2 English references Ulcerative bleeding
It is concluded that the amount and speed of bleeding depend on the type and inner diameter of eroded blood vessels, the relaxation and contraction of blood vessels and the coagulation mechanism of patients. When the capillary exudation reaches 5 ~ 10 ml every day, occult blood can be detected from feces. Positive can be caused by hemoglobin, myoglobin in diet or peroxidase from plants. Hemoglobin is black because it is oxidized by enzymes and bacteria in the intestine to produce methemoglobin. When the blood turns black, the time to pass through the intestine is more decisive than the bleeding point, and it is generally necessary to stay in the intestine for more than 8 hours. Blood stays in the stomach for a long time. Through the action of gastric acid, hemoglobin is converted into hemoglobin iron, which makes the vomited stomach contents brown. If the amount of venous bleeding is not very large, and there is not much blood in the stomach, it will be manifested as black stool, which can be tar-like or abnormal. If the intestine moves quickly, there may be blood in the black stool, and the bottom of the bedpan is often bright red. Arterial hemorrhage is generally acute massive hemorrhage, so vomiting blood is very common. Chronic gastric ulcer bleeding, mostly located in the posterior wall of gastric minor curvature, erodes the branch of left gastric artery. Chronic duodenal ulcer bleeding usually erodes the superior pancreaticoduodenal artery; The right gastroepiploic artery and pyloric artery are also often involved. A small amount of bleeding can be stopped by normal coagulation mechanism; The amount of bleeding will lower blood pressure, which will lead to thrombosis through vasoconstriction. After mechanization, granulation tissue is covered to stop bleeding, and it is generally difficult to obtain natural hemostasis for bleeding from great veins or arteries. Hemorrhage clinically refers to hypovolemic shock, with hemoglobin below 8g/ 100ml and red blood cell count below 3 million /mm3.
4 disease name ulcer bleeding
5 English name Ulcerative Hemorrhage
6 classification of gastroenterology >; Gastroduodenal diseases >: peptic ulcer
7 ICD number K25.0
Epidemiology: The blood vessels at the edge and bottom of ulcer are eroded, which can lead to different degrees of bleeding, ranking first among the causes of upper gastrointestinal bleeding. There were 519 15 cases of upper gastrointestinal bleeding in Beijing15 big hospitals, among which ulcer accounted for 48.7%, followed by esophageal varices rupture (25.4%). Followed by gastritis (4.5%) and gastric tumor (3.65438 0%). Hemorrhage accounts for about 20% ~ 30% of ulcer patients.
9 Causes of ulcer bleeding Both gastric ulcer and duodenal ulcer can be complicated, especially large area ulcer and deep ulcer, which often corrode the basal blood vessels of ulcer and cause bleeding. Pyloric ulcer and duodenal ampulla ulcer are more likely to cause bleeding, and it is often difficult to stop bleeding after bleeding.
10 Pathogenesis Generally, there is a small amount of bleeding on the ulcer surface, which is caused by the corrosion and destruction of capillaries at the bottom of the ulcer. When the larger blood vessels at the bottom of the ulcer are corroded and ruptured, both arteries and veins can cause massive bleeding. In the process of ulcer progress, the bottom tissue is constantly eroded, and the ulcer deepens, and finally it can penetrate the serosa layer of the stomach or duodenum wall and cause perforation. Acute perforation is common in anterior wall ulcer, and acute diffuse peritonitis is caused by duodenal or gastric contents flowing into abdominal cavity. Chronic ulcer penetration is common in posterior wall ulcers. A large number of scars can be formed in the healing process of pyloric anterior region, pyloric canal or duodenal ulcer. Due to the contraction of scar tissue, pyloric stenosis can be caused, and secondary inflammation, edema or pyloric muscle spasm around ulcer can also cause functional pyloric obstruction.
Clinical manifestations of ulcer bleeding 1 1 The clinical manifestations of ulcer bleeding depend on the amount and speed of blood loss, whether the bleeding lasts, the patient's age, anemia and dehydration, and mental state. Generally healthy adults, the amount of bleeding does not exceed 500ml, but there are no symptoms. Tissue fluid can restore blood volume within 36 hours, but the protein content is low and there is blood dilution, and red blood cells and hemoglobin can only be restored within 2 weeks. The reserve of normal spleen is too small to play much role.
When the blood loss is above 1000ml, symptoms such as palpitation, nausea and weakness may occur. When it exceeds 1500ml, hypotension may occur. According to the different bleeding speed, there are different manifestations such as dizziness, syncope and shock. If so, 2000ml will be lost in 15 minutes. Then there will be deep shock and even death. Half circulation was lost within 10h, and 10% of untreated patients died. If you lose blood for more than 24 hours, you will rarely die.
A large amount of blood loss reduces the blood volume, and the amount of blood returning to the heart decreases, so the cardiac output also decreases. Reflex vasoconstriction is caused by the action of sympathetic adrenaline; It is mainly the contraction of arterioles and veins, which reduces the blood flow of skin, skeletal muscle and viscera and increases the cardiac output by 25% to meet the blood supply of life-critical centers. Vascular contraction is beneficial to venous return, which is actually the transfer of blood from venous pool to arterial part of circulation to increase tissue perfusion. It is the performance of compensatory function before shock begins, especially when bleeding is slow. Therefore, in chronic bleeding, the estimation of blood pressure on bleeding volume is not a good indicator, especially for young people; Diastolic pressure is more valuable than systolic pressure to reflect the decrease of blood volume, except for hypertensive patients, whose diastolic pressure is easier to maintain than normal blood pressure. When the blood volume decreases, the heart rate increases before the arterial pressure decreases, so the change of pulse rate may provide more meaningful hints for blood loss. However, the pulse is influenced by mental state and rapid infusion, and the central venous pressure is a reliable index to reflect the return of blood to the heart. Urine volume per unit time can reflect tissue perfusion, but the possibility of high output syndrome in the presence of nephropathy and renal failure should be ruled out.
Hypovolemic shock is the main manifestation of massive hemorrhage, which is characterized by rapid pulse, systolic blood pressure lower than 10.7kPa(80mmHg), cold, wet and pale skin of limbs, shallow and rapid breathing, thirst, nausea, anxiety and mental disorder. Insufficient tissue perfusion can lead to oliguria and cell hypoxia; Anaerobic metabolism produces a lot of pyruvate and lactic acid. In the case of metabolic acidosis, the tension of blood vessels gradually disappears, the blood vessels gradually lose their response to endogenous adrenaline and norepinephrine, and finally the blood vessels dilate, and the patient may die of circulatory failure.
Ulcer bleeding complications 1. When acute massive hemorrhage exceeds 1000ml, there may be manifestations of hemorrhagic peripheral circulation failure, such as palpitation, dizziness, cold sweat, syncope, dampness and cold/minute, increased heart rate, rapid pulse, even irritability and delirium, and the heart rate often exceeds 120 times.
2. Fever: Patients with ulcer bleeding may have low fever, and the body temperature often does not exceed 38.5℃.
13 laboratory examination 1. Hemogram: The white blood cell and neutrophil counts often increase slightly, while the hemoglobin and red blood cell counts decrease (not obvious in the early stage).
2. Blood urea nitrogen: After bleeding, due to the increase of intestinal urea nitrogen, intestinal azotemia may occur. If the patient's renal function is normal, the degree of blood urea nitrogen increase can reflect the amount of bleeding.
14 auxiliary examination 14.65438+X-ray barium meal radiography has 70% ~ 90% accuracy in the diagnosis of ulcer. However, in shock state, it is not suitable when the patient can't stand or has a lot of blood clots in his stomach. It is generally advocated that this examination should be done after the condition is stable for 48 hours, and it should not be pressed during the examination. The presence of barium in gastrointestinal tract hinders the observation of arteriography results and should be considered in advance. At present, in the diagnosis of acute upper gastrointestinal bleeding, emergency gastroscopy has been chosen rather than the first choice.
14.2 The positive rate of gastroscopy can reach 80% ~ 95%, which is superior to X-ray gastrointestinal barium meal radiography in the diagnosis of upper gastrointestinal bleeding. Gastroscopy can not only see the nature of the lesion, but also see the reliable signs of active or recent bleeding, that is, fresh bleeding or oozing blood. The lesion area is dark brown with blood clots. According to the experience of 248 cases of emergency gastroscopy in 8 big hospitals in Beijing, it is considered that the risk of massive bleeding will not be increased. Hemostasis can be stopped under endoscope if necessary. As long as the patient's blood pressure is stable and close to normal, and the patient's worries and nervousness are eliminated, it will be performed next to the hospital bed or on the operating table. The inspection process should be simple and quick. Avoid rough lens insertion. The examination time should be within 24 ~ 48h after bleeding. Otherwise, some superficial mucosal lesions, such as erosion, superficial ulcer, mucosal tear and so on. , may lose diagnostic signs due to partial or total repair. There is no need for gastric lavage before examination. If the observation is affected by hematocele, the stomach can be washed with ice water before examination. Observation should be comprehensive, and don't be satisfied with finding a lesion and jumping to conclusions. After careful examination of esophagus, stomach and duodenum, diagnosis can be made. If necessary, biopsy can be performed for pathological examination. However, it should be noted that gastric varices sometimes appear as gray nodular bulges, but they are soft and elastic to the touch and easy to biopsy, which may cause serious bleeding.
14.3 selective celiac arteriography is also helpful for the localization diagnosis of acute upper gastrointestinal bleeding, but the positive rate of chronic minor bleeding is not high. Some hospitals take this as the first diagnosis step, and then do barium meal or other examination after failure.
14.4 The swallowing test method is simple. Generally, swallow one end with ordinary white thread for 30min minutes, and after taking it out, you can judge the bleeding according to the position where the front teeth are stained with blood. Pitman introduced fluorescence band test to diagnose upper gastrointestinal bleeding; After swallowing one end of the band, fluorescein was injected intravenously, then the band was pulled out, and the fluorescein-stained part was observed under ultraviolet light, and the length from the front teeth was calculated to determine the location of bleeding.
14.5 other experiments, such as the application of MillerAbbott(MA) double-lumen tube, continued to attract after being inserted into the gastrointestinal tract. When the tube draws blood downward, it is more effective to fix it with adhesive tape, take X-ray plain film to watch the position of the end and locate the slow bleeding. And red blood cells labeled with chromium. After intravenous injection, the radioactivity of every 1 sample taken from the horse tube was determined, and the sample with the strongest radioactivity contained 5 1 chromium, which was regarded as a bleeding point. This examination is of little value in the diagnosis of a small amount of intestinal bleeding. So it is rarely used.
14.6 Radionuclides scan red blood cells labeled with 99mTc, which overflow at the bleeding place after intravenous injection and gather in the gastrointestinal tract. Scan to detect radioactive signals in the gastrointestinal tract and indicate the location of gastrointestinal bleeding. But sometimes it is difficult to locate accurately.
15 ulcer bleeding history The diagnosis of ulcer, taking salicylic acid preparation or hormone history, combined with bleeding manifestations, is helpful for the diagnosis of this disease. 90% patients with peptic ulcer have "stomachache", but the pain disappears after bleeding. Unnecessary manual examination should be avoided during physical examination, and the abdomen should not be too hard. In order to further understand the electrolyte disorder and cardiac and renal function caused by bleeding and blood loss, it is necessary to draw blood to check hemoglobin, red blood cell and platelet count, hematocrit, sodium, potassium, chlorine, urea nitrogen or non-protein nitrogen, pH or carbon dioxide binding force and coagulation factors. When necessary, carbon partial pressure, blood volume, electrocardiogram and central venous pressure of oxygen and carbon dioxide should be measured to understand the state of circulatory system. It is of diagnostic and therapeutic significance to observe the urine volume per hour by indwelling catheter and insert gastric tube. First insert 40cm to suck out whether there is blood to exclude esophageal bleeding, and then insert it into the stomach to confirm that it is gastric or duodenal bleeding, and observe the bleeding dynamics. In order to make a further diagnosis, auxiliary examination should be considered.
16 Differential diagnosis 16. 1 Acute erosive gastritis or stress ulcer with bleeding often causes acute erosive gastritis or stress ulcer, such as taking non-steroidal anti-inflammatory drugs, brain injury, severe burns and multiple organ failure. Gastroscopy can confirm the existence of gastric mucosal congestion, edema, erosion and bleeding or stress ulcer.
16.2 patients with esophageal varices bleeding due to liver cirrhosis often have a history of liver cirrhosis. Physical examination can find spider nevus, liver palm, hepatosplenomegaly, ascites and edema, laboratory examination often shows liver function damage and pancytopenia, barium meal or gastroscopy can find varicose veins at the lower end of esophagus and gastric fundus.
16.3 patients with gastric cancer bleeding are generally in poor condition, with loss of appetite and obvious emaciation; Patients with advanced gastric cancer can often feel swollen lymph nodes in the left clavicle and palpable masses in the upper abdomen during physical examination. Barium meal and gastroscopy combined with mucosal biopsy can make a definite diagnosis.
17 treatment of ulcer bleeding 17. 1 medical treatment All ulcer patients with hematemesis or bloody stool should be hospitalized, and the patients should lie flat and raise their lower limbs. Keep warm, take oxygen, and measure pulse, blood pressure and breathing every 10 ~ 30 minutes. Give sedatives when necessary to calm the patient down.
17.1.1(1) In case of massive bleeding, blood transfusion should be started immediately during transit or after admission. Hypovolemic shock has occurred, and it is best to transfuse whole blood. In the process of blood type matching, you can first inject balanced solution or glucose physiological saline, and the infusion speed should be faster. When the blood pressure rises, the infusion speed and type should be determined according to the central venous pressure and urine output per hour. Measuring hemoglobin and hematocrit has direct guiding significance for blood transfusion. If it is difficult to transfuse "O" red blood cells into normal saline, the curative effect is good. Plasma can expand volume, but it can't carry oxygen, and it is easy to spread to extravascular space, which is not as ideal as whole blood. 5% human albumin and various plasma substitutes have a good effect on maintaining osmotic pressure. Crystal liquid is limited to meet the daily water demand, and should not be too much to avoid tissue edema. Can only play a short-term role in replenishing blood volume. Rapid blood transfusion has the risk of causing acute pulmonary edema and should be paid attention to. Generally, the hematocrit can rise to 40%, that is, there is no need for blood transfusion, and the blood in the blood bank should be heated first, close to the body temperature and then input. Otherwise, importing a lot of cold blood may lead to cardiac arrest. According to statistics, the incidence of cardiac arrest decreased from 58.3% to 6.8% when heated blood was given to patients with blood loss. Central venous pressure can reflect blood volume and right heart function. When the central venous pressure is lower than 0.5kPa(5cmH2O), infusion can be performed quickly, and care should be taken when it reaches 1kPa( 10cmH2O). Exceeding 1.5 kPa (1.5 cmH2O) indicates a large infusion volume. Urine volume can reflect cardiac output and tissue perfusion. For example, the urine output can reach 35 ~ 50ml per hour, indicating that the liquid intake has been basically satisfied. Continue to maintain and strictly record the amount of in and out.
17. 1.2 (2) The * * that maintains blood loss in the circulatory system can make blood vessels contract through the action of sympathetic adrenaline. Therefore, whether vasoconstrictors should be used after shock is still controversial. It is generally believed that vasoconstrictors are useless in hemorrhagic shock, but there are still many people who advocate using vasoconstrictors to avoid long-term hypotension when blood volume is not replenished in time. If the heart rate does not exceed 140 beats/min, 1 ~ 5 mg isoproterenol can be added into 500ml normal saline or other solutions for intravenous drip to enhance myocardial contractility, reduce venous pressure and peripheral resistance, and slightly dilate blood vessels. When the infusion volume is large, digitalis should be used to support heart function to prevent congestive heart failure. Commonly used hirsutin C (Ceylon) or toosendanin K, hirsutin C (Ceylon) is given intravenously at 0. 1 ~ 0.2 mg each time, and the dosage of 1 day does not exceed 1mg.
17. 1.3 (3) Correct acidosis, such as pH < 7.35, pCO2 > 6. 13 kPa (46 mmHg), suggesting respiratory acidosis, which requires deep breathing, adequate ventilation and discharge of accumulated carbon dioxide. If necessary, use a ventilator to assist breathing, or even do tracheal intubation to control breathing. If the binding force of carbon dioxide is low and there is metabolic acidosis, an appropriate amount of sodium bicarbonate solution should be injected intravenously according to the calculation. In order to avoid tissue edema caused by excessive sodium ions, intravenous infusion of THAM can correct metabolic acidosis and respiratory acidosis.
17. 1.4 (4) Hemostatic measures 17. 1.4. 1 ① Local drug hemostasis 4 ~ 8 mg of norepinephrine was added to 100ml physiological saline to temporarily constrict the blood vessels in the stomach to stop bleeding. 10 ~ 15 minutes can be repeated 1 time. Munsell solution is a basic ferrous sulfate [Fe2 (OH) 2 (SO4) 5] solution, which is made from crude ferrous sulfate after treatment with sulfuric acid and nitric acid. Pure liquid is brownish red and is a powerful astringent. When ulcer bleeding, it is usually diluted with normal saline to make a 5% solution. Montessori solution can't be taken orally, so it must be injected from the stomach tube. Use for 30 ~ 50ml each time, and repeat every 1 ~ 2h, which can be used for 2 ~ 3 times. Nausea, vomiting and stomach cramps occasionally occur after taking the medicine, which can be relieved by antispasmodic drugs.
Ice water gastric lavage has been popular for some time. Inject 250ml of ice water or ice salt water through the stomach tube every time, and then suck it out gently and slowly, and the total amount can reach 10L of ice water. Generally rinse for 20 ~ 30 min until the pumped water becomes clear. It has also been suggested that 1mmol/ml sodium bicarbonate solution is dripped through the stomach tube at the rate of 1000mmol/d, which has the effect of neutralizing gastric acid. Others advocate adding norepinephrine to ice water.
17. 1.4.2 ② histamine H2 receptor blocker, a systemic hemostatic drug, can reduce the secretion of basic gastric acid, which is helpful for hemostasis and ulcer healing. Although there are still different opinions on its curative effect, it is still used as an auxiliary hemostasis therapy in clinic. Cimetidine (0.4~0.6g) was diluted in 500 ml10% glucose solution and given intravenously twice a day. Ranitidine 0. 1g was dissolved in 500ml glucose solution and given intravenously 1 time/hour. Its efficacy can last for 10 ~ 12 hours. Famotidine can last for 24 hours, so it is generally given intravenously at 20mg( 100ml) once a day.
Somatostatin is a peptide with 14 amino acids. It has been found that intravenous drip can reduce abdominal blood flow and can be used for esophageal variceal bleeding caused by peptic ulcer and cirrhosis. 250μg somatostatin was diluted and then slowly injected intravenously, and then 250μg was injected every hour. After 8 ~ 12h treatment, the bleeding can stop.
17. 1.4.3 ③ Endoscopic hemostasis With the development of endoscopic treatment technology, endoscopic hemostasis of ulcer bleeding has achieved good results.
A. local compression to stop bleeding. For definite bleeding in a small part, direct compression of the bleeding site with biopsy forceps can temporarily stop bleeding during endoscopic examination. But it is more difficult for massive bleeding.
B, spraying local medicine to stop bleeding, inserting a plastic tube through the endoscopic biopsy hole, and directly spraying the medicine on the bleeding part. Commonly used drugs are 1% epinephrine solution and 5% Montessori solution.
C. local drug injection and warm hemostasis.
17.10.5 (5) Diet should be fasted when the stomach is in shock or full of nausea. There is a debate about the diet of patients with little bleeding, but most of them tend to eat. The reason is that diet can neutralize gastric acid, which is easy to maintain the balance of water and electrolyte and ensure nutrition. Eating can promote intestinal peristalsis, and blood and diet in the stomach can easily run down, which can reduce nausea and vomiting. There is also disagreement about what kind of diet to eat. Some people advocate liquid food or pure milk, while others advocate general diet. Whether it is possible for liquid food to wash away blood clots, advocate entering a semi-liquid nutritious and digestible diet, or soft food digested in advance. Most people hold the view that this diet itself is unlikely to cause bleeding.
Surgical treatment 17.2 About 20% ~ 25% of patients with bleeding due to ulcer need surgical treatment. The curative effect is satisfactory and it is easy to succeed, so the indication of operation is generally wide, and the problem lies in the timing of operation. I often meet some patients who are transferred to surgery late, have a long bleeding time, and have only 2 ~ 3g hemoglobin. As a rule, the operation should be performed after the bleeding stops and the hemoglobin rises to 6 ~ 8g. If the bleeding still doesn't stop, we must have an emergency operation, which is of course very dangerous. Surgical indications are summarized as follows:
(1) massive bleeding.
(2) Although the amount of bleeding is small, long-term conservative treatment is ineffective.
(3) Previous history of recurrent bleeding.
(4) The history of ulcer is long, and there were perforation or pyloric obstruction symptoms in the past.
(5) Those over 50 years old.
Preoperative preparation and choice of operation methods In the case of massive hemorrhage emergency, it is often not allowed to make perfect preparation before operation, but we should know the overall situation. Blood matching, blood transfusion and blood collection should be completed before entering the operating room. It's too late to insert gastric tube for gastric lavage, measure central venous pressure, indwelling catheter and wait until you enter the operating room. As for supplementing blood volume and correcting electrolyte disorder and acidosis, it can be done at the same time as the operation. Blood transfusion after thorough hemostasis will improve hemoglobin. Of course, if it is not an emergency, all this can be done before entering the operating room, which is bound to meet the requirements.
Chronic corpus callosum ulcer, gastric ulcer or huge ulcer are suitable for subtotal gastrectomy. Surgery should try to remove the ulcer, but it is sometimes difficult to remove the duodenal corpus callosum ulcer, and forced removal may damage important structures such as the common bile duct. At this time, after proper hemostasis, subtotal gastrectomy for open ulcer can be performed. However, it should be emphasized that the ulcer surface after suture hemostasis must be isolated from the gastrointestinal cavity, and the open ulcer cannot be left in the gastrointestinal cavity; Otherwise, when the hemostatic suture falls off after 7 ~ 8 days, fatal rebleeding will occur. Therefore, Nissen method can be used. Hemorrhagic callosum ulcer is often located in the posterior wall and medial wall of duodenal ampulla, while the anterior wall and lateral wall of duodenum opposite to ulcer are normal. The posterior and medial walls of the duodenum can be removed by sticking to the proximal edge of the ulcer, while the anterior and lateral walls opposite to the ulcer are left longer. Sewing the cutting edges of the front and outer side walls on the far edge of the ulcer is the first layer of suture. Then the seromuscular layer of the front side wall was sutured to the ulcer base as the second layer, and the mucosa on both sides of the ulcer interfered with the suture of the second layer. Can be properly eliminated. Finally, the seromuscular layer of the anterior side wall of the duodenum is stitched together with the proximal edge (cutting edge) of the ulcer or pancreatic sac to form a third suture. Therefore, the ulcer base after suture hemostasis is isolated from the gastrointestinal cavity (figure 1).
The patients with short medical history, small and soft ulcer and superficial and easy suture, especially young people, are suitable for selective vagotomy. If there is pyloric obstruction or pylorus has been cut to stop bleeding, pyloroplasty should be done at the same time. If gastrectomy for open ulcer or vagotomy after suture hemostasis cannot isolate the ulcer surface after suture hemostasis from the gastrointestinal cavity, the corresponding artery can be ligated to prevent rebleeding. Such as ulcer near pylorus and ligation of gastroduodenal artery; High gastric ulcer, left gastric artery ligation. The so-called blind subtotal gastrectomy is not reliable to stop bleeding; Finding the bleeding focus and cutting it off, or stopping bleeding completely, is a successful operation.
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18 prognosis After the peptic ulcer bleeding was cured by medical treatment, 10% ~ 50% of the patients bled again within 5 years. Mortality is closely related to age. The mortality rate under 60 years old is 2% ~ 5%, and the mortality rate over 60 years old is 2 ~ 3 times that of the former. The operative mortality rate varies from 2% to 10% in different hospitals. The operative mortality of duodenal ulcer bleeding is higher than that of gastric ulcer bleeding.
19 prevention of ulcer bleeding All patients with ulcer history should be treated actively, regularly and systematically to prevent ulcer bleeding, a complication of ulcer disease.
Related drugs: oxygen, epinephrine, norepinephrine, urea, salicylic acid, carbon dioxide, glucose, human albumin, isoproterenol, digitalis, sodium bicarbonate, ferrous sulfate, histamine, cimetidine, ranitidine, famotidine and somatostatin.
2 1 correlation examination of hemoglobin, red blood cell count, blood urea nitrogen, urea nitrogen, platelet count, hematocrit, carbon dioxide binding capacity, carbon dioxide partial pressure and bleeding time.
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