Pathogenesis of recurrences of acute gastroduodenal ulcerous bleedings

Based on analysis of morphologic data, oxygen regime and redox potential it is demonstrated that progressive ischemic necrosis in periulcerous zone is the basis of recurrence of gastroduodenal ulcerous bleedings. Systemic hemostatic therapy, antisecretion drugs, endoscopic methods of hemostasis don't guarantee absence of bleeding recurrence. Prognosis of recurrence of gastroduodenal ulcerous bleedings must be based on evaluation of clinical and endoscopic data. Partial pressure of oxygen and redox potential in ulcer's crater are the objective criteria of threat of bleeding's recurrence.     

Choice of treatment method at acute gastroduodenal ulcerous bleedings

Experience of treatment of 1307 patients with acute gastroduodenal ulcerous bleedings is analyzed. Three variants of treatment tactics are compared: expectant, active and differential. Differential tactics based on prediction of bleeding recurrence and assessment of patient's condition severity permit to improve the treatment results. Original clinical-endoscopic system of hemostasis stability assessment was used for prediction of bleeding recurrence, integral scale APACHE III--for assessment of patient's condition severity. Algorithm of treatment at acute gastroduodenal ulcerous bleedings is offered. Principles of differential treatment tactics have permitted to reduce overall lethality at acute gastroduodenal ulcerous bleedings to 3.2%, postoperative lethality--to 6.2%.     

Diagnosis and treatment of recurrence of gastroduodenal hemorrhage in the early postoperative period]

Results of treatment of 68 patients with early postoperative gastrointestinal bleedings operated upon for acute ulcerous bleedings were analyzed. Among the most frequent sources of the bleeding were sutured ulcer and acute postoperative ulceration of the mucosa. Therapeutic treatment was effective but in 42.6% of the patients which is related with the development of disseminated intravascular blood coagulation. Operations were performed on 36 patients, 9 of them died. Total lethality was 27.9%. Surgical measures for the postoperative gastrointestinal bleedings are discussed.     

Gastroduodenoscopy at diagnosis and treatment of ulcerous gastroduodenal bleedings

Results of treatment of 458 patients with ulcerous gastroduodenal bleedings are analyzed. It is demonstrated that argon-plasma coagulation (APC) is the most effective at primary endoscopic hemostasis and amounts to 92.5% compared with 87.5% at radio-wave coagulation and 79.7% at injection method. Treatment and diagnostic algorithm based on patients state severity assessment (by SAPS scale) and risk of bleeding (by Forrest) was developed. Use of this algorithm led to decrease of lethality due to acute blood less from 6.1 to 2.7% (including at conservative treatment from 4.5 to 2.2%) and postoperative lethality from 14.5 to 5.6%.     

Antisecretory therapy as a component of hemostasis in acute gastroduodenal ulcer bleedings

Results of antisecretory therapy (pyrenzepin, H(2)-blockers, inhibitors of proton pump, octreotid) in 962 patients with acute gastroduodenal ulcer bleedings (AGDUB) were analyzed over 14-years period. Antisecretory treatment in AGDUB has principally different goals and potential depending on risk of bleeding's recurrence and morphological changes in tissue of gastroduodenal ulcer. Antisecretory therapy is the main treatment in high risk of AGDUB recurrence or before urgent surgery. Intravenous infusion of omeprazol has demonstrated the highest clinical efficacy due to maximal inhibition of gastric secretion and absence of negative influences on oxygen regimen in tissue of ulcer.     

Immediate results of surgical treatment of gastroduodenal ulcer hemorrhage]

From 1979 till 1989 the authors made operations on 145 patients with gastroduodenal ulcerous bleedings, 87 of them were people of young and middle age. Vagotomy with pyloroplasty was successfully used in 110 patients with duodenal ulcerous bleedings. The method of choice at the peak of bleeding from the duodenal ulcer is thought by the authors to be subdiaphragmatic+ vagotomy with pyloroplasty after Heineke--Mikulicz. For delayed operations the authors prefer SPV with pyloroplasty after Finney. The authors consider that pyloroplasty after Finney excludes reflux of the duodenum content to the stomach and the dumping syndrome. Classical gastric resection is thought by the authors to have no alternative for gastric ulcerous bleedings. The authors think that emergency operation is the only correct method for continuing bleeding. Delayed operations were performed on patients with cupped bleeding and massive blood loss, as well as for recurrent bleeding independent of the degree of blood loss and as a rule within the first 24 hs. General lethality was 4.8% and after organ preserving operations--1.8%. In 95.2% of cases good immediate results were obtained, which allows the method to be recommended for wide practice in cases of gastroduodenal ulcerous bleedings.     

Principles of medical care of patients with gastrointestinal ulcer hemorrhage]

A new protocol of treatment policy is proposed based on the results of treatment of 518 patients with gastrointestinal ulcer bleedings. All the patients are divided into 3 groups: with continued bleeding, with unstable spontaneous hemostasis, and with stable spontaneous hemostasis. Corresponding policy of treatment was used: surgery, endoscopic hemostasis, conservative treatment. In endoscopic hemostasis we preferred to clamp vessel or ulcer leading to hemostasis in all 36 cases. Hemostasis was not achieved in 6% patients, recurrence of bleeding was in 4.2% patients, 24.6% patients underwent emergency operations. The majority of operated patients underwent stomach resection (51.6%). The proposed principles of treatment permitted to decrease overall lethality from 5.2 to 2.6%, postoperative lethality--from 15.7 to 7.5%.     

Treatment of gastroduodenal ulcer bleedings in a general hospital of emergency care

Treatment of patients with gastroduodenal ulcer bleedings in a general hospital of emergency care is a complex of measures including of endoscopic diagnosis and stopping of bleeding, use of effective antisecretory drugs with obligatory laboratory control of acid-producing function of the stomach, surgical treatment and eradication of H. pylori. Up-to-date methods of endoscopic hemostasis - spirituous infiltration, argon-plasma coagulation, clipping of vessels in ulcer and also their combination in difficult cases - provide reliable hemostasis and allow to avoid urgent surgery. Recently we succeeded in reducing the rate of urgent surgeries performed at the height of bleedings from 70 to 40%. These methods can be recommended for clinical practice because they reduce significantly lethality rates in patients with severe conditions.     

Surgical tactics in gastroduodenal hemorrhages caused by peptic ulcer

Among patients operated upon during the recent 10 years for gastroduodenal bleedings of ulcerous etiology emergency operations were performed at the height of bleeding on 12.6% of patients, urgent operations in the early interval on 42.3% of the patients. In the group of patients operated upon at the height of bleeding, the immediate postoperative lethality was high and made up 15.8%. After operations in the early interval 6.3% of patients died. General lethality among patients operated on for emergency and urgent indications made up 8.5%. After operations fulfilled during the late interval lethality was 2.8%.     

The surgical procedure in ulcerous duodenal hemorrhages]

Available are the results of treatment of 493 patients with duodenal ulcer complicated by bleeding in the center of gastro-intestinal bleedings at N. I. Pirogov City Hospital No. 1 in 1995-1996 years. 74 patients were operated. Overall lethality made up 1.8%, postoperative lethality rate--8.1%. In ulcer of posterior wall of the duodenum, 10 mm and more in diameter with blood loss of medium and high degree, the number of relapses made up 57.1%. In cases of urgent operations (n = 30); carried out on the first day of admittance to the hospital, 1 patient died. Expectant policy in treatment of patients with ulcer of posterior wall of the duodenum results in poor effect of the treatment and complications (4.1%). The advantages of active individual approach in treatment of patients with acute duodenal bleeding are outlined.     

Strategy of treatment of patients with ulcerous gastroduodenal bleedings

The work is based on an analysis of results of treatment of 557 patients with gastro-duodenal bleedings. It was shown that using modem endoscopic methods of bleeding arrest (APC) and antisecretory preparations allowed successful conservative treatment of patients with ulcerous gastroduodenal bleedings, thus minimizing the probability of the development of recurrent bleedings. The proposed medico-diagnostic algorithm allowed total lethality to be decreased from 29.5 to 11.2%, and the number of compulsory operations from 16 to 11.2%.     

The treatment in ulcerative hemorrhages in patients with liver cirrhosis and portal hypertension

Treatment of 34 patients with bleedings from chronic gastroduodenal ulcers associated with cirrhosis of the liver and portal hypertension was analysed. Overall lethality was 41.2%, postoperative lethality was 41.7%. Temporary hemostasis due to a solution of Caprofen used during fibrogastroduodenoscopy allows the operation to be delayed and complex intensive therapy can be performed in patients with hepatic insufficiency. Control medical endoscopic investigations should be performed 4 and 12 hours after admission to the hospital of patients with sub- and decompensated cirrhosis of the liver with portal hypertension and symptoms of unstable hemostasis. The emergency and delayed operative treatment of patients with subcompensated hepatic insufficiency should include organ-saving operations such as vagotomy with pyloroplasty and/or dissection of the ulcer. Operation is indicated to patients with cirrhosis of the liver at the stage of decompensation but if they have evident reappearance of bleeding and in minimal volume. The attainment of final endoscopic hemostasis will allow to avoid surgical interventions intolerable for this category of patients.     

Stenotic bleeding pyloric ulcers

Treatment results in 110 patients with stenotic bleeding pyloroduodenal ulcers (SBPU) were analyzed. Correlation dependence of hemorrhage severity and recurrence frequency from the degree of pyloroduodenal stenosis was revealed. Recurrence of ulcer gastroduodenal bleeding - is the main factor that determines lethality at SPBU. The total lethality against a background of SPBU recurrence was 16%, whereas in the absence of recurrence it was 10%. Treatment tactics in patients with SPBU was worked out. The best results were received after urgent operations which had been carried out after short-term preoperative preparation, aimed to blood replacement and correction of water-electrolytic and protein-energy disturbances at pyloroduodenal stenosis.     

Endoscopic hemostasis of erosive-ulcerous gastroduodenal bleeding with fibrin glue at critically ill patients

Experience of endoscopic hemostasis of acute erosive-ulcerous gastroduodenal bleeding with fibrin glue at critically ill patients is described. This glue is adhesive substance based on high-concentrated solution of fibrinogen (concentration of protein not less 60 g/l). Application of adhesive permitted to stop the bleeding at 84 of 87 extremely seriously ill patients (mean point according to APACHE--II scale was 19.5+/-0.9). Prolonged endoscopic control with repeated application of adhesive permitted to avoid bleeding clinical recurrences, to stop repeatedly with endoscopy 4 of 6 recurrent bleedings, to avoid forced surgery at 80 of these patients. Adhesive accelerated significantly the healing of ulcers despite of hypoxic injury of mucosa. Endoscopic hemostasis permitted to avoid forced surgical aggression, to improve treatment results and to decrease lethality at critically ill patients.     

Reasons for the need to resect bleeding chronic ulcers of the duodenum and stomach

The radical character of organ-preserving operations with vagotomy in the management of bleeding gastroduodenal ulcers can be raised by using methods providing for radical excision of the pathological substrate. Removal of the ulcer prevents reliably recurrent bleeding in the early postoperative period and recurrent ulcer formation, which is linked with normalization of the autoimmune processes in the organism. The methods developed by the authors were applied in 738 patients suffering from acute gastroduodenal bleeding due to peptic ulcer. Total postoperative mortality was 2.7%, the incidence of recurrent ulceration--2%.     

Control of acute gastroduodenal hemorrhage with cimetidine.

Thirty-four patients with acute gastroduodenal hemorrhage were treated with intravenous Cimetidine. Preliminary endoscopy was done at the onset of bleeding to determine the source of bleeding and to rule out the presence of a brisk arterial bleeding site that would require immediate operation for control. Sixteen of the patients had primary peptic ulcer disease and 18 patients had "stress ulcer" syndrome. The bleeding stopped following Cimetidine administration in 14 of the 16 peptic ulcer patients (88%) and in 13 of 18 stress ulcer patients (72%). There was no subsequent rebleeding. The data suggest that Cimetidine is of value in the immediate nonoperative management of acute gastroduodenal hemorrhage. Further, the availability of Cimetidine for postoperative use may modify the surgical approach to stress ulcer bleeding.     

Diagnostic and therapeutic treatment policy in ulcerous gastroduodenal bleedings

Results of treatment of 796 patients with ulcerous gastroduodenal bleedings (UGDB) are analyzed. The study group consisted of 676 patients who have undergone endoscopic hemostasis. The control group consisted of 120 patients treated with traditional therapy. Endoscopic hemostasis in the study group was effective in 628 (92.8%) patients, recurrence of bleeding was seen in 21 (3.3%) patients. Effective hemostasis in the control group was achieved in 92 (76.6%) patients, recurrence of bleeding occurred in 13 (14.1%) patients. Positive result of Helicobacter pylori detection was in 600 (88.7%) patients. It is concluded that local treatment of ulcer with glue applications reduces 3 times number of bleeding recurrences.     

Choice of surgical strategy in gastroduodenal ulcer hemorrhage

An analysis of 567 patients aged from 15 to 89 years with gastroduodenal bleedings was made. Ulcer disease of the stomach was diagnosed in 173 (30.5%) patients, ulcer disease of the duodenum--in 354 (62.4%) patients, 26 patients (4.6%) had combined gastroduodenal ulcers, 14 patients (2.5%) had ulcers of the gastroenteroanastomosis (after Billroth-II operations). Operations were fulfilled in 250 (44.1%) of all the patients. The operation of choice at the high state of bleeding is considered by the authors to be resection of 1/2 of the stomach by the method modified in the clinic. Postoperative lethality was 4%, complications were noted in 12% of the patients. All the complications were nonspecific, i.e. characteristic of any operations on organs of the abdominal cavity. Incompetence of the anastomosis sutures was not noted which in our opinion can be accounted for by a specific method of forming the anastomosis. The average amount of bed-days after the operations was 19.5 +/- 3.3.     

Treatment of gastroduodenal bleedings: from surgery to therapy?

Results of treatment of 2352 patients with gastroduodenal ulcer bleedings were analyzed. Surgical treatment was performed at 495 (21%) of them. Emergency life-saving operation was performed at 78 (15%) patients, urgent operation after primary hemostasis - at 114 (23%), elective operations - at 303 (62%). Various resections were carried out at 78% cases, organ-saving surgeries - at 22%. The main problem in the treatment program of these patients is the prophylaxis of bleeding recurrence. Rational pathogenetic out-patient treatment of ulcer disease, prophylaxis of recurrences and complications are the key points which need close collaboration between surgeons and gastroenterologists.     

腹腔镜治疗胃十二指肠急性大出血的体会

目的:探讨腹腔镜手术治疗胃十二指肠急性大出血的应用价值及手术技巧。方法:回顾分析2010年8月至2012年1月5例胃十二指肠急性大出血患者经胃镜确诊并初步止血后行腹腔镜手术的临床资料。其中胃窦巨大溃疡出血2例,十二指肠球后溃疡出血、胃底溃疡出血、胃间质瘤胃镜活检后出血各1例。结果:5例患者经胃镜确诊并初步止血后急诊行腹腔镜手术,疗效良好,无一例围手术期死亡,术后无手术相关并发症发生。结论:腹腔镜手术治疗胃十二指肠急性大出血术中能快速处理病灶,止血效果确切,具有较高的治疗价值。