Blood in the abdomen. Abdominal bleeding symptoms Abdominal bleeding

Internal latent bleeding, i.e., bleeding into closed body cavities, occurs mainly as a result of damage to internal organs (liver, lung, etc.), and blood is not released to the outside.

There are specific symptoms of internal bleeding, the knowledge of which can help in the timely diagnosis of this complex problem.

Such bleeding can be suspected only by changes in the general condition of the victim and by the symptoms of fluid accumulation in a particular cavity.

Bleeding into the abdominal cavity is manifested by pallor, weak frequent pulse, thirst, drowsiness, darkening of the eyes, fainting. With bleeding into the chest cavity, these symptoms are combined with shortness of breath.

When bleeding into the cranial cavity, signs of brain compression come to the fore - headache, impaired consciousness, respiratory disorders, paralysis, etc.

In modern surgery, special attention is paid to internal bleeding. This is due to the fact that internal bleeding compared to open bleeding is much harder to diagnose. This means that the medical assistance provided may be belated. Internal bleeding is called bleeding, characterized by an outpouring of blood into the natural cavities of the body or artificially created spaces.

Depending on the amount of blood shed, three degrees of bleeding are distinguished: moderate, moderate and severe.

The main reasons include: rib fractures with rupture of intercostal vessels and damage to lung tissue, malignant neoplasms of internal organs, closed injuries of the liver, spleen, intestines, complications of diseases of such organs as the esophagus (with varicose veins), stomach and duodenum, liver, female genital.

The main signs of internal bleeding:

sticky cold sweat
Pallor
shallow breathing
Pulse is frequent and weak

Signs and symptoms that are not so pronounced and may be revealed only after some time:

Blue skin (hematoma formation in the area of injury)
Soft tissues are painful, swollen, or hard to the touch
Feelings of agitation or anxiety in the victim
Fast, weak pulse, rapid breathing, nausea or vomiting, decreased level of consciousness
Pale skin that is cool or damp to the touch
Feeling of unquenchable thirst
Bleeding from natural body openings (nose, mouth, etc.)

First aid for internal bleeding:

Provide complete peace
Place the victim in a semi-sitting position
Apply ice or cold water to the suspected bleeding site
Urgently deliver the victim to the surgical hospital

Frequency of internal bleeding

Most often, bleeding occurs with damage to the organs of the gastrointestinal tract. Therefore, it is worth getting acquainted with the methods of emergency treatment of gastrointestinal bleeding. In total, about 20 diseases are distinguished, the most significant and common among which are: acute erosive gastritis and stomach cancer, esophageal varicose veins, cirrhotic liver damage. In the case of stomach cancer, the danger is a decaying tumor. The only sign that allows the patient to suspect something is wrong is the darkening of the feces, which occurs due to the coagulated blood contained in it. If vomiting occurs, then the vomited masses, again due to clotted blood, have the color of coffee grounds.

Symptoms of internal bleeding depend on its location and the degree of blood loss. In some cases, it is necessary to distinguish bleeding from the esophagus, stomach from bleeding with a damaged lung. In the case of lung pathology, foamy, unaltered scarlet blood is released.

Diseases of the female reproductive system can also cause internal bleeding. The most common cause is a tubal abortion. When the fallopian tube ruptures, blood accumulates in the abdominal cavity, creating a feeling of tension and some pressure in the pelvis, especially on the rectum. By the way, bleeding from the anus is also quite common. In the future, irritation of the peritoneum with blood occurs, which leads to the development of a state of shock, loss of consciousness, and fainting. The pulse in this case becomes frequent and thready. On examination, abdominal distention, stool and gas retention are detected. The patient becomes pale, covered with a cold sweat.

Symptoms of a hemothorax (blood in the chest)

How to identify and recognize internal bleeding in the chest? In the case of accumulation of blood in the pleural cavity, the so-called hemothorax develops. The pleural cavity is a small space that separates the lungs from the chest. The reasons leading to the development of hemothorax include the following: falls from a height, injuries with damage to the ribs and intercostal vessels, stab wounds, lung cancer, lung abscesses (that is, the formation of abscesses in the lung tissue).

With the accumulation of blood in the pleural cavity, there is difficulty breathing when inhaling and coughing, sharp pains in the chest, a violation of the general condition - dizziness, weakness, fainting, pallor of the skin, increased heart rate and respiration, sweating. Percussion of the patient's chest reveals a shortening of the percussion sound above the affected half, weakening or complete absence of breathing. On the radiograph, it is possible to determine signs of mediastinal displacement towards a healthy lung.

Hemarthrosis (blood in the joint cavity)

Frequent damage to the joints is the development of hemarthrosis, which means the accumulation of blood in the joint cavity. There is a similar condition as a result of trauma, less often with hemophilia, scurvy. The anemic symptom is expressed slightly in contrast to the local symptoms. The clinic distinguishes three degrees. With hemarthrosis of the 1st degree, mild pain is noted, the contours of the joint are slightly smoothed, the range of motion is not changed. In general, the volume of blood in the joint is up to 15 ml. Grade 2 is characterized by a pronounced pain syndrome, which increases with stress, smoothness of the joint is noted. There is an increase in the circumference of the affected joint by 1.5 - 3 cm compared to the healthy one. In the case of hemarthrosis of the knee joint, balloting of the patella is observed. The blood content in the cavity is up to 100 ml. At grade 3, the pain syndrome is acute, the outlines of the joint are completely changed. In circumference, the joint increases to 5 cm, mobility is sharply limited. Blood volume - more than 100 ml.

General symptoms

Thus, there are signs of bleeding that occur in any case, regardless of the source of bleeding. Early signs include: pallor of the skin and visible mucous membranes, cold sweat, general weakness, dizziness, darkening in the eyes, if the lungs are affected, cough with streaks of blood, if the digestive system is involved in the process, bloody vomiting or bloody diarrhea, symptoms of peritoneal irritation , which occurs when the internal organs (spleen, liver, kidney) rupture. With moderate bleeding, a number of symptoms may be either mild or not appear at all.

In other words, bleeding leads to the development of anemia. In addition to these symptoms, anemia is manifested by increased heart rate and hypotension, that is, a decrease in blood pressure. The changed parameters directly depend on the degree of blood loss: with moderate blood loss, the pulse is not more than 75 beats per minute, systolic pressure drops to 100 mm Hg. Art.; with an average - the pulse rises to 100 beats per minute, blood pressure decreases to 90-80 mm Hg. Art.; in severe cases, the pulse rises to 120-140 beats per minute, systolic blood pressure drops below 80 mm Hg. Art.

Diagnostics

With a combined injury, laparocentesis is performed, it is a simple, fast, affordable and sparing method for diagnosing damage to the abdominal organs and internal bleeding. Also sometimes produce ultrasound of the abdominal cavity.

An important point in confirming the diagnosis is the conduct of laboratory blood tests. The analysis reveals a decrease in the number of red blood cells, the amount of hemoglobin and a drop in hematocrit.

If such symptoms and diagnostic data are detected, it is necessary to immediately identify the cause of the underlying disease and begin treatment. It should be remembered that the earlier the cause of internal bleeding is identified, the more effective and faster the recovery process will be.

Internal bleeding is one of the most dangerous types of bleeding, requiring immediate hospitalization.

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Probably everyone has come across such a concept as “bleeding”. It would seem that it would not be difficult for anyone to recognize him. But everything is always clear only with external ones, but if internal bleeding occurs, the symptoms of which can be hidden, everything is much more complicated. After all, no one will immediately understand in which tissues and organs it happened. And the further treatment of the affected tissue depends on this.

Bleeding - what is it?

Bleeding refers to any situation where the blood goes beyond the limits of the vessels. Distinguish between external and internal bleeding. External are those in which blood flows into the external environment through natural openings or wounds, for example, uterine or from the final sections of the intestine. Internal bleeding occurs when the blood does not come out, but remains inside the body, forming hematomas in the organs - accumulations of blood. An example is when blood flows into the pleura, abdominal cavity, joints, heart shirt.

In addition to the division into external and internal, as well as hidden or explicit, they are divided according to which vessel is damaged:

capillary;
venous;
arterial;
parenchymal;
mixed.

Capillary bleedings differ in saturation. Blood is released rather slowly in the form of droplets that resemble dew. Capillaries are the smallest human vessels. You can stop this bleeding by tightly bandaging the wound. If there are no problems with the coagulation system, then medical assistance is not needed in this case.

With venous bleeding, dark flowing blood is released from the wound surface. Serious bleeding is possible. The victim must be taken to a medical institution, tight bandaging is used as first aid.

When bleeding from an artery, the blood pulsates and flows. It is scarlet in color, quickly flows out of the wound. It is necessary to apply a tourniquet above the damaged area. On the wound - a tight bandage. The tourniquet can be kept for no more than an hour.

Parenchymal bleeding can occur with injuries of the bone cancellous bone, cavernous tissue and perenchymal organs. Such bleeding is very life-threatening, the victim must be taken to the hospital as soon as possible. Such bleeding cannot be stopped on its own, it can be profuse.

With mixed bleeding, blood can flow from various vessels, as well as be combined with parenchymal ones. Most often, such blood loss occurs with injuries of organs in which the vascular network is well developed.

Types of internal bleeding

Internal bleeding, the symptoms of which are very insidious, pose a great danger to health and even human life. The severity of the condition of the victim with this pathology directly depends on how large the vessel has suffered, that is, on its diameter. The larger the affected vessel, the more dangerous the bleeding, and the greater the blood loss can be.

There are such types of internal bleeding:

into the abdominal cavity, when the internal organs are torn - the spleen, liver - abdominal bleeding;
from the pelvic organs: uterus, ovaries, fallopian tubes;

All these pathologies have their own signs and characteristics that allow the doctor to suspect something was wrong inside the body.

Causes of internal bleeding

Internal bleeding, the symptoms of which may be erased, never occurs as the main pathology. They are caused either by an underlying disease, or an injury, or a number of different circumstances. Internal bleeding can occur due to the following reasons:

abdominal injuries, both open and closed, in which internal organs such as the small intestine, spleen, liver can be damaged;
a ruptured ovary can lead to internal bleeding;
ruptured pelvic or ovarian cyst;
traumatic injuries of the lower back;
ulcers of the intestine and stomach;
varicose veins of the stomach or esophagus;
aortic dissection (with aneurysm);
malignant tumors of the abdominal and retroperitoneal space of the stomach, intestines in the stage of decay;
damage to the esophagus.

intestinal bleeding

Intestinal bleeding can occur with various diseases of the intestine (both thick and thin). The most common cause is a duodenal ulcer. Also, bleeding can cause tumor rupture and simple trauma. The patient may feel dizzy, flashing flies before his eyes, sticky cold sweat. If there is bleeding in the upper intestines, there may be vomiting of coffee grounds, the stool will be black or dark cherry. Intestinal bleeding most often requires urgent surgical intervention. In any case, stopping internal bleeding and treating its consequences are carried out in a hospital under the supervision of medical personnel.

Symptoms of internal bleeding

If a person suddenly turns pale, he has a sticky sweat, a sharp drop in blood pressure, an increased pulse, internal bleeding can be suspected. The symptoms of this pathology will leave no doubt, if you are careful. There may also be drowsiness, indifference to the outside world literally five minutes after the person was sociable and active.

Bleeding in the stomach

Internal bleeding of the stomach is one of the most dangerous conditions. A person feels the general symptoms characteristic of internal bleeding. In addition, he most often appears to vomit coffee grounds and black feces. Such bleeding can be caused by a stomach ulcer, a malignant decayed tumor, or an abdominal injury.

What to do if there is bleeding of internal organs?

If a person has a deterioration in well-being, indicating that he has internal bleeding, the symptoms of which are basically similar to each other, you should immediately call an ambulance. Before the arrival of health workers or if the patient has to be transported on his own, you must first of all lay him on his back. Apply cold to the suspected area of bleeding. Do not try to stop internal bleeding on your own, only a doctor should treat.

Methods for stopping internal bleeding of the abdominal cavity

At the first symptoms of internal bleeding, you should immediately consult a doctor. You should not console yourself with the illusion that it will stop, because such a state is life-threatening. After taking a medical history, specialists collect a small amount of feces and vomit to send them for analysis. This study is done to check for the presence of blood in them.

After diagnosing the disease, doctors provide assistance with internal bleeding - diagnostic manipulations, for example, such as endoscopy, X-ray, recto-manosigmoidoscopy, colonoscopy and some others. All these activities are carried out in order to determine exactly where the source of bleeding is. In some cases, a therapeutic and diagnostic injection of a sclerosing agent is used, electrocoagulation can be used. Another effective method is laser radiation.

But the most effective is the radical method - surgical. Especially often this procedure is resorted to when the bleeding is acute, and there is no time for unnecessary actions. But after surgery, there is no guarantee that it will not open again. Therefore, the patient is observed in the hospital for some time.

All therapeutic measures are aimed at the implementation of several goals during bleeding.

The use of drugs that reduce the activity of gastric secretion.
Stop bleeding as soon as possible.
Additionally, blood is injected if its losses are large.
There is a struggle with DIC-syndrome.
It is also important to bring a person out of a state of shock, the fight against collapse is being carried out.

Who is subject to such bleeding?

There is a certain risk group - people who are more likely to experience internal bleeding. We have already considered the symptoms of this condition. These are patients who have pathologies such as:

nonspecific ulcerative colitis;
oncological diseases of the abdominal organs;
erosive gastritis;
intestinal intussusception;
any gastroenterological hypertrophic diseases;
polyposis;
stomach ulcer;
some benign tumors of the gastrointestinal tract.

But these diseases are not necessarily accompanied by bleeding. You should not panic, you need to remember that the blood in these cases can almost always be stopped. The main thing is to take the necessary measures to stop it and not to delay contacting a doctor. Having such diseases that are at risk, you need to remember all medical prescriptions. For example, about strict adherence to a diet, the correct diet, the necessary organization of a healthy lifestyle. It is important to monitor your health and contact specialists in time.

- outflow of blood into the peritoneal cavity or retroperitoneal space due to a violation of the integrity of the blood vessels located here, parenchymal or hollow organs. With bleeding into the abdominal cavity, weakness, pallor, cold sweat, rapid pulse, drop in blood pressure, abdominal pain, fainting or shock develop. The main role in the diagnosis of bleeding into the abdominal cavity is played by the examination of the patient, the dynamics of hemoglobin and hematocrit levels, laparocentesis and laparoscopy. Surgical treatment of bleeding into the abdominal cavity - laparotomy with revision of internal organs; in parallel, anti-shock, hemostatic and transfusion therapy is carried out.

General information

Bleeding into the abdominal cavity (intra-abdominal bleeding, hemoperitoneum) in gastroenterology can be a symptom of any disease or damage to internal organs and tissues. The danger of bleeding into the abdominal cavity, like any internal bleeding, is its hidden nature, which can pose a threat to the life of the patient. As a result of bleeding into the abdominal cavity, hemoperitoneum occurs - the accumulation of blood in the peritoneal cavity and retroperitoneal space. Bleeding into the abdominal cavity is complicated by the development of hypovolemic and neurogenic shock. Hypovolemic shock is associated with a rapid decrease in circulating blood volume (by 25% or more) and hemodynamic disturbances, neurogenic (traumatic) shock is associated with excessive pain impulses.

Causes of bleeding into the abdominal cavity

At the heart of bleeding into the abdominal cavity are the causes of traumatic and non-traumatic nature. Bleeding into the abdominal cavity may be due to mechanical trauma of the chest and abdominal trauma: closed - upon impact, compression; open - with a gunshot or stab wound, as well as injuries associated with abdominal operations. In this case, a traumatic rupture of the parenchymal or hollow organs of the gastrointestinal tract, the genitourinary system, as well as blood vessels located in the folds of the peritoneum, thicker than the mesentery and the greater omentum occurs. Bleeding into the abdominal cavity in the postoperative period is usually associated with slipping (eruption) of the ligature applied to the vessels of the mesentery or organ stump.

Bleeding into the abdominal cavity of non-traumatic origin develops spontaneously in the complicated course of certain diseases and pathological processes of internal organs. Bleeding can be observed with tumors of the abdominal organs; conditions leading to a decrease in blood clotting; ectopic pregnancy; ruptured abdominal aortic aneurysm, ruptured spleen in malaria, ruptured cyst, and ovarian apoplexy. Bleeding into the retroperitoneal space is much less common.

Symptoms of bleeding into the abdomen

The clinical picture of bleeding into the abdominal cavity is determined by the severity of blood loss - its intensity, duration and volume.

Signs of intra-abdominal bleeding are pallor of the skin and mucous membranes, general weakness, dizziness, cold perspiration, a sharp drop in blood pressure, severe tachycardia (pulse rate - 120-140 beats per minute), local or diffuse pain in the abdomen, aggravated by movement. A patient with bleeding into the abdominal cavity to reduce abdominal pain tries to take a sitting position (a symptom of "roly-up").

If the diaphragmatic peritoneum is irritated by accumulated blood, the pain may radiate to the chest, shoulder blade and shoulder; with bleeding into the retroperitoneal space, pain in the back is noted. In the case of profuse bleeding into the abdominal cavity, the pain syndrome becomes intense, loss of consciousness is possible; with acute massive blood loss, collapse develops.

Diagnosis of bleeding in the abdominal cavity

A patient with suspected bleeding into the abdominal cavity is subject to urgent examination in a hospital. An examination of the abdomen is carried out to identify the characteristic signs of injury (open wounds, abrasions, bruising).

Surface-orienting palpation reveals softness and slight soreness of the anterior abdominal wall, its limited participation in breathing, and mild symptoms of peritoneal irritation. Deep palpation is carried out carefully, as it causes sharp pain in the area of the damaged organ or the entire abdominal wall. Percussion of the abdomen in the presence of bleeding into the abdominal cavity is very painful, due to the accumulation of blood, there is a dullness of sound in sloping places. Abdominal auscultation showed a decrease in bowel sounds. When a hollow organ is ruptured, local manifestations of bleeding into the abdominal cavity may be masked by signs of incipient peritonitis.

Digital rectal and vaginal examinations reveal swelling and sharp pain in the anterior wall of the rectum and posterior vaginal fornix. If a disturbed tubal pregnancy is suspected, an important diagnostic value is assigned to the puncture of the abdominal cavity through the wall of the posterior fornix of the vagina. A laboratory study of blood during bleeding into the abdominal cavity shows an increasing decrease in hemoglobin, red blood cell count and hematocrit.

A plain x-ray in case of internal bleeding helps to determine the presence of free fluid (blood) in the abdominal cavity. Ultrasound of the pelvic organs and ultrasound of the abdominal cavity reveals the source of bleeding in the internal organs and the accumulation of anechoic fluid. The main methods for diagnosing bleeding into the abdominal cavity are endoscopic studies -

In case of acute blood loss and a sharp drop in blood pressure, antishock and antihemorrhagic infusion therapy is carried out: transfusion of blood substitutes (or reinfusion of blood that has recently leaked into the abdominal cavity), administration of analeptic drugs. This helps to increase and replenish BCC, improve the rheological properties of blood and microcirculation.

When establishing the fact of bleeding into the abdominal cavity, an emergency surgical intervention (laparotomy) is indicated, including a revision of the abdominal organs to detect the source of bleeding and stop it, and eliminate existing injuries.

The prognosis for bleeding into the abdominal cavity is quite serious, depending on the cause and intensity of bleeding, as well as the speed and volume of surgical intervention.

With internal bleeding, blood accumulates in the organs and cavities of the body. It cannot be determined visually!

First aid for internal bleeding:

With internal bleeding into the weed of the pelvis and abdomen, you can help by pressing the abdominal aorta to the spine with your fist. It is advisable to put a handkerchief or several layers of gauze between the skin and the hand.

With gastrointestinal bleeding, the patient is allowed to swallow pieces of ice.

You can not warm the injured area, give laxatives, give enemas or give medicines that stimulate the activity of the heart!

The reasons

Internal bleeding is the outflow of blood into the cavity of the body or organs of a person and into the interstitial spaces. The cause of this condition may be associated with trauma or chronic pathologies.

The following diseases and conditions can lead to internal bleeding:

injuries with damage to internal organs (liver, lungs, spleen);
peptic ulcer of the duodenum and stomach;
rupture of the internal cyst;
closed fractures;
exfoliating aortic aneurysm;
gynecological diseases (ovarian apoplexy, ectopic pregnancy);
varicose veins of the esophagus and stomach;
decaying malignant tumors.

These conditions can be provoked by accidents, strong blows, falling from a height, active physical activity, alcohol abuse, and a heavy meal.

Symptoms

With internal bleeding, the following signs develop that require first aid. Clinically, the condition is accompanied by objective (external manifestations) and subjective (feelings of the victim) symptoms. The first one includes:

pointed facial features;
pallor of the skin and mucous membranes;
low blood pressure;
hand tremor;
tachycardia (pulse more than 100 beats per minute);
cold sweat, perspiration;
dyspnea;
muscle tension;
cold extremities;
fainting.

Subjective signs:

dizziness;
drowsiness, weakness;
darkening in the eyes;
yawn;
nausea;
noise in the head;
dry mouth;
tinnitus;
nausea, vomiting;
confused mind.

With a hemorrhage in the abdominal cavity, pain occurs during palpation (palpation) and heaviness in the abdomen, the Roly-Vstanka symptom is the development of pain in the left or right shoulder, neck in a supine position, while sitting, the pain disappears, but dizziness appears.

Gastrointestinal bleeding is characterized by the absence of abdominal pain, melena (black feces), brown vomiting (coffee grounds).

With a rupture of the abdominal aorta, trauma to the kidneys and adrenal glands, blood accumulates in the retroperitoneal space, pain in the lower back occurs, and when tapped on this area, it becomes unbearable. Red blood cells may also appear in the urine.

With the outpouring of blood into the muscles, bruising and hematomas occur in the area of damage. In this case, the main help is cold.

If bleeding is caused by gynecological diseases, then hyperthermia, pain, heaviness, a feeling of fullness in the lower abdomen, pressure on the anus, and a feeling of swelling of the mucous tissues inside join the general symptoms.

Injury to a vessel in the lungs is usually accompanied by a cough, with which foamy blood or its streaks come out.

With cerebral bleeding, the tissues of the organ are compressed, resulting in unbearable headaches, vomiting, impaired speech and motor activity, and convulsions.

The severity of the condition can be judged by the indicators of pulse and blood pressure. Systolic pressure below 80 mm Hg. Art. and pulse above 110 beats per minute. indicates a serious condition and the need for assistance and urgent hospitalization. With a blood loss of more than 2-3.5 liters, a coma develops, after which there is agony and death.

Diagnostics

Diagnosing internal bleeding can be quite difficult; for this, first of all, they perform an examination, measure blood pressure and pulse, tap and palpate the abdominal cavity, and listen to the chest. To assess the severity of blood loss and the amount of assistance needed, laboratory tests of hemoglobin and hematocrit (erythrocyte volume) are performed.

Diagnostic methods depend on the cause of internal hemorrhage:

In the pathology of the gastrointestinal tract: esophagogastroduodenoscopy, digital examination of the rectum, colonoscopy, gastric probing and sigmoidoscopy;
With lung damage - bronchoscopy;
In case of bladder disease - cystoscopy.

Ultrasound, radiological and radiological techniques are also widely used. If there is a suspicion of outpouring of blood into the abdominal cavity, laparoscopy is performed, and for intracranial hematoma, echoencephalography and radiography of the skull are performed.

Specialized medical care

Victims receive full assistance and are treated in a hospital. The department of which depends on the type of bleeding, the therapy is carried out by doctors of different profiles: gynecologists, thoracic surgeons, neurosurgeons, traumatologists, etc.

The main goals of medical care:

urgent stop of internal hemorrhage;
restoration of microcirculation;
replacement of lost blood;
prevention of empty heart syndrome with the help of BCC replenishment;
prevention of hypovolemic shock.

In all cases, infusion therapy is performed (the volume depends on internal blood loss): transfusion of polyglucin, saline, stabizol, gelatinol, glucose, blood and its preparations (albumin, fresh frozen plasma, erythrocyte mass), plasma substitutes. At the same time, blood pressure, CVP and diuresis are controlled.

If blood pressure does not rise due to infusions, norepinephrine, dopamine and adrenaline come to the rescue. With hemorrhagic shock, heparin, trental, steroid hormones and chimes are prescribed.

In some cases, internal hemorrhage is stopped by cauterization or tamponade of the bleeding area. But more often urgent surgical intervention under anesthesia is necessary. If hemorrhagic shock is suspected, transfusion measures are mandatory.

With gastric bleeding, resection is indicated, with a duodenal ulcer - vagotomy and suturing the vessel. The outpouring of blood from a fissure of the esophagus is stopped endoscopically in combination with cold, antacids and hemostatic drugs. If the assistance provided does not bring results, the cracks are sutured.

With internal bleeding from the lungs, it is necessary to plug the bronchus. Accumulated blood from the pleural cavity is removed by puncture; in severe cases, a thoracotomy is necessary with suturing of the site of lung injury or ligation of the vessel. Emergency laparotomy is performed in all cases of ruptures of the abdominal organs, and craniotomy is necessary for intracranial hematoma.

For internal gynecological hemorrhages, vaginal tamponade or surgery is performed, sometimes with removal of the ovary, fallopian tube, or uterus.

External and internal bleeding of varying severity are observed in almost any injury. An ordinary bruise is a subcutaneous accumulation of blood from damaged vessels. In patients with blood clotting disorders (hemophilia), even small wounds bleed very heavily. Superficial wounds of the face and head, palmar surface of the hands, soles, where the network of vessels is well expressed, a small layer of adipose tissue and a relatively large amount of connective tissue, are characterized by profuse bleeding.

Yu.P. Butylin, V.Yu. Butylin, D.Yu. Butylin; service of anesthesiology-reanimation of medical and health-improving association of the Cabinet of Ministers of Ukraine; Department of Anesthesiology, Resuscitation and Disaster Medicine of the National Medical University. A.A. Bogomolets; Department of Resuscitation and Intensive Care of the Institute of Cardiovascular Surgery named after A.I. N.M. Amosov Academy of Medical Sciences of Ukraine

The intensity of hemorrhage is affected by the caliber of the vessel, the level of blood pressure, the presence or absence of clothing, shoes. The greatest danger to life is external and internal damage to large arterial and venous trunks, accompanied by large blood loss.

Internal bleeding

Pulmonary bleeding - the release of pure blood in portions from 5-10 to 50 ml or more.

The reasons. Destructive lung diseases: tuberculosis (66%), suppurative diseases (8.8%), bronchiectasis (5.9%), pneumosclerosis (2.7%), cancer (2.1%). Bleeding may be due to pneumonia, pulmonary infarction, air cysts, severe forms of candidiasis and some extrapulmonary diseases (mitral valve stenosis, aortic aneurysm, hypocoagulation) with hypertension or congestion in the pulmonary circulation (left ventricular failure, aortic valve defects), Goodpasture's syndrome (necrotizing alveolitis of unknown etiology), Rendu-Osler disease (hereditary hemorrhagic telangiectasia). A complex of various factors is involved in the pathogenesis of pulmonary hemorrhage. The main role is played by specific and nonspecific changes in the vascular wall in contact with the affected areas of the lung. The main sources of bleeding are bronchial arteries, which are eroded or ruptured during inflammatory processes. Vessels, as a rule, are deformed, expand aneurysmically, their walls lose their elasticity and often ulcerate.

In most patients with inflammatory lung diseases, vascularization of the submucosal layer and bronchial mucosa is pronounced, with erosion of which also occurs profuse bleeding. This is facilitated by the activation of local fibrinolysis and impaired hemocoagulation as a result of prolonged intoxication and massive chemotherapy, especially in pulmonary tuberculosis at the 4-6th month of treatment. Only medium or large blood loss (500 ml or more) leads to obstructive respiratory disorders, acute hypovolemia and the development of emergency conditions. Massive pulmonary blood loss is considered to be more than 240-600 ml within 24-48 hours. In severe cases of profuse bleeding, sudden death is possible, the cause of which is the development of asphyxia due to widespread airway obstruction and concomitant bronchospasm. The amount of blood loss in this case plays a secondary role. Only massive sudden pulmonary bleeding with aortic aneurysm rupture into the respiratory tract, lung cancer and erosion of a large vessel can lead to rapid asphyxia. Fulminant pulmonary hemorrhage is not accompanied by a cough.

The most common complication of pulmonary hemorrhage is aspiration pneumonia.

Therapeutic measures should be strictly differentiated depending on the etiology of the underlying disease (Fig. 1).

Abdominal bleeding

Distinguish between bleeding from the digestive tract, intra-abdominal, retroperitoneal.

To the reasons in which there is bleeding from the organs of the digestive tract, include the following.

Diseases of the esophagus (malignant and benign tumors, diverticula, ulcerative esophagitis, periesophageal hernias, foreign bodies, specific and nonspecific diseases).
Diseases of the stomach and duodenum (ulcers, malignant and benign neoplasms, diverticula, erosive gastritis, duodenitis, Mallory-Weiss syndrome, tuberculosis, syphilis).
Diseases of nearby organs (hiatal hernia, pancreatic cyst, calculous pancreatitis, abdominal tumors growing into the stomach and duodenum).
Diseases of the liver, spleen and portal vein (cirrhosis, tumors, cholelithiasis, liver injury, thrombosis of the portal vein and its branches).
Diseases of the heart and blood vessels (atherosclerosis, hypertension, periarteritis nodosa).
General diseases accompanied by ulcers of the stomach and duodenum (burns, infectious diseases, postoperative acute ulcers, acute ulcers that occur with diseases of the nervous and cardiovascular systems, with drug, hormonal therapy and poisoning).
Hemorrhagic diathesis and diseases of the blood system (hemophilia, leukemia, Werlhof's disease, lymphogranulomatosis).

The most common cause (60-75% of cases) of gastrointestinal bleeding are destructive changes in the walls of the stomach or intestines. In percentage terms, they are distributed as follows: ulcers of the dilated veins of the esophagus - 15, stomach ulcers - 10, duodenal ulcers - 40, erosive gastritis - 10, stomach cancer - 15, ulcerative colitis - 4, hemorrhoids - 1, other causes - 5 .

The mechanism of bleeding is due to general (blood clotting disorders and hormonal reactions) and local (erosion of the mucous membrane and submucosal layer of the stomach and intestines, followed by erosion of the vessel) factors.

Ulcerative bleeding can be arterial, venous and capillary, but rarely occur simultaneously from two or three vessels. Common disorders include a slowdown in the third phase of hemostasis under the influence of hydrochloric acid (peptic factor). Especially dangerous is an increase in the concentration of trypsin in the blood, which activates the conversion of profibrinolysin to fibrinolysin and thus triggers the reaction of local fibrinolysis, local hypophyrinogenemia, lysis of a blood clot in the vessel and the resumption of bleeding. The most typical localization of sources of bleeding is shown in Figure 2.

Description of the clinical picture and principles of therapeutic management of a patient with abdominal bleeding is shown in Figure 3.

stomach bleeding

Often, gastric bleeding is the first and only symptom of the disease.

The reasons: gastric ulcer, benign (polyp, leiomyoma, neurinoma, lipoma) and malignant neoplasms (cancer, sarcoma), erosive (hemorrhagic) gastritis, Mallory-Weiss syndrome, chronic hepatitis, liver cirrhosis, gastric syphilis, tuberculosis, medication (salicylates, anticoagulants, glucocorticoids). In the acute period of myocardial infarction, bleeding from acute erosions and ulcers of the mucous membrane of the digestive tract is observed.

Critically ill patients (sepsis, shock) often develop stress ulcers; mucosal ischemia, disruption of the gastric mucosal barrier and an increase in the concentration of hydrochloric acid in the gastric contents, which destroy the surface epithelium, play the main role in their pathogenesis. Massive bleeding occurs in 4-15% of patients with stress ulcers, often from small superficial mucosal defects.

Clinic heterogeneous, depending on the volume and duration of blood loss. Almost always, before the onset of extensive symptoms, the occurrence of hematemesis and black stools, increasing lethargy, weakness, increased fatigue, and decreased ability to work are noted. Typical signs of acutely developing anemia are as follows: dizziness, noise in the head, ringing in the ears, flashing "flies" before the eyes, pale skin and mucous membranes, shortness of breath, cold clammy sweat, drop in blood pressure, tachycardia. These symptoms occur immediately after the onset of bleeding, appear the faster, the more intense it is, and characterize the latent period. The duration of bleeding depends on the degree and speed of blood loss. Bloody vomiting and tarry stools (melena) are the most reliable, but not always the first signs of gastric bleeding. Melena can appear both in a few hours and in one or two days after the onset of bleeding.

Vomiting can be scarlet blood, clots, sometimes the vomit has the color of coffee grounds, it depends on the location of the ulcer and the massive bleeding. Scarlet blood is usually observed with bleeding from the veins of the esophagus or stomach ulcers, vomit the color of coffee grounds - with perforation of a duodenal ulcer. A characteristic symptom of ulcerative bleeding is the disappearance or reduction of abdominal pain, the so-called. "silent" period.

The final diagnosis is established after the patient is taken out of shock. Radiography, endoscopy allow you to make an accurate diagnosis in 90% of patients. During gastroscopy, local hemostasis is possible.

Treatment. In severe blood loss, hemostatic and replacement therapy is necessary. Acute blood loss (up to 1-1.5 liters) is compensated with plasma substitutes (colloids, crystalloids, dextran, rheogluman, rheosorbilact, hecodes), which are administered intravenously by stream or drip from 400 to 1200 ml. The rate of administration is determined by the general condition of the patient, the level of blood pressure, heart rate, the value of Ht. Moderate hemodilution (Ht 25-30%) is a favorable factor. With a blood loss of 1.5 to 3 liters, the ratio of plasma-substituting solutions and canned blood for transfusion therapy should be 1:1, with losses of more than 3 liters - 1:2. The amount of plasma-substituting drugs should always be about a third of the blood volume (maximum - 1.5 liters) with the obligatory consideration of the Ht indicator.

An emergency operation is indicated.

bloody stool

The localization of the source of bleeding can be judged by the consistency and color of the feces.

Liquid, dark cherry stool is typical of massive colonic bleeding; tarry - for acute profuse from the small intestine; black decorated (melena) - from the stomach and duodenum. If bleeding occurs from the blind, ascending and transverse colons, then the color of the stool is maroon or reddish-brown, from the descending colon and sigmoid - bright red or cherry-raspberry. The closer the defect of the vessel to the anus, the less the color of the blood changes. When bleeding from the rectum, an admixture of blood is found on the surface of normally stained feces. If it is abundant, then pure blood without feces is often excreted. When internal hemorrhoids bleed, blood accumulates in the ampulla of the rectum and is then thrown out when the urge to defecate. Scarlet color indicates the presence of hemorrhoids or rectal fissures. With a combination of bleeding with diarrhea, the stool is bright red. To exclude the presence of a bleeding tumor or other source of bleeding, it is necessary in all cases to conduct a digital examination of the rectum and colonoscopy.

Intra-abdominal bleeding

The reasons: trauma, ectopic pregnancy, surgery. Penetrating and non-penetrating wounds, compression, crushing, falling from a great height, a strong blow to the abdomen can lead to ruptures of internal organs with subsequent bleeding into the abdominal cavity. Typical localization of damage is shown in Figure 4.

Clinic determined by the amount of blood loss and the consequences of damage to hollow organs. If the intestines and bladder are not affected, then at first the blood does not irritate the peritoneum, so the stomach is soft; later, a distinct symptomatology of peritonitis is revealed. Diagnosis of blunt abdominal trauma is especially difficult. It can result in severe bleeding from ruptures of the liver, spleen, mesentery, or kidney.

Treatment: indicated emergency surgery.

Ectopic pregnancy

The reasons: implantation and development of the fetal egg outside the uterus, most often (99% of cases) in the fallopian tube, which is destroyed by the chorionic villi. As a result, the fetal egg either exfoliates from the wall and is expelled into the abdominal cavity (tubal abortion), or the fallopian tube is torn. The type of termination of an ectopic pregnancy determines the features of the clinical picture.

Clinic. A common symptom for both types of bleeding is pain in the lower abdomen with a relatively small delay in menstruation (1-3 weeks). Pain is often accompanied by nausea, vomiting, increased heart rate, decreased blood pressure and other signs of increasing bleeding. Against this background, symptoms appear that are characteristic of a rupture of the fallopian tube or tubal abortion. Rupture of the tube is characterized by an acute onset and rapid dynamics of symptoms. Usually, against the background of a general good condition, there is a sharp pain in the lower abdomen with irradiation to the external genitalia and rectum. Pain in the rectum is often misinterpreted by the patient as an urge to defecate. With heavy bleeding, it can radiate to the neck and shoulder blade. Soon there are symptoms of bleeding and an acute abdomen: vomiting, dizziness, fainting, tachycardia, decreased blood pressure, severe weakness. Palpation of the abdomen determines the tension of the muscles of the abdominal wall, especially in the lower sections, a positive symptom of Shchetkin-Blumberg. With massive bleeding into the abdominal cavity, dullness of percussion sound is found in the lateral parts of the abdomen. With careful movement of the patient from side to side, the borders of dullness move. Bloody discharge from the genitals may not be.

With careful vaginal examination (rough examination increases bleeding!) Detect mild cyanosis of the mucous membranes of the vagina and cervix. With a gestational age of up to 7 weeks, the size of the uterus corresponds to it. If the period is longer, there is some lag in the size of the uterus from the expected period (one of the characteristic signs of an ectopic pregnancy). Sometimes a tumor-like formation is palpated in the area of the uterine appendages without clear boundaries (peritubal hematoma). The back of the vaginal fornix is sharply painful on palpation, the pain intensifies with the displacement of the uterus to the pubis.

Tubal abortion begins with intermittent or constant pain in the lower abdomen and in the sacrum, radiating down. Each new flow of blood into the abdominal cavity is accompanied by an increase in pain and a fainting state. On the 2-3rd day, characteristic dark bloody discharges stand out from the genital tract, sometimes parts of the falling off membrane depart. Allocations are persistent and do not stop, despite the use of uterine contracting agents and even diagnostic curettage (a characteristic sign!). In the intervals between attacks of pain, the patient's condition is satisfactory. Near the fallopian tube or in the recto-uterine space, hematomas are formed, which can be detected during vaginal examination. Symptoms of internal bleeding and peritoneal irritation are less pronounced and may even be absent.

The diagnosis of disturbed ectopic pregnancy is based on the data of the anamnesis, clinic and additional research methods. In history, a delay in menstruation for 2-3 weeks, less often - more. In some patients, with a very early termination of pregnancy, there may not be a delay, and spotting associated with the decay and release of the falling membrane is mistaken for the onset of normal menstruation.

All types of ectopic pregnancy are characterized by pain on palpation of the posterior part of the vaginal fornix and the presence of a tumor-like formation in the uterine appendages. Of great diagnostic importance is the puncture of the posterior fornix of the vagina. With severe bleeding due to rupture of the fallopian tube or a rapidly ongoing tubal abortion, when the picture of internal bleeding is not in doubt, there is no need for this manipulation. Obtaining dark blood with small clots during the puncture confirms the diagnosis. Bright blood, rather, indicates a wound in the blood vessel. With a tubal abortion, the blood coagulates and therefore is not detected during a puncture. This does not exclude the presence of an ectopic pregnancy.

Treatment. If the diagnosis of a disturbed tubal pregnancy is established or suspected, urgent hospitalization is indicated. Before transportation, the patient should not be given painkillers, so as not to change the clinical picture of the disease, cold should not be applied to the lower abdomen. In the hospital, an emergency operation is performed, the BCC deficiency is replenished, and symptomatic therapy is prescribed.

Retroperitoneal bleeding

Retroperitoneal bleeding, as a rule, is the result of severe trauma or complications of needle biopsy, angiography, anticoagulant and fibrinolytic therapy (Fig. 5).

Dissecting aortic aneurysm

The reasons. Most patients with aortic dissection (mainly men) have hypertension, atherosclerosis, or syphilis. According to localization, acute aortic dissections are divided into three types. In type I, the dissection begins in the region of the ascending aorta and continues distally; in type II, the rupture is limited to the ascending aorta; in type III, the rupture begins distally to the origin of large vessels of the aortic arch.

Clinic: sudden severe pain inside the chest radiating to the back, epigastric region and lower limbs. With damage to the thoracic part of the aorta, pain is localized behind the sternum, in the back or epigastrium, with damage to the abdominal part of the aorta - in the abdomen and lumbar region. Pain rarely radiates to the upper extremities and usually spreads along the spine (along the dissection), gradually reaching the lower abdomen and pelvis. Symptoms of a dissecting aneurysm of the thoracic aorta are similar to manifestations of myocardial infarction, and the abdominal part - with renal colic. In acute aortic dissection, pulsation in the peripheral arteries may be disturbed or disappear. As a result of retrograde dissection, acute regurgitation of the aortic valve is possible. In almost 50% of cases, neurological symptoms are detected. Often there is a loss of consciousness. Most patients develop a collapse, a sharp drop in blood pressure is not always observed. The diagnosis is confirmed by symptoms associated with the spread of aortic dissection to the area of origin of the main vessel or several vessels (pulse asymmetry in the upper and lower extremities, hemiparesis, paraplegia or stroke, pain in the lumbar region, hematuria, swelling of the scrotum).

X-ray, computed tomography, nuclear magnetic resonance of the chest and abdomen can provide reliable information about the location of the aneurysm. ECG changes indicate left ventricular hypertrophy and are caused by hypertension. There is also a decrease in the content of erythrocytes and hemoglobin in the blood.

Treatment: the first is anesthesia, the second is surgery, the third is the correction of blood loss.

Chapter from the book “Intensive care of emergency conditions. Pathophysiology, clinic, treatment. Atlas" is published with the permission of the authors and Novy Druk LLC.