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Gastroduodenal bleedings

Gastroduodenal bleedings. Surgical department of TMA for general practitioners. Actuality. Bleeding from proximal parts of GIT is ONE of the frequently complications at a GIT pathology . Hospitalization of the patients 102 cases to 100000 population

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Gastroduodenal bleedings

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  1. Gastroduodenal bleedings Surgical department of TMA for general practitioners

  2. Actuality Bleeding from proximal parts of GIT is ONE of the frequently complications at a GIT pathology . Hospitalization of the patients 102 cases to 100000 population The frequency of this complication at men 2 times more than at women; Than senior age of the patient, more risk of bleedings from GIT; At 70-80 % GIB a source of the bleeding is in proximal parts of GIT.

  3. Acute bleeding is a consequence of various damages and diseases and quickly results in deep infringements of function of all vital organs, it can for short time become the reason of death of the patient. Now mortality from acute bleedings remains high, reaching 15-30 %.

  4. Factors affecting GIB outcomes • Volume of a bleeding. • Speed of blood losing of blood (arterial,venous, capillary bleeding). •         of a Condition at the moment of a bleeding starting (available diseases, saturation by water, volume of circulating blood etc.). • Age of the patient.

  5. Gastric blood supply

  6. Duodenal blood supply 1 — truncus coeliacus; 2 — a. gastrica sinistra; 3 — a. hepatica communis; 4 — a. lienalis; 5 — a. gastro-epiploica dextra; 6 —a. pancreaticoduodenalis superior anterior; 7 — a. pancreaticoduodenalis inferior posterior; 8 — a. pancreaticoduodenalis inferior anterior; 9 — a. mesenterica superior; 10 — flexura duodenojejunalis; 11 — duodenum; 12 — a. pancreaticoduodenalis superior posterior; 13 — a. gastroduodenalis; 14 — a. hepatica propria. 1 — v. portae; 2 — v. gastro-epiploica dextra; 3 — v. gastrica dextra; 4 — v. lienalis; 5 — v. mesenterica inferior; 6 — v. mesenterica superior; 7 — flexura duodenojejunalis; 8 — v. pancreaticoduodenalis inferior anterior; 9 — v. pancreatico-duodenalis inferior posterior; 10 — duodenum; 11 — v. pancreaticoduodenalis superior posterior; 12 — v. pancreaticoduodenalis superior anterior.

  7. Innervation of a stomach

  8. Clinical manifestations: BLOODY vomit - IT IS MARKED At 60-70 % of the PATIENTS BLOODY stool - melena COMMON ATTRIBUTES of bleeding: SENSATION of WEAKNESS, NOISE In ears, blinkings, PALPITATION, COLD SWEAT. At 12-16 % of the PATIENTS DEVELOPMENT BLEEDING IS ACCOMPANIED by unCONSCIOUSNESS. Anamnestic dates: ulcerous anamnesis POISONING alcoholism « SMALL ATTRIBUTES » hepatitis And OTHERS.

  9. occult bleeding signs • vertigo; • Weakness; • unconsciousness; • Cold sweat; • Noise in ears; • Decreasing BP, tachycardia

  10. Signs of evident GI bleedings : • haemathomesis • melenomesis • melena • haemathoshysis • Decreasing Hb • decreasing BP • Tachycardia

  11. reminder • The allocation of dark blood by stool always means a bleeding from upper parts of GIT. • Allocation freshen of scarlet blood by stool in patient with stabile haemodynamic dates means, that the source is NOT from upper GIT. • Any type of blood (freshen also old), allocated as vomit or coming out from nasogastral sound means, that the source is upper GIT

  12. target Мозг

  13. Decreasing CBV Vascular conservation Acute losing 50% of blood volume Haemorrhagic shock Acute circulatory insufficiency Disproportion between vessels volumeand circulating blood volume Tissue anoxia

  14. bleeding RBC losing Endogenous toxemia Systemic changes Immune agression Stimulation of erithropoesis Rheologic changes volume increasing DIC syndrome

  15. Decreasing P in aorta Decreasing capillar blood flow P decreasing at right a atrium bleeding Cardiac changes at GIB Decreasing stroke volume Blood supply disorders in heart muscles

  16. Solid bleeding Renal insufficiency at GIB Renal blood supply violations Increased renin secretion Tubular blood supply disoders Acute renal insufficiency

  17. bleeding Liver hypoxia Functional violations Acute liver failure Liver failure

  18. basic sources of upper GIB . aortic aneurism rupture to duodenal space erosive-ulcerous lesions of a stomach and duodenum Blood diseases gastric and intestinal Angiodysplasia ( Veber-Osler-Randu disease ) alien bodies Bleedings from Varicose dilated Esophageal veins Gastric tuberculosis, syphilis. Hypertrophic gastritis gastrinoma, Gastric poliposis Malory-Weiss syndrome

  19. № causes % I ulcerous 52,69 Stomach ulcer 20,87 Acute SU 1,57 Duodenal ulcer 29,79 Peptic ulcer of anastomosis 1,44 Perforated ulcer of a duodenum and a stomach 0,59 Basic sources of bleedings

  20. II Non ulcerous bleedings: 43,11 Gastric cancer 15,22 Hemorrhagic gastritis 4,72 Benign stomach tumors 2,17 Cirrhosis by varicose dilated veins 4,46 Diaphragml hernias 2,49 Gullet cancer 0,53 Esophageal-bronchial fistula 0,07 Esophageal diverticula 0,33 Duodenal diverticula 1,18 Duodenal tumors 0,3 Faterove nipples malignant tumors 0,13 Oslers diseases 0,2 Pancreatic diseases 0,46 Blood diseases 1,44 III nondeterminated 4,2 In all 100

  21. Tasks This direction of diagnostic job assumes the decision of several questions: • Establishment of a source of a bleeding, its localization and character. Definition of attributes allowing to make judgement about mechanisms of the organic changes which have served By the reason of a bleeding in a digestive path. • Establishments of the fact proceeding or rested bleeding (by Forrest) • In conditions of a stopped bleeding - decision of a question on stability of hemostasis • Diferential diagnosis from upper GIB.

  22. Establishment of a bleeding • complaints Establishment of causative factors EEGDFS ЭEB F-Ia Urgent surgery No response Endoscopic coagulationby ethanol, Adrenalin chiping F-Ib Urgent surgery Recurrent GIB Endoscopic coagulation,checking BP, Ps, Нв, Ht F-IIa Postpone surgery F-IIb Haemostatic therapy, checking (Bp, Ps, Нв, Ht), pathogenic therapy discharging F-IIc Refusins from interventions

  23. Classification J.A.FORREST (1974г.) * FIА – streaming arterial bleedibg * FIB – tiny venous bleeding * FIIA – friable thrombus at the bottom of a ulcer * FIIB – organized thrombus at the bottom * FIIC – ulcer without signs of a bleeding (covered by fibrin)

  24. bleeding(J.A. Forrest, 1974 ) F-Ia F-Ib

  25. bleeding(J.A. Forrest, 1974 ) F-IIа F-IIb F-IIc

  26. Blood in a stomach.

  27. Duodenal ulcer

  28. Dilated varicose veins of esophagus.

  29. Tactics

  30. General practitioners tasks • Duly revealing and active conservative treatment of the patients by illness. • Duly revealing of complications, explanation to the patient of necessity of surgical treatment and direction of the patient in surgical department.

  31. What to do? • If blood fresh and scarlet, and the patient is old, it is high time to work resolutely and safely. • If the patient is young, and blood dark and old, is possible to relax and postpone

  32. General principles of conservative treatments Emergency hospitalization Strict bed rest In the sharp period of a bleeding starvation General and local hemostatic therapy Restoration CBV anti-shock measures

  33. Local hemostatic therapy • Imposings of a bubble with ice on epigastral area • Washing of a stomach by cold water • hemostatic medications in a cavity of a stomach

  34. preventive measures • ranitidin • omeprazole • Secretin • somatostatin

  35. electrocoagulation

  36. Laser hemostasis

  37. Infiltration hemostasis

  38. Injection hemostasis

  39. diathermo-coagulation

  40. Medicines application

  41. cryotherapy

  42. clipping

  43. Mechanical hemostasis

  44. Film-forming medicines

  45. The conservative stop of a bleeding in most cases gives a positive effect, opportunity of preparation of the patient, if necessary (large huge ulcer, repeated bleeding) to lead(carry out) operative intervention in deferred, favorable conditions. • The surgical intervention as a means of a final stop GDB in optimum for the patient terms certainly has advantage before other methods. At 90-95 % of the patients it allows to make the proved surgical treatments of illness • The decisions on the indications and choice of a method of operation depend on weight of a condition of the patient, degrees operational risk, from localization and character of a bleeding ulcer, from intensity of a bleeding

  46. Surgical tactics at GDB • Active tactics - early operative intervention at профузном a bleeding in first 24-48 ч from a beginning of a bleeding. • (With. With. Юдин 1933. Финстерер 1939) • Actively - выжидательная tactics - beginning of treatment профузных of bleedings from conservative measures and only at renewal of a bleeding - operative treatment. • (Ю.Ю.Джанелидзе 1933. В.И.Стручков and Э. In. Луцевич 1961) • Выжидательная tactics - stop of a bleeding by conservative methods, the operations carried out only after the termination(discontinuance) of a bleeding in « межуточном the period ». • (Е. Л. Березов 1935.. To. Рабинович 1939) • Active individualized tactics - patient with high risk of a relapse of bleedings operate in the urgent order before a relapse of a bleeding. • (And. And. Горбашко 1987)

  47. Surgical tactics at GDB includes: • Definition of the indications to operation • Definition of term of realization of operations • Choice of a method of operation

  48. Indications to surgery • Proceeding bleeding at the patients who are taking place in a condition of a shock, with the indications on a bleeding of a ulcerous nature. In such cases specification of a source of a bleeding and the attempts of its stop by conservative ways are inexpedient because of danger of loss of time. • The proceeding bleedings at the patients, if at a massive bleeding persevering conservative measures switching endoscopic coagulation and laser coagulation are not effective. • Recurrent bleeding at the patients in the surgical branch which has come after its stop as a result of conservative treatment.

  49. Intervention TYPEs at GDB • The emergency operation is indicated at patients (is spent during first 6-12ч.) • In a condition of a shock • With a massive bleeding at an inefficiency of conservative measures • With a recurrent bleeding after resting as a result of conservative treatment in hospital • The urgent operation is shown (till 72 hours) • At massive bleedings when the transfusion 1500 мл of blood does not stabilize a condition of the patient, CBV, RBC, Ht and HB remain at a former level or are reduced. Diuresis 60-70 mл/h. • At the patients of elderly and senile age. • At calleous ulcers in a zone of large vessels. • The deferred operations are shown (through 3 and more than day from a beginning of a bleeding) • At a stop of a bleeding and stabilization of a condition of the patient

  50. Kinds of operation at GDB • Radical operations ulcer of a stomach Combination of ulcers of a stomach and duodenum when there is a small degree of operational risk • Conditionally radical operations At the patients with a high degree of operational risk, with an accompanying pathology CS, pulmonary system, kidneys etc. At elderly • Palliative operation At height of a bleeding at the heavy and elderly patients. Is directed on rescue of life of the patient

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