Gastrointestinal bleeding is the outflow of blood from the blood vessels eroded or damaged by the pathological process into the lumen of the digestive organs. Depending on the degree of blood loss and the localization of the source of bleeding, vomiting of the color of “coffee grounds”, tar-like stools (melena), weakness, tachycardia, dizziness, pallor, cold sweat, fainting states may occur. The source is established taking into account the data of FGDS, enteroscopy, colonoscopy, rectoromanoscopy, diagnostic laparotomy. Bleeding can be stopped conservatively or surgically.
Gastrointestinal bleeding is the most frequent complication of a wide range of acute or chronic diseases of the digestive system, representing a potential danger to the patient’s life. The source of bleeding can be any part of the gastrointestinal tract – esophagus, stomach, small and large intestines. According to the frequency of occurrence in abdominal surgery, gastrointestinal bleeding ranks fifth after acute appendicitis, cholecystitis, pancreatitis and strangulated hernia.
Causes of gastrointestinal bleeding
To date, more than a hundred diseases have been described that can be accompanied by gastrointestinal bleeding. All hemorrhages can be conditionally divided into 4 groups: bleeding with gastrointestinal tract damage, portal hypertension, vascular damage and blood diseases.
Bleeding that occurs with gastrointestinal tract lesions may be caused by gastric ulcer or peptic ulcer of the 12p. intestine, esophagitis, neoplasms, diverticula, hernia of the esophageal orifice of the diaphragm, Crohn’s disease, ulcerative colitis, hemorrhoids, anal fissure, helminthiasis, injuries, foreign bodies, etc. Bleeding on the background of portal hypertension, as a rule, occurs with chronic hepatitis and cirrhosis of the liver, thrombosis of the hepatic veins or portal vein system, constrictive pericarditis, compression of the portal vein by tumors or scars.
Bleeding that develops as a result of vascular damage, etiologically and pathogenetically may be associated with varicose veins of the esophagus and stomach, nodular periarteritis, systemic lupus erythematosus, scleroderma, rheumatism, septic endocarditis, beriberi C, atherosclerosis, Randu-Osler disease, thrombosis of mesenteric vessels, etc.
Bleeding often occurs in diseases of the blood system: hemophilia, acute and chronic leukemia, hemorrhagic diathesis, vitamin K deficiency, hypoprothrombinemia, etc. Factors directly provoking pathology may be taking aspirin, NSAIDs, corticosteroids, alcohol intoxication, vomiting, contact with chemicals, physical stress, stress, etc.
The mechanism of occurrence of gastrointestinal bleeding may be due to a violation of the integrity of blood vessels (with their erosion, rupture of walls, sclerotic changes, embolism, thrombosis, rupture of aneurysms or varicose nodes, increased permeability and fragility of capillaries) or changes in the hemostasis system (with thrombocytopathy and thrombocytopenia, violations of the blood coagulation system). Often, both vascular and hemostasiological components are involved in the mechanism of bleeding development.
Depending on the part of the digestive tract, which is the source of hemorrhage, there are bleeding from the upper parts (esophageal, gastric, duodenal) and lower gastrointestinal tract (small intestine, large intestine, hemorrhoidal). The outflow of blood from the upper parts of the digestive tract is 80-90%, from the lower – 10-20% of cases. In accordance with the etiopathogenetic mechanism, ulcerative and non-ulcerative gastrointestinal hemorrhages are isolated.
Acute and chronic bleeding are distinguished by duration; by the severity of clinical signs – obvious and hidden; by the number of episodes – single and recurrent. According to the severity of blood loss, there are three degrees of bleeding. The mild degree is characterized by a heart rate of 80 per minute, systolic blood pressure – not lower than 110 mm Hg, satisfactory condition, preservation of consciousness, slight dizziness, normal diuresis. Blood counts: Er – above 3.5 x 1012 / l, Hb – above 100 g / l, Ht – more than 30%; BCC deficiency – no more than 20%.
With moderate bleeding, the heart rate is 100 beats per minute, systolic pressure is from 110 to 100 mm Hg, consciousness is preserved, the skin is pale, covered with cold sweat, diuresis is moderately reduced. In the blood, a decrease in the amount of Er is determined to 2.5 x 1012 / l, Hb – up to 100-80 g / l, Ht – up to 30-25%. The deficit of the BCC is 20-30%. A severe degree should be considered with a heart rate of more than 100 beats. in min. weak filling and tension, systolic blood pressure less than 100 mm Hg, patient’s inhibition, adynamia, sharp pallor, oliguria or anuria. The number of red blood cells in the blood is less than 2.5 x 1012 / l, the Hb level is below 80 g/l, Ht is less than 25% with a BCC deficiency of 30% or higher. Bleeding with massive blood loss is called profuse.
Gastrointestinal bleeding symptoms
The clinic of gastrointestinal bleeding manifests with symptoms of blood loss, depending on the intensity of hemorrhage. The condition is accompanied by weakness, dizziness, skin poverty, sweating, tinnitus, tachycardia, arterial hypotension, confusion, sometimes fainting. When the upper gastrointestinal tract is affected, bloody vomiting (hematomesis) appears, which looks like “coffee grounds”, which is explained by the contact of blood with hydrochloric acid. With profuse gastrointestinal bleeding, the vomit masses have a scarlet or dark red color.
Another characteristic feature of acute hemorrhages from the gastrointestinal tract is a tar-like stool (melena). The presence of clots or streaks of scarlet blood in the stool indicates bleeding from the colon, rectum or anal canal. The symptoms of hemorrhage are combined with the signs of the underlying disease. At the same time, there may be pain in various parts of the gastrointestinal tract, ascites, symptoms of intoxication, nausea, dysphagia, belching, etc. Latent bleeding can be detected only on the basis of laboratory signs – anemia and a positive reaction of feces to latent blood.
The examination of the patient is carried out by an abdominal surgeon, begins with a thorough clarification of the anamnesis, assessment of the nature of vomit and bowel movements, finger rectal examination. Pay attention to the color of the skin: the presence of telangiectasias, petechiae and hematomas on the skin may indicate hemorrhagic diathesis; jaundice of the skin indicates trouble in the hepatobiliary system or varicose veins of the esophagus. Palpation of the abdomen is carried out carefully, in order to avoid increased gastrointestinal bleeding.
From laboratory parameters, the calculation of erythrocytes, hemoglobin, hematocrit number, platelets is carried out; coagulogram study, determination of creatinine, urea, liver samples. Depending on the suspected source of hemorrhage, various radiological methods can be used in the diagnosis: radiography of the esophagus, stomach x-ray, irrigoscopy, angiography of mesenteric vessels, celiacography. The fastest and most accurate method of examination of the gastrointestinal tract is endoscopy (esophagoscopy, gastroscopy, colonoscopy), which allows you to detect even superficial mucosal defects and the direct source of gastrointestinal bleeding.
To confirm the bleeding and identify its exact localization, radioisotope studies are used (gastrointestinal scintigraphy with labeled erythrocytes, dynamic scintigraphy of the esophagus and stomach, static intestinal scintigraphy, etc.), MSCT of the abdominal cavity. Pathology must be differentiated from pulmonary and nasopharyngeal bleeding, for which X-ray and endoscopic examination of the bronchi and nasopharynx is used.
Gastrointestinal bleeding treatment
Patients are subject to immediate hospitalization in the surgical department. After clarifying the localization, causes and intensity of bleeding, therapeutic tactics are determined. With massive blood loss, hemotransfusion, infusion and hemostatic therapy is performed. Conservative tactics are justified in the case of hemorrhage developed on the basis of hemostasis disorders; the presence of severe intercurrent diseases (heart failure, heart defects, etc.), inoperable cancer processes, severe leukemia.
When bleeding from varicose veins of the esophagus, its endoscopic stop can be performed by ligation or sclerosing of altered vessels. According to the indications, they resort to endoscopic stopping of gastroduodenal bleeding, colonoscopy with electrocoagulation or piercing of bleeding vessels. In some cases, surgical arrest of gastrointestinal bleeding is required.
So, with a stomach ulcer, a bleeding defect is stitched or an economical stomach resection is performed. In case of a duodenal ulcer complicated by bleeding, the stitching of the ulcer is supplemented with stem vagotomy and pyloroplasty or antrumectomy. If the bleeding is caused by nonspecific ulcerative colitis, subtotal resection of the colon is performed with the imposition of ileo- and sigmostomy.
Prognosis and prevention
The prognosis for gastrointestinal bleeding depends on the causes, the degree of blood loss and the general somatic background (patient’s age, concomitant diseases). The risk of an adverse outcome is always extremely high. Prevention consists in the prevention and timely treatment of diseases that can cause hemorrhage.