urgent stop of internal bleeding, compensation for blood loss and improvement of microcirculation. From the very beginning of treatment, for the prevention of empty heart syndrome (reflex cardiac arrest due to a decrease in the volume of BCC), the restoration of the volume of circulating fluid and the prevention of hypovolemic shock, a jet transfusion of 5% glucose solution is performed, physiological saline, blood, plasma and blood substitutes.

Sometimes internal bleeding is stopped by tamponade or cauterization of the bleeding area. However, in most cases, urgent surgical intervention under anesthesia is required. With signs hemorrhagic shock or the threat of its occurrence at all stages (preparation for surgery, surgical intervention, period after surgery) transfusion measures are performed.

Internal bleeding due to ectopic pregnancy is an indication for emergency surgical intervention. With dysfunctional uterine bleeding, tamponade of the uterine cavity is performed, with massive bleeding due to abortion, birth trauma, and after childbirth, surgery is performed.

Infusion therapy is carried out under the control of blood pressure, cardiac output, central venous pressure and hourly diuresis. The volume of infusion is determined taking into account the severity of blood loss. Blood substitutes of hemodynamic action are used: dextran, rheopolyglucin, solutions of salts and sugars, as well as blood products (albumin, fresh frozen plasma, erythrocyte mass).

Bleeding in a child occurs due to dysfunction of blood clotting processes. There are whole groups and subgroups given state. Have bleeding that comes on instantly or lasts for a long time without visible signs. There are also bleeding that arose as a result of various diseases. internal organs, internal hemorrhage occurs.

With blood diseases, some children have impaired clotting function. Spontaneous hemorrhages are observed, as well as with ordinary injuries, the blood does not stop for a long time. It is necessary to quickly stop the blood and find out the cause of the appearance, otherwise there may be irreversible consequences, leading to an unfavorable outcome.

In children, gastric or is least often observed, but the most common is discharge. There are several factors that cause nosebleeds:

• Elevated temperature of inhaled air;
• The specific location of the child's head;
• Minor nose injuries during games;
• The presence of infectious agents.
• Body of foreign origin;
• Violation of the mucous membrane of the nasal septum (telangiectasia);

AT recent times cases in children have become more frequent, as a result of which hemorrhages from the nose also occur. The child must be examined by a pediatrician to exclude such a pathology.

internal

Most the most important reasons occurrence of internal bleeding in children:

• Various injuries;
• Infectious diseases;
• Diathesis of hemorrhagic genesis;
• Pathologies from the heart;
• Respiratory failure and other illnesses lung tissue.

The most common cases of internal bleeding in children involve the respiratory and digestive systems.

Hemophilia

Often bleeding is inherited. Such a disease is hemophilia. But it should be noted that such a pathology occurs exclusively in males, in boys. The female sex is a carrier, so girls do not suffer from such a pathology.

There are many factors that can cause bleeding in hemophilia. These factors include:

• Small cuts or abrasions of the skin;
• Injury to the mucous membrane of the nasal and oral cavity;
• Idiopathic blood from other parts of the body.

It should also be noted that there is another disease in which there is high risk bleeding - thrombopenic purpura. Blood can be released from the lungs with the lung tissue of a child.

Symptoms

Clinical manifestations of hemorrhage in children depend on the nature of blood loss, the cause of the disease, and the variety. If this is a factor in injury, then the bleeding is temporary. In this case, it is enough to stop the blood (hemostasis).

Depending on the severity of the injury, bleeding may be arterial, venous or capillary in nature.

If there is blood loss in a child long time, you may experience the following symptoms:

• Apathy;
• Weakness;
• Loss of consciousness;
• Hemorrhagic shock.

Of all blood loss, the most dangerous is recurrent bleeding. In this condition, the child has anemia, with further development. With frequent blood loss observed:

• Deterioration general condition child;
• anemic state of the body;
• Rapid fatigue, weakness.

So, based on this, the most dangerous bleeding is that which is repeated again and again. In this case, you need to urgently apply for medical care, to identify the etiology of the pathological process.

Diagnostics

In order to make a diagnosis, it is necessary to examine the child completely. When the doctor examines the baby, he turns his attention to certain signs of a clinical nature. If there is an injury, then there is bleeding.

If the cause of bleeding was the penetration of infection into the body of the child, then this process should be stopped. In order to identify infections in a child, it is enough to conduct some diagnostic tests:

• General blood analysis;
• Analysis of feces;
• General urine analysis.

If you need to check hereditary predisposition, then you need to carefully study the anamnesis of the child and parents. Indeed, in this way it is possible to clearly determine the history of the pathology that is observed in the baby.

At various diseases hearts need to do a cardiogram. This method will make it possible to determine what is bothering the patient, what is the cause of the symptoms. An echogram is also needed for heart disease. In order to study the pressure in a child, it is necessary to use a tonometer, a simple and painless diagnostic method.

If a child is suspected of thrombopenic purpura, then a clinical study should be carried out. As a result of the disease, you can observe:

• A sharp decrease in platelets in the blood;
• Enlargement of the spleen (splenomegaly).

There is a duration of bleeding according to Duka. If there is a violation in time, that is, more than 4 minutes, then this is already a violation in clotting.

If a child has a huge suspicion that the blood in the cavity is due to tuberculosis, then sputum should be examined. This is a 100% method that gives a positive or negative answer. If the doctor is not clear enough with the lungs of a child, then it is necessary to conduct an x-ray examination of the lung tissue. This is necessary if pulmonary tuberculosis is suspected.

Treatment and first aid

How to stop bleeding? If your child is bleeding, the following should be done. It is necessary to calm the baby and create optimal condition for his general condition. At the same time, it is necessary to accelerate the search for the origin of this bleeding. It is also necessary to quickly stop bleeding in children.

If a child is diagnosed with bleeding from the nose, then you need to take Urgent measures. These actions include:

• Put the baby in a state of elation;
• Throw your head back;
• Do not let the child blow his nose;
• Avoid picking in the nasal cavity.

It is urgently necessary to plug the nasal passage with cotton wool. But in no case should cotton wool be dry. You need to wet the swab with such liquids as: table vinegar, hydrogen peroxide, as well as meat of raw origin. If the child has a small injury, then normally the blood will stop quickly.

If observed strong highlight from the nose, you need to carefully press the nose towards the septum (press on the nasal wings).

• Ingestion;
• Cacl 10% administered orally;
• Give the baby a liquid to drink, the composition of which is salt and water.

If you give a solution table salt must adhere to a certain proportion. For one cup of water, there is about one teaspoon of ordinary tea salt. You need to drink in doses, drink one tablespoon of this liquid every hour. As for such a solution as calcium gluconate, you need to drink 2 dessert spoons per day.

1. Questions to test the initial level of knowledge.

1. List of diseases that can cause bleeding from the gastrointestinal tract (GIT).

2. List general symptoms bleeding regardless of the site of bleeding.

3. List the changes that occur in the body during bleeding.

4. Methods of examination of children with gastrointestinal tract.

5. Additional Methods examinations of children with gastrointestinal tract.

2. Determining the objectives of the lesson

The student should know: 1. Classification of bleeding depending on the level of bleeding. 2. List of diseases causing bleeding from all three levels of the gastrointestinal tract. 3. Diseases that can cause bleeding from any part of the gastrointestinal tract. 4. ZhKK clinic. 5. Diagnosis and differential diagnosis of gastrointestinal tract. 6. Additional examination methods for gastrointestinal tract. 7. First aid for gastrointestinal bleeding. 8. Methods of treatment of gastrointestinal tract: conservative and surgical. The student should be able to: 1. Determine the severity of blood loss. 2. Conduct a differential diagnosis of the level of bleeding. 3. Taking into account the anamnesis and clinical data, identify the disease that caused the gastrointestinal tract. 4. Make a delivery plan emergency care and carry out treatment. 5. Draw up a program for examining a child with gastrointestinal tract. 6. Estimate the volume and diagnostic value laboratory and instrumental methods studies (blood tests, ultrasound, endoscopic, x-ray). 7. Formulate a clinical diagnosis. 8. Substantiate indications for surgical treatment.

Literature: 1. Yu.F. Isakov, E.A. Stepanov, L.K. Krasovskaya. Abdominal surgery in children. M.1998 2. Surgical diseases ed. M.I. Kuzina Medicine M. 2006. 3. A.I. Zaprudnov, K.N. Grigoriev, N.F. Dronov. Gastrointestinal bleeding in children Medicine M. 1998. 4. Surgical diseases childhood. v.t.1,2 ed. Yu.F. Isakova Moscow ed. house "GOETAR-Med" 2004. 5. I. Andreev, I. Voptarov, H. Mikhov, A. Angelov. Differential Diagnosis major symptoms childhood illnesses. Med and Fizk Sofia 1981.

3. Tasks for independent work

1. Specify the main symptoms of gastrointestinal bleeding.

general weakness, dizziness, noise and ringing in the ears, darkening in the eyes, shortness of breath, pain in the heart, tachycardia, pallor, excessive sweating, cold extremities, drowsiness, confusion, pulse of weak filling and tension, low blood pressure, pallor skin and mucous membranes
fatigue, dizziness, glossitis, stomatitis, anemia, melena is possible, the absence of vomiting with blood or "coffee grounds" is characteristic.

2. What are the main symptoms of bleeding from upper divisions GIT?

vomiting blood (hematemesis) and black, tarry stools (melena)

3. What are the main symptoms of bleeding from the small intestine?

The secreted blood is dark red in color, but in some cases it may appear as melena. Intussusception usually develops in infants but occasionally occurs at any age. The child has cramping pains in the abdomen, accompanied by stretching of the legs, a high-pitched cry, and the release of stools consisting of blood and mucus ("redcurrant jelly").

4. Symptoms of bleeding from the colon?

Diverticular disease is complicated by bleeding, causing massive colonic. Cause 70-90% of bleeding from right half colon diverticula are, in 70% these bleedings stop spontaneously. It is believed that diverticular bleeding is the result of rupture of vessels located near the diverticulum. In most patients, bleeding caused by diverticular disease is minor and stops on its own. A third of patients have massive bleeding due to colonic diverticulosis and develop posthemorrhagic anemia. Diverticular bleeding is not characterized by abdominal pain. Massive bleeding in diverticulosis of the colon in 10-20% of cases ends in death.

5. Depending on the level of bleeding, what are the main research methods to be carried out?

Bleeding from the upper GI tract

well-recorded anamnesis. Has the patient had previous episodes of GI bleeding? Did he have a previously diagnosed stomach or duodenal ulcer? Whether he makes complaints, specific to a peptic ulcer? Has he had previous surgery for peptic ulcer or portal hypertension? Does he have other medical conditions that could lead to bleeding, such as cirrhosis of the liver or coagulopathy? Does the patient abuse alcohol, regularly take aspirin or NSAIDs? Does he have nosebleeds? It is desirable to get an answer to these questions if the patient is conscious and contact enough, for example, is not in a state of alcohol intoxication. Examination of the skin and visible mucous membranes reveals stigmata of liver cirrhosis, hereditary vascular anomalies, signs of capillary toxicosis, and paraneoplastic manifestations. Palpation of the abdomen may reveal tenderness ( peptic ulcer), splenomegaly (cirrhosis of the liver or thrombosis of the splenic vein), tumor of the stomach. Intraperitoneal bleeding (for example, with a disturbed ectopic pregnancy) is sometimes manifested by signs of acute anemia similar to GCC. The presence of symptoms of peritoneal irritation, characteristic of bleeding into the abdominal cavity, may help in differential diagnosis these states. If auscultation of the abdomen reveals increased peristalsis there is reason to believe that it is caused by blood that has entered the intestine from the upper gastrointestinal tract. Most important information gives esophagogastroduodenoscopy (EGDS); it allows not only to establish with a high degree of accuracy the localization of the source of bleeding and its nature, but also to carry out hemostatic measures, which in a significant number of cases make it possible to stop the bleeding. radioisotope scanning(99TC labeled colloidal sulfur or albumin) and angiography are very important in some situations, but practical value do not have, since they can rarely be performed for emergency reasons.

Bleeding from lower divisions gastrointestinal tract

If there is blood in the stool, it is important to find out if the blood is mixed with stool(the source is located high) or is excreted in a relatively unchanged form at the end of defecation, which is more typical for low-lying bleeding tumors and hemorrhoids. Palpation of the abdomen and digital examination anus required for all patients. Finger rectal examination, according to statistics, allows you to identify up to 30% of all tumors of the colon, including those complicated by bleeding. The next stage of diagnosis is anoscopy and rectosigmoscopy, the effectiveness of which in oncological diseases the colon is 60%. In the presence of tarry stools, which may be the result of both gastroduodenal bleeding and bleeding from ileum and right colon, nasogastric aspiration through a tube and endoscopy are recommended to rule out pathology of the stomach and duodenum. Colonoscopy is the most informative method diagnosis of colonic pathology, however, with heavy bleeding it is quite difficult to perform. If the bleeding stops at least for a while, then with the help of this procedure a wide variety of pathologies, including vascular ones, can be diagnosed. Mesenteric arteriography for intestinal bleeding allows you to identify extravasation of the contrast and determine the side and approximate localization of the source of bleeding. Angiography is the only way to diagnose bleeding in small intestine, it makes it possible to inject vasopressin directly into the bleeding artery. Extravasation is determined only with sufficiently massive bleeding, but even in the absence of its signs, arteriography can detect vascular pathology, which is the cause of bleeding. Scintigraphy with erythrocytes labeled with 99 Tc, or with platelets labeled with radioactive In, - more than sensitive method; the source of bleeding is detected even at its relatively low intensity, but scintigraphy takes a long time and therefore it can hardly be considered an emergency diagnostic method. contrast methods x-ray examination(irrigoscopy and irrigography) are not able to identify the source of bleeding, but can help in the diagnosis of a tumor, diverticulosis, intussusception and other diseases complicated by bleeding.

6. Make a plan for treatment and examination for bleeding from the upper gastrointestinal tract.

1. Blood test (hemoglobin, reticulocytes, hematocrit, platelets, etc.).

2. Study of the coagulation properties of blood (prothrombin time, etc.).

3. Electrolytes, urea and blood creatinine.

4. Blood type and Rh factor.

5. Blood gases.

6. ECG.

7. X-ray chest(x-ray of the abdomen) special indications

Medications are not alternative treatments acute bleeding if surgery is indicated, but they can help stop bleeding and prevent its recurrence. Efficiency drug treatment It is determined by many circumstances, but regardless of them, the appointment of ranitidine (Zantac), omeprazole (Losek) or famotidine (Kvamatel) is justified. One of them is administered intravenously (Zantac 50 mg, Kvamatel 20 mg, Losek 40 mg) for 2-5 minutes 3 times a day at intervals of 8 hours to 3 days. This reduces the risk of stress ulcers and rebleeding, but does not stop ongoing bleeding. After stopping the intravenous administration of an antisecretory drug for erosive and ulcerative bleeding, it is justified to prescribe it orally (ranitidine 150 mg, or famotidine 20 mg 3 times a day, or omeprazole 20 mg 2 times a day).

Endoscopic Therapycarried out depending on the source of bleeding:

1. Sclerotherapy of the veins of the esophagus with their varicose expansion.

2. Injection of liquid fibrinogen or instillation of liquid thrombin in the ulcer area.

3. Laser photocoagulation.

4. Diathermocoagulation.

Due to insufficient effectiveness, gastric lavage is not recommended. ice water, the use of vasoconstrictors (adrenaline, etc.) and antacids. The hemostatic effect of somatostatin in ulcerative bleeding, omeprazole and sucralfate in hemorrhagic gastritis, and sinestrol in hereditary telangiectasias have been confirmed. Somatostatin (Sandostin) inhibits the secretion of gastric and pancreatic juice, reduces blood flow in the organs - abdominal cavity, which helps to stop ulcer bleeding and bleeding from the dilated veins of the esophagus. It is administered intravenously at a dose of 250 mcg / hour until the onset of affect. In hemorrhagic gastritis, omeprazole is prescribed twice a day, 20 mg at intervals of 12 hours, in combination with sucralfate (12-16 g per day) for several days, followed by a decrease daily dose omeprazole up to 20 mg, and sucralfate up to 4 g. Sinestrol is injected intramuscularly daily at 1 ml of a 2% oil solution in order to prevent repeated episodes of bleeding from hereditary telangiectasias.

7. Solve test tasks:

A) A 13-year-old child has vomiting with blood, tarry stools. History of hunger and night pain in the epigastric region. The abdomen is soft and painless. Most likely diagnosis:

a) gastroduodenitis

b) bleeding from dilated veins of the esophagus

in) peptic ulcer stomach or duodenum

d) Meckel's diverticulitis

e) nonspecific ulcerative colitis

B) A 12-year-old child has a clinic of gastrointestinal bleeding, melena. It is advisable to start the survey:

a) from a contrast study of the stomach and duodenum 12

b) gastroduodenoscopy

c) laparoscopy

d) laparotomy and revision of the abdominal wall

e) colonoscopy.

8. Compose test according to the above example.

Chronic bleeding from the digestive tract in children occurs when:

Non-Spice ulcerative colitis , Meckel's diverticulum, intestinal angimatosis, rectal polyp, intestinal polyposis

9. Compose questions for the clinical problem and give the correct answer:

A 13-year-old boy was taken to the emergency department. Yesterday the child had a single vomiting, resembling coffee grounds. Today was tarry stool.

From the anamnesis: during the last 1.5 years the child had pains in the epigastric region, belching, sometimes vomiting food, after which relief came. On examination, the abdomen is not swollen, soft on palpation, moderately painful in upper half. At the control x-ray examination persistent deformation of a duodenum comes to light.

preliminary diagnosis. Treatment tactics.

Ulcer of the duodenal bulb 12. For treatment use the following medications: Omez, De Nol, third generation antibiotics

10. Make a clinical task: the child has scarlet blood in the stool.

A district pediatrician examines a 6-year-old child with complaints of a tendency to constipation during last year and the allocation of scarlet blood at the end of the act of defecation in the last 2 days.

preliminary diagnosis. Tactics of examination and treatment.

The question of what may cause bleeding in a child is not easy to answer. There can be many reasons for bleeding. In other words, bleeding is a symptom a large number diseases. In order to understand what the matter is, it is necessary to understand the nature of the outpouring. It can be:

• traumatic, that is, one that arose due to traumatic injury blood vessels(strike, injection, laceration);
• non-traumatic, that is, one that arose due to the erosion of the vascular wall by the focus of the disease.

Symptoms

The first signs of bleeding are the appearance of blood where it should not be. However, it must be understood that the outpouring does not always occur outside. Hemorrhage may also occur internally child's body. In order to understand in time what is happening, it is necessary to pay attention to the discharge of the child. A simple example is gastrointestinal bleeding, which can be diagnosed by bloody vomit or stools containing blood. But do not forget: blood can penetrate into digestive tract not only because of the disease of the organs of this system. The effusion may occur elsewhere, such as in the lungs. And then it goes into the stomach.

Parents should know that in case of any alarming symptom, it is necessary to call a doctor or go to an appointment on their own to find out the causal circumstances of the unhealthy condition of the child.

To understand the symptoms of hemorrhage, you also need to know that this phenomenon is divided into several types in accordance with clinical manifestations:

• external bleeding - when blood flows out of the body, that is, into the external environment;
• cavitary or internal bleeding - a latent effusion, during which blood penetrates into one or more internal organs or cavitary parts of the body (most common cause such bleeding in children - diseases of the gastrointestinal tract, especially an ulcer).

Diagnosis of bleeding in a child

It is not difficult to identify external hemorrhage. It is impossible not to notice the red liquid that is released from the body of the child. But how to diagnose internal bleeding? By what signs can it be recognized?

The first signs of internal bleeding in a child are as follows:

• weakness,
• drowsiness,
• pallor of the skin,
• cold sweat,
• constant thirst
• possible fainting.

You can find out that the baby has internal bleeding by measuring the pulse. If the blood loss is insignificant, then the pulse will increase to eighty beats per minute. If the outpouring is characterized by moderate severity, then the pulse per minute will be from ninety to one hundred beats. If the case is severe, the pulse may rise to one hundred and ten beats within sixty seconds.

Bleeding that threatens the life of a child is characterized by the following features:

• decrease in systolic pressure to sixty millimeters of mercury,
• convulsions,
• severe bradycardia,
• coma,
• dryness and coldness of the skin,
• pupil dilation.

Complications

The following may occur due to bleeding:

• the tissues of the child's body will no longer be supplied with blood in the required amount;
• the little patient will lose too much blood;
• the organs will no longer be supplied with oxygen to the required extent, because of which their functions will be seriously impaired.

Treatment

What can you do

If parents suspect internal bleeding in a child, they should immediately consult a doctor. In this situation, they, not having the proper experience and medical education, can help their child only in this way.

If the bleeding is external, mom and dad, as well as others who notice the outpouring, can easily provide first aid to the baby. In the vast majority of cases, a bandage helps to stop blood loss. It is noteworthy that the body of children is able to stop the outpouring on its own. If the child is less three years, with bleeding, a pressure bandage is relevant for him. If a small patient is more than three years old, it is important to use a tourniquet. It is worth knowing that such a tourniquet differs from the “adult” tourniquet by increased elasticity.

The most common mistakes when applying a tourniquet:

• the use of this method of stopping bleeding is unreasonable (a tourniquet is relevant for arterial outflow),
• applying a tourniquet too far from the injured area,
• overlay on the naked body,
• too tight or too loose.

What can a doctor do

Bleeding is not a disease. It's a symptom disease state. That is why the treatment of bleeding involves the fight against the disease, which provoked a violation of the integrity of the blood vessels.

The main goals of first aid for bleeding are:

• stop bleeding in a child,
• replenishment of lost blood,
• coagulopathy treatment,
• prevention of rebleeding
• prevention of deterioration of liver function.

If a small patient with internal bleeding gets to the doctor, the doctor examines him, talks with relatives and the child himself, and then prescribes a number laboratory research and analyses. The main task is to determine what exactly provoked a violation of the integrity of blood vessels.

If a child with an external arterial bleeding, the doctor, with the help of nurses or orderlies, will do what the parents did not have time to do - he will apply a special bandage. For this purpose, the doctor will apply sterile gauze to the area of ​​​​the body that is bleeding. After that, a bandage is applied on top, folded several times. Once pressure bandage will be pressed, the outpouring of blood will stop.

If for age little patient more relevant is the application of a tourniquet instead of a bandage, the doctor will do just that. By applying the tourniquet correctly, the hemorrhage will immediately be stopped. Further, the doctor will decide on other issues. Namely, to treat what provoked a violation of the integrity of blood vessels.

Prevention

Preventive actions, designed to prevent the development of bleeding in children, directly depend on what is the cause of the outpouring of blood. Main preventive measure, aimed at reducing the risk of external bleeding, - keeping cutting and stabbing objects away from children.