Transcript Presentation

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
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.
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 %.
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.
Gastric blood supply
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.
Innervation of a stomach
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.
occult bleeding signs
• vertigo;
• Weakness;
• unconsciousness;
• Cold sweat;
• Noise in ears;
• Decreasing BP, tachycardia
Signs of evident GI bleedings :
• haemathomesis
• melenomesis
• melena
• haemathoshysis
• Decreasing Hb
• decreasing BP
• Tachycardia
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
target
Haemorrhagic shock
Acute losing 50% of blood volume
Acute circulatory insufficiency
Disproportion between vessels volume and
circulating blood volume
Decreasing CBV
Tissue anoxia
Vascular conservation
Systemic changes
bleeding
RBC losing
Stimulation of erithropoesis
Rheologic changes
volume increasing
DIC syndrome
Endogenous toxemia
Immune agression
Cardiac changes at GIB
bleeding
P decreasing at right a atrium
Decreasing stroke volume
Decreasing capillar blood flow
Decreasing P in aorta
Blood supply disorders in heart muscles
Renal insufficiency at GIB
Solid bleeding
Renal blood supply violations
Increased renin secretion
Tubular blood supply disoders
Acute renal insufficiency
Liver failure
bleeding
Liver hypoxia
Functional violations
Acute liver failure
erosive-ulcerous
lesions
of a stomach and
duodenum
Bleedings from
Varicose dilated
Esophageal veins
gastric and intestinal
Angiodysplasia
( Veber-Osler-Randu disease )
Gastric tuberculosis, syphilis .
Hypertrophic gastritis
Malory-Weiss syndrome
aortic aneurism rupture
Blood
to duodenal
diseases
space
alien bodies
gastrinoma,
Gastric poliposis
Basic sources of bleedings
30
я.б.ж.
№
causes
%
I
ulcerous
52,69
Stomach ulcer
20,87
Acute SU
1,57
Duodenal ulcer
29,79
Peptic ulcer of
anastomosis
1,44
25
20
15
10
5
0
о.я.
я.б.12пк
п.я.а.
п.я.ж.12
пк
0,59
Perforated ulcer of a
duodenum and a
stomach
II
16
14
12
10
8
6
4
2
0
р.ж
г.г
д.о.ж.
ц.п.
г.п.о.д.
р.п.
п.б.с.
д.п.
д.12пк.
о.12пк
д.о.ф.с.
б.о.
р.п.ж.
з.к.
III
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
nondeterminated
4,2
In all
100
Tasks
This direction of diagnostic job assumes the decision of several questions:
1.
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.
3.
4.
Establishments of the fact proceeding or rested bleeding (by Forrest)
In conditions of a stopped bleeding - decision of a question on stability
of hemostasis
5. Diferential diagnosis from upper GIB.
Establishment of a
bleeding
•complaints
F-Ia
F-Ib
F-IIa
EEGDFS
ЭEB
Endoscopic
coagulation by ethanol,
Adrenalin chiping
Establishment of causative
factors
No response
Urgent
surgery
Urgent surgery
Endoscopic coagulation,
checking BP, Ps, Нв, Ht
Recurrent
GIB
Postpone
surgery
F-IIb
F-IIc
Haemostatic therapy,
checking (Bp, Ps, Нв, Ht),
pathogenic
therapy
discharging
Refusins
from
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)
bleeding
(J.A. Forrest, 1974 )
F-Ia
F-Ib
bleeding
(J.A. Forrest, 1974 )
F-IIа
F-IIb
F-IIc
Blood in a stomach.
Duodenal ulcer
Dilated varicose veins of esophagus.
Tactics
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.
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
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
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
preventive measures
• ranitidin
• omeprazole
• Secretin
• somatostatin
electrocoagulation
Laser hemostasis
Infiltration hemostasis
Injection hemostasis
diathermo-coagulation
Medicines application
cryotherapy
Mechanical hemostasis
Film-forming medicines
• 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
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)
Surgical tactics at GDB includes:
• Definition of the indications to operation
• Definition of term of realization of operations
• Choice of a method of operation
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.
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
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
Radical operations
• resection 2/3 by B 1
• resection 2/3 by B 2
• Vagotomypilorantrumectomy
Conditionally radical operations
Conditionally radical operations
Conditionally radical operations
Palliative operations
• Gastrostomy with ligating of a bleeding vessel
or wedge-shaped excision of a ulcer
• Operation on S. J. Mintz (1980) ligating of a
bleeding ulcer of a stomach through all layers
(without opening a stomach) endoscopic
intraoprational by the control
• Bandaging of vessels of a stomach and
duodenum
Thank you
for attention!!!