Diagnosis and treatment of patients with recurrent gastroduodenal hemorrhage - Shaprynskyi V.O. 2009

Introduction

Class="center">List of Abbreviations

BP - Blood pressure

AGIB - acute gastrointestinal bleeding

ITT - infusion-Transfusion Therapy

EHT - endoscopic hemostatic therapy

SVR - systemic vascular resistance

CBV — circulating blood volume

RR - respiratory rate

HR - Heart rate

CVP - central venous pressure

CT - computed tomography

MRI - Magnetic Resonance imaging

US - Ultrasound examination

ARF - ACUTE RENAL FAILURE

CRF - chronic renal failure

IV - intravenously

PCWP - pulmonary capillary wedge pressure

Under all circumstances, recurrent bleeding is an ominous sign, indicating that the Hemorrhage will continue and, even if it has stopped again, will recur.

Moshe Schein. Common Sense in Emergency Abdominal Surgery. Moscow. Geotar-Med, 272 p.

Despite significant progress in the conservative management of gastric and duodenal ulcers, and The Use of new effective H2-blockers and proton pump inhibitors that ensure long-term relapse-free disease course, the Treatment of gastroduodenal ulcers complicated by bleeding remains highly relevant. Profuse recurrent gastroduodenal bleeding is the most severe complication of PEPTIC ULCER DISEASE, associated with high mortality.

According to data from leading surgical clinics in Russia, the USA, and the UK, the overall mortality rate for acute gastrointestinal bleeding ranges from 1030% in Russia, 6-10% in the USA, and 4-10% in the UK. Moreover, in the USA and Russia, it has not changed over the last 30-40 years (A.A. Grinberg et al., 1999; Yu.M. Pantsyrev and E.D. Fedorov et al., 1999). Mortality is particularly high among individuals over 60 years of age (up to 40%), as well as among patients with Liver cirrhosis — up to 65% (V.V. Boyko et al., 2006, 2007; P.D. Fomin et al., 2005, 2006, 2008).

The occurrence of recurrent bleeding from gastric and duodenal ulcers after spontaneous or drug- and endoscopy-induced hemostasis is one of the most critical and challenging issues in the treatment of acute gastroduodenal ulcer bleeding. It is known that the cessation of ulcer bleeding, either spontaneously or under METABOLISM/18.html">The Influence of therapeutic measures, occurs in 85-95% of patients (Gostishchev V.K., Ivseev M.A., 2004). The use of systemic hemostatic therapy, effective antisecretory agents, the widespread clinical Structure/175.html">Implementation of endoscopic hemostasis Methods, and the recently popular eradication of Helicobacter pylori allow most physicians and many surgeons to rely solely on conservative hemostasis and transfer this category of patients to medical wards. However, another well-known fact—namely, the occurrence of recurrent ulcer bleeding in 12-35% of patients with duodenal ulcers and in more than 40% of patients with gastric ulcers (Saenko V.F. et al., 1997; Mityuk I.I. et al., 2002; Gostishchev V.K., Ivseev M.A., 2004; Bratus V.D., Fomin P.D., 2007; P.G. Kondratenko et al., 2007; Ye.M. Shepetko et al., 2008; Pandzins, 1994; Rockall et al., 1996)—makes such hopes, at least today, highly doubtful.

The famous surgeon S.S. Yudin called surgical interventions for recurrent bleeding 'operations of despair,' because 'these are the cases when, after failed hopes for conservative treatment... in cases of repeated bleeding, patients were taken without a pulse, almost always unconscious, with such severe anemia that one could hope not so much for the surgery as for a miracle' (Yudin S.S., 2003).

An analysis of domestic and foreign literature, as well as our own experience, shows that the treatment of patients with recurrent gastroduodenal bleeding remains a complex and unresolved problem.

Over the last decades, specialized centers for the treatment of patients with acute gastrointestinal tract bleeding have been established in Ukrainian cities such as Kyiv, Donetsk, Lviv, Odesa, Vinnytsia, and others. This book reflects the experience of the Vinnytsia Municipal Specialized Center, located at the abdominal department of the M.I. Pirogov Regional Clinical Hospital and the Clinic of Hospital Surgery and Endoscopy of the M.I. Pirogov Vinnytsia State Medical University, covering the period from 1996 to 2009. This gastrointestinal bleeding center has ensured rapid Diagnosis of the bleeding source and the provision of Emergency care at a high level.

According to consolidated WHO data, in countries where specialized clinics for this category of surgical patients had not been established at the time, a significant difference in treatment outcomes was observed (Saienko V.F. et al., 1997; Mitiuk I.I. et al., 2002; Gostishchev V.K., Evseev M.A., 2004; Kondratenko P.G. et al., 2006; Bratus V.D., Fomin P.D., 2007). However, despite modern advances in surgery, anesthesiology, endoscopy, and transfusion medicine, the treatment outcomes for patients with recurrent gastroduodenal hemorrhage remain far from optimal.

New insights into the causes of recurrent bleeding and the overall Pathogenesis of peptic ulcer disease, along with a wide range of modern pharmacological agents, have gradually led to a significant narrowing of indications for surgical intervention in peptic ulcer disease complicated by gastroduodenal hemorrhage. A substantial reduction in the number of surgeries has also been achieved due to continuous improvements in endoscopic hemostasis techniques (including irrigation of the bleeding source with medications, infiltration, electro- and photocoagulation, mechanical clipping, etc.).

However, Surgical treatment currently remains the only definitive preventive method to forestall recurrent bleeding, and an active surgical approach based on predicting the risk of bleeding recurrence remains the strategy of choice today for managing patients with gastroduodenal hemorrhage of ulcer Etiology.

Well-known monographs on gastroduodenal hemorrhage of ulcer etiology (Saienko V.F. et al., 1997; Kondratenko P.G. et al., 2006) published in recent years do not fully cover the application of modern capabilities for predicting recurrent bleeding, the Morphological Characteristics of recurrent ulcers, the use of sorbents and advanced antisecretory drugs in comprehensive conservative therapy, and potential surgical options for this pathology. Therefore, we believe that the publication of this book, aimed at familiarizing surgeons, oncologists, anesthesiologists-intensivists, and endoscopists with Modern Methods of Prevention, diagnosis, and treatment, as well as providing proper, expert care to patients with recurrent gastroduodenal hemorrhage, will be highly beneficial.

In writing this book, approximately 1,500 medical records of inpatients with peptic ulcer disease complicated by bleeding were analyzed, and the treatment outcomes of 285 patients with recurrent gastroduodenal hemorrhage of ulcer etiology were summarized. Familiarity with this experience should provide physicians with substantial assistance in addressing this challenging surgical issue. The monograph reflects the authors' long-term clinical experience in treating this specific patient population. We hope that the new approaches presented in this book will help improve the overall treatment outcomes of recurrent gastroduodenal ulcer bleeding.

Recognizing The complexity of addressing this issue, the authors will highly appreciate any constructive criticism and feedback, and will incorporate them into their future work. We hope that this book will be useful to a wide range of surgeons, oncologists, anesthesiologists-intensivists, endoscopists, gastroenterologists, resident physicians, and senior medical students.