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%.     

Differential treatment of gastroduodenal ulcerous bleedings

Results of treatment of 827 patients with bleedings from chronic gastric and duodenal ulcers are analyzed. Potentialities of various methods of endoscopic hemostasis were studied. Diathermocoagulation was the least effective method of hemostasis (59%). Irrigation of the bleeding source provided hemostasis in 88.7% patients, combined methods - in 94.1%. Methods of irrigation are appropriate in diffuse bleeding from ulcer (Forrest 1B). Stream bleeding (Forrest 1A) is indication for combined methods of hemostasis. It is demonstrated that type of endoscopic procedure does not influence rate of bleeding recurrences. The main element of conservative treatment of gastroduodenal ulcerous bleedings is antisecretory therapy. Proton pump blockers are more effective than H2-blockers; the rate of recurrences was 5.0 and 28.9%, respectively. Prediction of bleeding recurrences and preventive operations are the main way to treatment results improvement.     

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%.     

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%.     

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.     

Recurrence of acute gastroduodenal ulcer bleedings

Multifactor analysis of 818 cases of acute gastroduodenal ulcer bleedings (clinical and laboratory examination, gastroscopy, morphological studies) was carried out, 97 of these patients had recurrence of bleeding. It is demonstrated that recurrence of gastroduodenal ulcer bleeding is cause by progressed ischemic necrosis in periulcerous zone in condition of local hypoperfusion as a result of systemic hemodynamic disorders due to acute blood loss syndrome and chronic ischemia dueto ulcerous process. Systemic hemostatic therapy, antisecretory drugs, methods of endoscopic hemostasis don't guarantee absence of bleeding recurrence. Prognosis of the recurrence must be based on assessment of significant clinical and gastroscopic data. Dynamical determination of pO2 in periulcerous zone is an additional prognostic criterion. Recurrence of gastroduodenal ulcer bleeding increases general and postoperative lethality 2 times as minimum. Active surgical policy based on prognosis of bleeding recurrence probability permitted us to reduce total lethality in acute gastroduodenal ulcer bleedings to 6.2%, postoperative lethality to 8.5%.     

Use of the protocols of organization of the medico-diagnostic care for ulcerous gastroduodenal bleedings in clinical practice

Results of realization of the protocols of organization of the medico-diagnostic care to patients with bleedings from chronic gastric and duodenal ulcers since 2002 have been analyzed. A simplified scale of the assessment of severity of ulcerous bleedings (UB) at admission including 8 criteria is proposed. Protocols of medical strategy for "severe UB" under conditions of the resuscitation unit are discussed. The principles of rendering the medico-diagnostic care for UB allowed stabilization of total lethality among these patients at the level of 3.4-3.7% at operative activity 27%. The possibility to improve results of the treatment of this pathology in future is associated by the authors with the available and high quality elements of conservative treatment.     

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.     

The hemostasis system state in patients with ulcerous gastrointestinal bleedings

In patients with gastrointestinal bleedings there occurs activation of the hemostasis system directed to arrest of bleeding. Short-term hypercoagulation directed to arrest of the bleeding gives place to hypocoagulative changes. Their degree and duration depend on the severity and rate of blood loss. The excessive intravascular activation of blood is accompanied by the formation of fibrin deposits not only in the area of the bleeding source but in other regions of the blood channel. There appears disseminated intravascular coagulation of blood deteriorating the reparative processes in the ulcer, initiating and maintaining generalized plasminemia which promotes the thrombus lysis in the ulcer crater and recurrent bleeding.     

Diagnosis, treatment and prophylaxis of acute ulcero-erosive gastroduodenal bleedings at cardiosurgical patients

Results of treatment of 495 patients who has undergone various cardiac operations with artificial circulation are analyzed. The complex program "Blood-free surgery" was used at 388 (78.4%) of them. Among the patients treated traditionally the acute gastroduodenal erosions and ulcers were diagnosed at 25.7% patients, the rate of gastroduodenal bleedings was 3.0%. Complex of prophylactic measures permits to reduce the rate of acute erosions and ulcers in 1.5 times (18.4%) and the rate of postoperative gastroduodenal bleedings--to 0.7%. Control of risk factors, timely diagnosis, complex prophylaxis and treatment of acute gastroduodenal erosions and ulcers are effective way to improvement of operations results at cardiosurgical patients. "Blood-free" program doesn't lead to increase of acute postoperative gastroduodenal erosions and ulcers rate. Endoscopic (including repeated) hemostasis at acute ulcero-erosive gastroduodenal bleedings is available method and permits to achieve the stable hemostasis.     

Potential of endoscopic hemostasis in patients with gastroduodenal bleedings

The authors have analyzed their experiences with treatment of 61 patients using the method of endoscopic clipping: 24 of them had the source of bleeding in chronic ulcers of the duodenal bulb, 6 had chronic gastric ulcers, 15 had acute gastric ulcers, 2 had acute ulcers of the duodenal bulb, Mallory-Weiss syndrome was found in 2 patients, Dieulafoy syndrome in 10 patients and one patient had peptic ulcer of the gastro-entero-anastomosis. The endoscopic clipping was made in 11 patients, in 31 patients injections of adrenaline and coagulation were added, in 9 patients--coagulation only, in 2 patients--irrigation with caproferon, in 8--adrenaline injections. In 57 out of 61 patients reliable hemostasis was achieved.     

Acute gastroduodenal bleedings against the background of diabetes mellitus

The authors have analyzed results of treatment of 60 patients with acute gastroduodenal bleedings against the background of diabetes mellitus. The main methods of diagnosis are the endoscopic and laboratory methods. In 60% of the patients the source of bleeding was acute erosion-ulcerous lesions, in 40% -chronic ulcers. Choice of the method of treatment depended on the source of bleeding, the degree of carbohydrate metabolism, the spectrum of concomitant pathology. Endoscopic hemostasis is the method of choice in treatment of acute and chronic ulcers of high risk of relapses in somatically burdend patients.     

The prevention and treatment of the gastroduodenal ulcer bleedings

The results of the complex prophylaxis and treatment of 33 458 patients with gastric or duodenal ulcer were analyzed. Of the analyzed group, 1002 (2,99%) patients experienced ulcer bleeding. The complex out-patient and stationary treatment of the ulcer disease allowed of bleeding frequency from 8,6 to 2,1%; the decrease of recurrent bleedings from 13,0% to 0; allowed to avoid major surgery (the previous frequency was as high as 14,5%) and decreased lethality rate from 9 to 1%.     

Vagotomy in the treatment of bleeding reflux-esophagitis and gastroduodenal bleedings

Fifteen-year experience in the treatment of 588 patients with esophageal and gastroduodenal bleedings is analyzed. Surgery was performed in 286 patients, 302 patients were treated conservatively including 71 patients who underwent endoscopic procedures. Principles of differentiated treatment policy are developed. Selective proximal vagotomy in combination with fundoplication (if indicated, with surgeries draining the stomach) is surgery of choice in bleeding reflux-esophagitis and gastroduodenal ulcerous bleedings. These methods eliminate pathogenetic factors of bleeding gastro-esophageal reflux, lower acidity of gastric juice.     

The role of endoscopy in diagnosis and treatment of gastroduodenal bleedings

The experience in diagnosis and treatment of 469 patients with gastroduodenal ulcer bleedings is presented. Sensitivity of endoscopy in detection of bleeding source was 98.8%, in detection of ulcer size -- 93.4%, specificity -- 80.6%. It is demonstrated that the most frequently recurrence of bleeding occurs when ulcer size is more than 1 cm. Location of ulcer on posterior, posterior-superior and posterior-inferior walls of the duodenal bulb is an unfavorable prognostic symptom (rebleeding occurs in 17.1, 30.0 and 12.5% cases, respectively). Types Forrest-Ia and Forrest-IIa are especially dangerous for recurrence (21.4 and 15.6%, respectively). In types Forrest-Ib and Forrest-IIb rebleeding occurs less frequently (4 and 6%, respectively). In types Forrest-Ia and Forrest-Ib rebleeding occurs mainly on the first day, rebleeding in types Forrest-IIa occurs more often on the first-second day, however it is possible up to day 7. Rebleeding in types Forrest-IIb occurs also mainly during the first two days. Endoscopic hemostasis (electrocoagulation and injection therapy) was performed in 40 patients. In 6 (15%) cases hemostasis was not achieved. In 8 (20%) cases endoscopic hemostasis led to a temporary effect, i.e. rebleeding was seen within 24-72 hours after endoscopic procedure. Stable hemostasis with endoscopy was achieved in 26 (65%) patients.     

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.