BLEEDING FROM THE DIGESTIVE TRACT. CAUSES, DIAGNOSTIC AND DIFFERENTIAL DIAGNOSTIC, TREATMENT TACTIC.
GASTRIC ANATOMY AND PHYSIOLOGY
Pic. The anatomic relationships in the upper abdomen. The stomach is bounded on its left by the spleen, posteriorly (dorsally) by the pancreas, inferiorly (caudally) by the colon, and to its right by the duodenum along the liver’s edge.
Pic. 1 — lig. hepatogastricum; 2— lien; 3— gaster; 4— lig. gastrocolicum; 5— duodenum; 6— lig. hepatorenale; 7— foramen epiploicum (Winslovi); 8 — lig. hepatoduodenale; 9 — vesica fellea; 10 — hepar; 11 — lig. teres hepatis
Pic. 1 — lien; 2 — aa. et vv. gastricae breves; 3 — a. et v. gastrica sinistra; 4 — trun-cuscoeliacus; 5-а. lienalis; 6-а. he-patica communis; 7 — a. et v. gastro-epiploica sinistra; 8—gaster; 9— omentum majus; 10—a. et v. gastroomentalis dextra; 11 — duodenum; 12—a. et v. gastricadextra; 13-а, et v. gastroduodena-lis; 14 — ductus choledochus; 15 — v. cava inferior; 16— v. portae; 17 — a. hepatica propria; 18 — hepar; 19 — vesica fellea
Pic. Anatomically, the stomach is divided into several segments. Functionally, the cardia and the antrum differ from the body in that they contaio acid secretory properties. The incisura is an area on the lesser curvature, which marks the antrum-body junction and is often easily seen on barium upper intestinal series.
ACUTE GASTROINTESTINAL BLEEDINGS.
The efflux of a blood in a cavity of a gastrointestinal tract is united in a syndrome of gastrointestinal bleedings, which can be acute, arising suddenly, and chronic, beginning imperceptibly and quite often proceeding for long time. Besides the gastrointestinal bleedings can be obvious and concealed. At concealed hemorrhages the impurity of a blood in contents of a gastrointestinal tract (vomitive masses, stools) can be found out only with the help of laboratory methods of research (for example, reaction of Gregerson), and such bleedings are not included into group of acute gastrointestinal bleedings. At obvious bleedings the blood is found out iot changed kind together with contents of a gastrointestinal tract and its presence is found out at usual survey of vomitive masses or stools. In clinical current of a peptic ulcer of a stomach and duodenal intestine the gastrointestinal bleedings can arise in any of the listed above variants.
At an ulcer of a stomach and duodenal intestine the gastrointestinal bleeding arises at each fourth – fifth patient with these diseases. Approximately at half of persons, died from a peptic ulcer of a stomach and duodenal intestine a gastrointestinal bleeding was an immediate cause of death.
ETIOLOGY.
More than 100 diseases of the man are knowow, during which there can be an acute gastrointestinal bleeding. In frame of the reasons of such bleedings about 60 % are made by an ulcer of a stomach and duodenal intestine; others 40 % — other diseases: tumours of a stomach (15—17 %), errosive and hemorrhagic gastritis (10 — 15 %), syndrome of Mellory – Vase (8 — 10 %), syndrome of a portal hypertension (7 — 8 %), tumours of an intestine, ulcerative colitis, divertuculosis and other diseases (7 — 10 %).
Pathogenesis of acute gastrointestinal bleedings at various diseases is various: at malignant neoplasms the reason of bleedings usually is the disintegration and ulceration of a tumour; at a syndrome of a portal hypertension — trophic changes of mucosa, ulceration and breaks of walls of the extended veins of a stomach and esophagus owing to a portal crisis; at a syndrome of Mellory – Vase — destruction of walls of blood vessels owing to break mainly of mucous and submucous layers of a cardial department of a stomach; at an angiostaxis, leukoses, illness of Verlgoff, general diseases of a blood and hemorrhagic diathesises the pathogeny of bleedings is connected to change of coagulative properties of a blood, disorders of a capillary permeability and quantitative or (and) qualitative failure of thrombocytes.
The pathogeny of acute gastrointestinal bleedings at an ulcer of a stomach and duodenal intestine is rather complex, as in one cases the bleeding occurs from arrosived large vessels in the field of an ulcer, in others — from small arteries both veins of walls and fundus of an ulcer, in third — there is a parenchymatous bleeding from a mucous coat of stomach outside of an ulcer, where alongside with a hyperpermeability of a vascular wall multiple small arrosions, being a source of a profuse bleeding, quite often are found out. Plentiful meal of rasping nutrition, especially under conditions of difficulty of its evacuation from a stomach, physical strain, the blunt trauma of a stomach, especially at the filled stomach provoke gastrointestinal bleedings at a peptic ulcer.
At a bleeding owing to an arrosion of a wall of a large blood vessel in the field of an ulcer, arising as a result of a necrosis and the subsequent influence of a gastric chyme on a wall of a naked blood vessel (more often of an artery), destruction of a vascular wall and the occurrence of a bleeding usually occurs in a phase of an exacerbation of a peptic ulcer and the lumen of an arrosived vessel frequently remains open, as the destruction of tissue frames prevails above proliferative processes in a zone of a bleeding point. The local factors of a hemostasis, including a retraction of a vessel (rather circumscribed owing to degenerative changes of a vascular wall and fibrosis of environmental tissues), aggregation of elements of a blood, the formation of a thrombus, are insufficient for spontaneous stopping of a bleeding and it quite often accepts profuse character.
At a slowly progressing ulcer outside of a phase of an exacerbation the productive inflammation of a vascular wall can handicap to a massive bleeding even at an arrosion of a large vessel, which lumen frequently appears narrowed owing to a proliferation of an intima and subendothelial frames, therefore clottage of such vessel can be sufficient for a spontaneous stopping of a bleeding. However in a wall of chronic ulcers there can be focal degenerative changes of blood vessels with formation of arterial aneurysms in the field of edges and fundus of an ulcer. The destruction of thin walls of these aneurysmal expansions is accompanied by serious profuse bleedings.
The pathogeny of bleedings is less investigated at microscopical defects in walls of small blood vessels of a fundus and edges of an ulcer, but in these cases, apparently, a progressing necrosis in a crater of an ulcer, inherent to a phase of an exacerbation of disease, has the decisive meaning in a pathogeny of a bleeding. A pathogeny of bleedings from a mucosa of a stomach outside of an ulcer also is unsufficiently found out. On the data of series of researches, the basic pathogenetic mechanisms of such bleedings can be:
— A permanent plethora of all vascular system of a stomach, especially superficial capillaries and veins causing a hypoxia and disorder of a vascular-tissue permeability, that results to massive erythropedesis and hemorrhage;
— Expressed dystrophia of superficial layers of a mucosa and decrease of an exchange of nucleic acids promoting to formation of microerosion;
— Accumulation of neutral mucopolysaccharides as a consequence of disintegration of tissue peptic-carbohydrate bonds and increase of a vascular permeability;
— Disorder of rhythms of polymerization and depolymerization of acidic mucopolysaccharides in a wall of blood vessels, change of a permeability of hematoparenchymatous frames;
— Hyperplastic and dystrophic processes, reorganization and pathological neogenesis of Glands of all gastric systems, breaking secretory activity of a stomach, bolstering a vasodilatation and tissue hypoxia (V.D. Bratus)
The appreciable role in a pathogeny of acute gastroduodenal bleedings at a peptic ulcer is played also by disorders in system of a hemostasis. They are reduced to decrease and complete loss by an arrosived vessel of ability to a retraction, which posesses a rather essential role in mechanisms of a local spontaneous hemostasis. In acidic medium there is an inactivation of Thrombinum, that results in decrease of coagulant ability of a blood, and than above acidity of a gastric juice, especially is oppressed coagulant system of a blood in the intragastric center of a bleeding. Simultaneously with dropping of a coagulability of a blood immediately in the field of a locating of a bleeding point, under influence of acidic medium of a gastric chyme and chemically active proteolytic enzymes, contained in it, the fibrinolytic activity raises. This is promoted also by trypsinums, discharged with a tissue of a pancreas, if the bleeding ulcer penetrates in this organ.
In process of increase of gravity of a hemorrhage there are attributes of a hypercoagulation of a blood, its fibrinolytic activity even more amplifies and reologic property are worsened owing to progressing aggregation of elements of blood (V.V. Rumantsev).
The deficiency of vitamins P, C, K, especially in the winter-spring period, when the exacerbations of a peptic ulcer arise most frequently, also breaks mechanisms of a hemostasis. For these reasons, despite of decrease of bloody pressure in bleeding vessels, owing to an oligemia and collapse the independent spontaneous stopping of a gastroduodenal bleeding at an ulcer of a stomach and duodenal intestine is always problematic. As well as at any acute hemorrhage, the condition of the patient is characterized by the following changes: decrease of mass of a circulating blood, centralization of a circulation and disorder of cardiac activity, that at the end results in an oxygen starvation first of all of cardiac muscle, parenchymatous organs and brain.
PATHOLOGICAL ANATOMY.
Most frequently morphological changes at acute gastroduodenal bleeding specify the roughly progressing necrosis reaching deeplocated blood vessels with a necrosis of their walls at a kept lumen. In other cases on a surface of an ulcer there is a thin layer of necrosed tissue consisting of unstructured basis, in which parts of nuclear disintegration are non-uniformly posed. Quite often in unstructured basis there are strings of a fibrin more concentrated in the field of a fundus of an ulcer, than its edges. Less often zone of a necrosis is absent and surface of an ulcer is covered only with strings of a fibrin containing in a plenty the rests of breaking up nucleuses of leucocytes and lymphocytes. More often zone of a necrosis penetrates in deeper located connective tissue, which at a chronic ulcer is usually covered with granulations, is plentiful infiltrated by leucocytes, hystiocytes, plasma cells. The fundus of an ulcer, as a rule, consists of a fibrous connective tissue, poor for cellular elements, and the infiltration with lymphoplasmocytes is expressed mainly on a course of blood vessels and in its superficial layers.
CLASSIFICATION.
The acute gastroduodenal bleedings are differed basically to two classification attributes: bleedings owing to a peptic ulcer of a stomach both duodenal intestine and bleeding of a not ulcerative etiology. Bleedings also are distinguished on localization of its source (stomach, duodenal intestine and their anatomic departments). The rather large practical importance there is a classification of gastroduodenal bleedings by gravity of a hemorrhage. Thus, the application of these simple classification attributes provides an establishment of the etiological and topical diagnoses in aggregate with definition and degree of gravity of a hemorrhage, that is necessary for definition of medical tactics and contents of transfusion therapy.
Clinic. The acute gastroduodenal bleedings usually arise suddenly on a background of habitual for the patient an exacerbation of a peptic ulcer or other of the listed above diseases. Quite often after the begun gastrointestinal bleeding at peptic ulcers pains in epigastric area, available up to it, disappear (sign of Bergmann). Simultaneously with it or earlier common signs of an acute hemorrhage occur — paleness of seen mucous and dermal integuments, giddiness, hum in a head, ears, quite often syncopal condition, and then in 15 — 20 minutes and later occur a hematemesis and melena. The vomitive masses at acute gastroduodenal bleedings can be as «coffee», that usually specifies a slow bleeding, and the given vent blood has time in a lumen of a stomach to react with acidic gastric contents, therefore the haemoglobin turns to a hydrochloride hematin having dark brown colour. At a plentiful bleeding, especially if its source is posed in a stomach the given vent blood has not time to react with a gastric chyme, it is coagulated and forms blood clots which are filling lumen of a stomach. These clots on appearance sometimes remind a crude liver and the patients quite often mark a vomiting «with pieces of a liver*. At a very intensive bleeding the overflow of a stomach and the vomitive act arises earlier, than blood clots have time to be formed and there is a vomiting by a scarlet blood, that is. as well as vomiting with blood clots, attribute of a serious bleeding from the top departments of a gastrointestinal tract. The vomiting replicating in short intervals of time, specifies continuation of a bleeding, and the occurrence of a vomiting in a long interval testifies to a relapse of a bleeding.
At a slow and not intensive bleeding, especially if the source located in a duodenal intestine, on a background of the moderately expressed signs of an acute hemorrhage the dark stools can appear, the impurity of a blood in which is easily found out by the expressed positive reaction of Gregerson. In case of an anamnestic bleeding shown by a melena, at inspection of the patient it is necessary to carry out digital research of a rectum, that allows to determine character of its contents and presence of an impurity, undergone to decomposing with formation of sulfurous Ferri lactas of a blood, that gives dark colour to such clots. At more intensive bleeding owing to exaltation by the given vent blood of peristaltic activity of an intestine occurs a liquid tarry stools, and at a very intensive bleeding stools, sometimes consensual, can look like «cherry jam» or consist from small-transformed blood.
The acute gastrointestinal bleedings, shown only by a melena, have more favorable prognosis in comparison with bleedings, shown by a hematemesis. There is the most adverse prognosis at bleedings, shown by a hematemesis and a melena.
At a mild degree of a hemorrhage its common attributes are unstable, as they are caused not by an oligemia, but reflex reactions and pathological deposition of a blood. The creation of conditions of physical and mental rest results in series of cases in disappearance of these attributes. The appreciable disorders of a hemodynamics caused by bleedings, usually occur at a hemorrhage more than 0,5 I, as the rate of a bleeding even at an arrosion of a large vessel in an ulcer does not exceed rate of a hemorrhage at exfusion of a blood at the donor. Besides approximately in 15 min after a hemorrhage the compensatoric hydremia develops, and quite often on a background short-term reflex arterial hypertension, therefore in early terms from a beginning of a bleeding the hemodinamic changes can be less expressed in comparison with due at this degree of a hemorrhage. In subsequent, at an appreciable hemorrhage, there is a thirst, dryness of mucosas of an oral cavity, the diuresis is reduced, that specifies a dehydration owing to a hemorrhage. These signs usually arise already on a background of hemodinamic changes — tachycardia, decrease of arterial pressure, compensatoric tachypnea etc.
Diagnostics of acute gastroduodenal bleedings is carried out on the basis of the clinical and laboratory data. An anamnesis has the essential importance in an establishment of the reason and location of a bleeding point, which can be found out from the overwhelming majority of the patients rather in details, however approximately at one third of patients the arisen bleeding is the first clinical sign of disease. It is necessary also to find out, whether the patient uses medicines which can cause a bleeding (aspirinum, steroid preparations, derivative of pyrosolon etc.).
The bleedings with a hemorrhage up to 0,5 I essentially are not reflected in a common condition of the patient and only sometimes are shown by short-term common delicacy, giddiness, and then the occurrence of a black stools is found out. At a plentiful hemorrhage there are expressed signs of an acute anemia with the subsequent occurrence of a hematemesis and tar-like stools. The duration of the period between occurrence of common signs of an acute hemorrhage and hematemesis or melena changes from several minutes up to day and more, that depends on intensity of a bleeding. At bleedings owing to a peptic ulcer decrease of intensity of pains is marked (sign of Bergmann). At a blood analysis in early terms decrease of quantity of erythrocytes and the decrease of a haemoglobin content can be absent or to be considerably less expressed in comparison with size of a hemorrhage, the repeated blood analysises with simultaneously definition of a pulse rate and level of arterial pressure are necessary for judgement about its sizes, quite often after a hemorrhage there is a leukocytosis, rising of ESR. These changes, as well as fervescence, apparently, are caused by toxic action of products of disintegration of a blood, absorptived from an intestine. The changes in a muscle of heart are expressed by decrease of wave T and segment ST, that more probable is connected to a hypoxia of a myocardium (F.I. Komarov). At serious bleedings there can be psychic disfunction as exaltation and hallucinations. The occurrence of the listed changes depends on intensity of a bleeding and size of a hemorrhage, which can be determined under the formula: V = 37x( 1,064 — d), where V — size of a hemorrhage in litres, d — densities of a blood, determined on a method of G.A. Barashkov. The character of vomitive masses and stools also matters at scoping of hemorrhage volume and bleeding point, but this importance is rather. Last years the establishment of the etiological and topical diagnosis at acute gastroduodenal bleedings became more perfect due to more and more wide application of gastroduodenoscopy with the help of fibrogastroscopes. Gastroduodenoscopy at acute gastroduodenal bleedings is carried out as urgent research and at an individualization of a premedication there are practically no contraindications to its. The application of an endoscopy allows to establish the correct etiological and topical diagnosis of a gastrointestinal bleeding more than at 90 % of the surveyed patients.
At impossibility of endoscopic research the radiopaque research of a stomach in a horizontal position of the patient can be applied for an establishment of localization and character of a bleeding point, but this research is considered counterindicative (before steady stabilization of hemodinamic parameters) at serious bleedings, accompanied by syncope or collaptiod condition. Other additional methods of diagnostics of acute gastroduodenal bleedings (hepatolienography, celiacography, external radiometry etc.) are applied seldom.
At differential diagnostics with pulmonary bleedings it is necessary to have in view, that at bleedings from the top respiratory ways the hematomesis has foamy character, is accompanied by tussis, and variegrated moist rale caused by hit of a blood in tracheobronchial tree quite often are auscultated in lungs.
TREATMENT.
At a prehospital stage the first medical assistance at acute gastroduodenal bleedings consists in the following:
— Strict bed regimen;
— Antacids inside (almagelum, phospholugelum etc.), thrombostatic preparations (250 units of thrombinum in 50 ml of water on one spoon 15 mines within 2 hours);
— Bubble with ice (heater filled by cold water) on area of an epigastrium;
— At a serious hemorrhage: inhibitors of a fibrinolysis inside (solution of epsilon-aminocapronicum acidum 5 % — 60,0 on one spoon in 15 mines within 2 hours; to raise the foot end of a bed or to give a position of Trendelenburg, 10 ml of 10 % solution of calcium chloridum intravenously, Vicasolum 5 ml or Dicynonum 2 ml intramuscularly. Change (with registration in a list of observation) of arterial pressure and pulse rate in everyone 15 — 30 min.
The delay of the patient at a prehospital stage is inadmissible, and even the proved suspicion on an acute esophageal or gastroduodenal bleeding is the absolute indication for urgent hospitalization of the patient in the nearest surgical hospital. The evacuation of the patient should be made in a laying position in support of the medical personnel.
At entering of such patient in a surgical hospital the group of a blood first of all should be determined at him and the conservative treatment based on keeping of the following principles has to be continued:
— replenishment of deficiency of volume of a circulating blood by transfusion of an integral blood of small terms of a storage and hemocorrectors (plasma, solution of Albuminum, erythrosuspension etc.);
— Suppression of a gastric secretion and neutralization of a hydrochloric acid of a gastric juice by application of antacids, cholinolytics, H-blockers (Cimetidinum, hystodil. Tagametum, cinaet on 0,4 gr 3 — 4 times per day, famotidin — on one tablet once per day etc.), local hypothermia;
— Local and common hemostatic therapy;
— nasogastral intubation for erasion of gastric contents, control of a hemostasis and stopping of a bleeding by use of 4 ml of Noradrenalinum in 150 ml of an isotonic solution of Sodium chloridum, then the probe is blocked on 2 h, if this introduction is noneffective — the operative treatment (O.S. Kochnev) is shown to the patient;
— Maintenance therapy (cardiovascular preparations, use of Oxygenium, warming of extremities etc.), cleansing enema for erasion of the given vent and breaking up blood from an intestine.
In a special card of observation or the case history basic parameters of a hemodynamics, peripheric blood and diuresis are recorded (better graphic way).
The importance of purposeful both intensive hemostatic and maintenance therapy considerably grows with application of a medical endoscopy, at which the stopping of a bleeding is made by application of an electrocoagulation, laser and other ways of an artificial hemostasis.
The indications to urgent operative measure concerning acute bleedings at an ulcer of a stomach or duodenal intestine are:
— The serious bleeding, when the intensive care during 6 — 8 hours appears unsuccessful;
— A serious bleeding stopped at conservative treatment, but when the occurrence of a relapse even with a small hemorrhage represents real danger to life of the patient;
— The relapse or proceeding bleeding irrespective of its intensity, especially at penetrating ulcers of a stomach and duodenal intestine confirmed by an endoscopy;
— Endoscopic attributes of instability of a hemostasis.
The first operations concerning a bleeding ulcer of a stomach were made in Russia by prof. S.P. Fedorov in 1903. Now concerning acute gastroduodenal bleedings at an ulcer of a stomach and duodenal intestine the vagotomy (usually truncal) with a ligation or underrunning of a bleeding vessel (ulcer) and one of variants of draining operations or resection of a stomach together with erasion of an ulcer are even more often carried out.
GASTRIC ULCER
The gastric ulcer is the chronic disease with polycyclic passing. The main typical of peptic ulcer is the presence of ulcerous defect in a mucous tunic. One of basic places belongs among the gastroenterology diseases to this pathology. Such phenomenon explained by not only considerable distribution of disease but also those dangerous complications which always accompany gastric ulcers.
Pic. The presence of ulcerous defect in a mucous tunic.
Etiology and pathogenesis
Frequency of morbidity on the peptic ulcer among the adult population is about 4 %. More frequent age in patients with gastric ulcers is 50–60 years.
To development mechanism of disease is still not enough studied. From a plenty of different theories in relation to genesis of peptic ulcer no one able to explain the disease. So, each of such factors as neurogenic, mechanical, inflammatory, vascular is present in the mechanism of development of peptic ulcer. Consider for today, that disturbance between the factors of aggression and defense of mucous tunic arose peptic ulcer. To the first factors belong: hydrochloric acid, pepsin, reverse diffusion of ions of hydrogen, products of lipid hyperoxidizing. To the second: mucus and alkaline components of gastric juice, property of epithelium of mucous tunic to permanent renewal, local blood flow of mucous tunic and submucous membrane.
In the terminal stage of mechanism of origin of gastric ulcers important role has the peptic factor and disturbance of trophism of gastric wall as a result of local ischemia. It confirmed by decreasing of blood flow in the wall of stomach at patients with ulcers on 30–35 % compared to the norm. It is proved, that a local and functional ischemia more frequent arises up on small curvature of stomach in the areas of ectopy of the antral mucous tunic in acid-forming. Exactly there ulcers appear.
Important part in ulcerogenesis is acted by duodenogastric reflux and gastritis. Also, gastrostasis can provoke hypergastrinaemia and hypersecretion and formed gastric ulcers.
Numeral scientific developments of the last years testify to the important infectious factor in the mechanism of origin of peptic ulcer conditioned, mainly, by helicobacter pylori.
Pathomorphology
Such stages of disease are distinguished: erosion, acute and chronic ulcers.
Erosions, mainly, are plural. Their bottom as a result of formation of muriatic haematine is black, edges — infiltrated by leucocytes. A defect usually does not penetrate outside muscular tissue of the mucous tunic. If necrosis gets to more deep layers of wall of stomach, a acute ulcer develops. It has a funnel-shaped form. Bottom is also black, edges is swelled. Chronic ulcers are mainly single, sometimes arrive to the serous layer. A bottom is smooth, sometimes hilly, edges is like elevation, dense.
Classification
For today the most known classification of gastric ulcers by Johnson (1965). There are three types of gastric ulcers are distinguished: I – ulcers of small curvature (for
Clinical management
The complaints of patients with the gastric ulcer always give valuable information about the disease. The detailed analysis of their anamnesis allows to pay attention to the possible reasons of origin of ulcer, time of the first complaints, to the changes of symptoms.
Pain. A pain symptom in the peptic ulcer disease is very important. There are typical passing for this disease: hunger – pain – food intake – facilitation – again hunger – pain – food intake – facilitation (so during all days). Night pain for the gastric ulcer is not typical. The such patients rarely wake up in order to take a food. For diagnostics of ulcer localization it is important to know the time of appearance of pain. Between acceptance of food and appearance of pain it is the shorter, than the higher placed gastric ulcer. Thus, at patients with a cardial ulcer pain arises at once after the food intake, with the ulcers of small curvature — in 50–60 minutes, at pyloric localization — approximately in two hours. However this feature it is enough relative and some patients in general do not mark dependence between food intake and pain. In other patients the pain attack is accompanied by the salivation.
A epigastric regioear the xiphoid process is typical localization of pain. The irradiation of pain is not usual for gastric ulcers. Irradiation occur in patients with penetration and depended from organ, in which an ulcer penetrates.
At the examination of ulcerous patient it is expedient to determine the special pain points: Boas (pain at pressure on the left of the Х–ХII pectoral vertebrae), Mendel (pain at percussion on the left to epigastric region).
Vomiting, the sign of disturbance of motility function of stomach, is the second typical symptom of gastric ulcer. More frequent gastrostasis arises as a result of failure of stomach muscular, it atony which can be effect of organ ischemia. Vomiting could arises both on empty stomach and after food intake.
Heartburn is one of early symptoms of gastric ulcer, however at the prolonged passing of disease it can be hidden or quite disappear. Often it precedes of pain arising (initial heartburn) or accompanies a pain symptom. Mostly heartburn arises after the food intake, but can appear independently. it is observed not only at hypersecretion of the hydrochloric acid, but at normal secretion, even reduced acidity of gastric juice.
The belching at gastric ulcers is examined rarely, more frequent in patients with cardial and subcardial ulcers. It is necessary to bind to disturbance of function of cardial valve.
The general condition of patients with the uncomplicated gastric ulcer usually satisfactory, and in a period between the attacks — even good. However for most patients lost of the body weight and pallor are typical. In a epigastric region hyperpigmental spots are examined after the prolonged application of hot-water bottle. At palpation of stomach in this area sometimes appears local painful. It is needed also to check up “noise of splash”, the presence of which can be the sign of possible gastrostasis.
At the examination of mouth cavity a tongue has whiter-yellow incrustation. In patients with penetration ulcers and disturbances evacuations from a stomach examined dryness of tongue.
Stomach, as a rule, regular rounded shape, however during the pain attack is pulled in. There is antiperistalsis arises during the pylorostenosis.
The increased secretion of hydrochloric acid in patients with gastric ulcers observed rarely and, mainly, at prepyloric ulcer localizations. Mostly secretion is normal, and in some patients is even reduced.
X-Ray examination. The direct signs of ulcer at X-Ray examinations are: symptom of “Haudek’s niche” (Pic. 3.2.1), ulcerous billow and convergence of folds of mucous tunic. Indirect signs: symptom of “forefinger” (circular spasm of muscles), segmental hyperperistalsis, pylorospasm, delay of evacuation from a stomach, duodenogastric reflux, disturbance of function of cardial part (gastroesophageal reflux).
Gastroscopy can give important information about localization, sizes, kind of ulcer, dynamics of its cicatrization, and also allow to perform biopsy with subsequent histological examination.
Clinical variants and complication
The gastric ulcer passing can be acute and chronic. Acute ulcers arise as answer for the stress situations, related to the nervous overstrain, trauma, loss of blood, some infectious and somatic diseases. By a diameter ulcers has from a few millimeters to centimeter, a round or oval form with even edges. Thus in most cases clinically observed clear ulcerous clinical signs. If complications is absent (bleeding, perforation) such ulcers treated and mostly heal over.
G.J. Burchynskyy (1965) such variants of clinical flow distinguished:
1. Chronic ulcer which does not heal over long time.
2. Chronic ulcer which after the conservative therapy heals over relatively easily, however inclined to the relapses after the periods of remission of a different duration.
3. Ulcers, which localization are had migrant character. Observed in people with acute ulcerous process of stomach.
4. Special form of gastric ulcer passing after the already carried disease. Passed with the expressed pain syndrome. Characterized by the presence in place of ulcerous defect of scars or deformations and absence of symptom of “niche”.
There are such complications can develop in patients with gastric ulcer: penetration, stenosis, perforation, bleeding and malignization.
Diagnosis program
1. Anamnesis and physical examination.
2. Endoscopy.
3. X-Ray examination of stomach.
4. Examination of gastric secretion by the method of aspiration of gastric contents.
5. Gastric pH metry.
6. Multiposition biopsy of edges of ulcer and mucous tunic of stomach.
7. Gastric Dopplerography.
8. Sonography of abdominal cavity organs.
9. General and biochemical blood analysis.
10. Coagulogram.
Pic. Symptom of “Haudek’s niche”
Pic. Peptic ulcer of the stomach (endoscopy)
Differential diagnostics
Chronic gastritis, as well as at an gastric ulcer, characterized by the pain syndrome, that arises after the food intake. In such patients it is possible to observe nausea and vomiting by gastric content, heartburn and belch. However, unlike an gastric ulcer, for gastritis typical symptom of “quick satiation by a food”. Unsteady emptying, diarrhea also more inherent to gastritises. At gastric ulcer more frequent the delays are observed, constipation for 4–5 days.
The cancer of stomach, it is comparative with an gastric ulcer, has considerably more short anamnesis. The most typical clinical signs of this pathology are: absence of appetite, weight loss, rapid fatigability, depression, unsociability, apathy. In such patients X-Ray examination expose the “defect of filling”, related to exophytic tumor and deformation of walls of organ. A final diagnosis is set after the results of multiposition biopsy of shady areas of mucous tunic of stomach.
Differential diagnostics also needs to be conducted with the so called precancerous states: gastritis with the achlorhydria; chronic, continuously recurrence ulcers, poliposis and Addison-Biermer anemia.
Tactic and choice of treatment method
Conservative treatment of gastric ulcer always must be complex, individually differentiated, according to the etiology, pathogeny, localization of ulcer and character of clinical signs (disturbance of functions of gastroduodenal organs, complication, accompanying diseases).
Conservative therapy must include:
· Omeprazole 20 mg 2 time per day or Н2- blocker histamine receptor (ranitidine) — 150 mg in the evening, famotidine — 40 mg at night,
roxatidine — 150 mg in the evening
· antiacid drugs — in accordance with the results of pH-metry;
· reparative drugs (dalargin, solcoseryl, actovegin) — for 2 ml 1–2 times per days
· antimicrobial drugs (clarytromicine 500 mg twice daily, de-nol, metronidazole)
Treatment of patient with a gastric ulcer must continues not less than 6–8 weeks.
Surgical treatment must performed in cases:
а) at the relapse of ulcer after the course of conservative therapy;
б) in the cases when the relapses arise during supporting antiulcer therapy;
в) when an ulcer does not heal over during 1,5–2 months of intensive treatment, especially in families with “ulcerous anamnesis”.
г) at the relapse of ulcer in patients with complications (perforation or bleeding);
д) at suspicion on malignization ulcers, in case of negative cytological analysis.
The choice of method of surgical treatment of gastric ulcer depended from localization and sizes of ulcer, presence of gastro- and duodenostasis, accompanying gastritis, complications of peptic ulcer (penetration, stenosis, perforation, bleeding, malignization), age of patient, general condition and accompanying diseases. In patients with cardial localization of ulcer the operation of choice is the proximal resection of stomach, which, from one side, allows to remove an ulcer, and from other — to save considerable part of organ, providing it functional ability (Pic. 3.2.2). In case with large cardial ulcers, when the vagus nerves pulled in the inflammatory infiltrate and it is impossible to save integrity even one of them, operatioeeds to be complemented by pyloroplasty. It will give possibility to warn pylorospasm and gastrostasis, which in an early postoperative period can be the reason of anastomosis insufficiency and other complications.
At the choice of method of surgical treatment of gastric ulcers with subcardial localization on small curvature without duodenostasis it is better to apply the methods of stomach resection with saving of passage through a duodenum.
For this purpose we are developed the method of segmental resection of stomach with addition selective proximal vagotomy. The redistribution of gastric blood flow between the functional parts of stomach as reply to medicinal vagotomy (intravenous introduction 1,0 ml 0,1 % solution of atropine of sulfate) is studied. Hyperemia of acid-forming part of stomach comes after introduction of preparation. The functional scopes of stomach parts are determined. The border between acid-forming and antral parts are the most frequent localization of gastric ulcers.
During this operation middle laparotomy is performed, intravenously entered 1,0 ml 0,1 % solution of atropine, then the scopes of functional stomach parts are identified and by stitches-holders is marked a intermedial segment. Selective proximal vagotomy is performed. After mobilization of large curvature of stomach within the limits of intermedial segment it resection is performed. After that gastro-gastro anastomosis “end-to-end” is formed (Pic. 3.2.3).
The analysis of supervisions of the patients operated by such method in postoperative period has good results. It allows to recommend this operation for clinical practice, in case of gastric ulcers of subcardial localizations, without duodenostasis, penetration, malignization or nerves Latarjet damaging.
The operation of choice in patients with subcardial ulcers and duodenostasis is gastric resection by Billroth II.
At the choice of method of surgical treatment of ulcers which are localized in upper and middle third of stomach, it is necessary to consider such factors, as absence of penetration in a small omentum and absence of the duodenostasis. In such patients is performed segmental resection of stomach with ulcer removing with selective proximal vagotomy. In case of penetration ulcer in a small omentum with involvement in infiltrate Latarjet nerves, such operation is impossible because of future spasm of pylorus and gastrostasis. If duodenostasis is absence than better to apply pylorus-saving resection by Maki-Shalimov. In patients with duodenostasis better to apply gastric resection by Billroth II.
At the border of gastric resectioear pyloric sphincter can be spasm and gastrostasis in a postoperative period . Avoiding such complication is possible, if this border of gastric resection passes no more than
Patients with antral ulcers without the duodenostasis performed the gastric resection by Billroth I (Pic. 3.2.6), and on presence of duodenostasis – Billroth II.
Prepiloric ulcers is similar to the ulcers of duodenum. Such localization of gastric ulcers without malignization allow to perform selective proximal vagotomy. However, at large prepyloric ulcers with penetration without duodenostasis is better to perform the gastric resection by Billroth I and on presence of duodenostasis – by Billroth II.
By contra-indication to operations with saving of food passing through the duodenum are also decompensated pylorostenosis , functional gastrostasis and duodenostasis. In such patients it is better to perform gastric resection by Billroth II.
Pic. Billroth I and Billroth II resection
Pic. Billroth I reconstruction
Pic. Billroth II recontruction
DUODENAL ULCER
The duodenal ulcer is the chronic recurrent disease which characterized by ulcerous defect on a mucous tunic of duodenum. Pathology often makes progress with complications development.
Etiology and pathogenesis
There are some etiologic factors of the duodenal ulcer: Helicobacter pylori, emotion tension and neuropsychic stress overstrain, heredity and genetic inclination, presence of chronic gastroduodenitis, disturbance of diet and harmful habits (alcohol, smoking). In pathogenesis of peptic ulcer a leading role is played disturbance of equilibrium between aggressive and projective properties of secret of stomach and it mucous tunic. The aggressive factors are vagus hyperfunctioning and hypergastrinemia; hyperproduction of hydrochloric acid and pepsin, and also reverse diffusion of the ions Н+, action of bilious acids and isoleucine, toxins and enzymes of helicobacter pylori (HP). There are factors which are contribute to ulcerogenic action: disturbance of motility of stomach and duodenum, ischemia of duodenum, and metaplasia of the epithelium.
Pathomorphology
Morphogenesis of duodenal ulcer fundamentally does not differ from ulcer in a stomach. Chronic ulcers are mainly single, is localized on the front or back wall of bulb (bulbar ulcer) and only in 7–8 % cases – below it (postbulbar ulcer). The plural ulcers of duodenum are met in 25 % cases.
Classification
(by A.L.Hrebenev, A.O.Sheptulin, 1989)
The duodenal ulcer is divided:
I. By etiology:
А. True duodenal ulcer.
Б. Symptomatic ulcers.
II. By passing of disease:
1. Acute (first exposed ulcer).
2. Chronic:
a) with the rare exacerbation;
b) with the annual exacerbation;
c) with the frequent exacerbation (2 times per a year and more frequent).
III. By the stages of disease:
1. Exacerbation.
2. Scarring:
a) stage of “red” scar;
b) stage of “white” scar.
3. Remission.
IV. By localization:
1. Ulcers of bulb of duodenum.
2. Low postbulbar ulcers.
3. Combined ulcers of duodenum and stomach.
V. By sizes:
1. Small ulcers up to
2. Middle — up
3. Large — up to
4. Giant ulcers over
VI. By the presence of complications:
1. Bleeding.
2. Perforation.
3. Penetration.
4. Organic stenosis.
5. Periduodenitis.
6. Malignization.
Clinical management
Pain in the epigastric region is the most expressed symptom of duodenal ulcer, often with displacement to the right in the projection area of bulb of duodenum and gall-bladder. Also for this pathology is typical the pain, that arises in 1,5–2 hours after food intake, “hungry” and nightly pain. As a rule, it is acute, sometimes unendurable, and is halted only after the use of food or water. Such patients complains for the seasonal exacerbation, more frequent in spring and in autumn. However exacerbation can be also in winter or in summer. In the acute period of disease heartburn often increases. However heartburn is the frequent symptom of cardial insufficiency and gastroesophageal reflux. For an duodenal ulcer the acute burning feeling of acid in a esophagus, pharynx and even in the cavity of mouth is especially typical. Often are belch by air or sour content, excessive salivation. Vomiting is not a typical symptom for duodenal ulcer. More typical sign is nausea. Sometimes for facilitation patients wilfully cause vomiting. These symptoms, arises in the late periods of passing of duodenal ulcer.
Intensity of pain and dyspepsia syndromes depends both on the depth of penetration and from distribution of ulcerous and periulcerous processes. Superficial ulceration within the mucous tunic, as a rule, does not cause the pain because it does not have sensible receptors. However, more deep layers of wall (muscular and especially serous) have plural sensible vegetative receptors. Therefore, on deepening and distribution of process arises visceral pain. At evident periulcerous processes and penetration of ulcers to neighboring organs and tissues, usually, a parietal peritoneum, that has spinal innervation, is pulled in. Pain becomes viscero-somatic, more intensive. A such pain syndrome (with an irradiation in the back) is typical for low postbulbar ulcers and bulbous ulcers of back wall, which penetrates in a pancreas and hepato-duodenal ligament. Usually such patients has good appetite. Some of them limit themselves in acceptance of ordinary food, go into to the dietary feed by small portions, and some — even hold back from a food, being afraid to provoke pain, and as a result of it weight is lost. Some of patients feeds more intensive and often.
The psychical status of patients often are changed as a asthenoneurotic syndrome: irritates, decline of working capacity, indisposition, hypochondria, abusiveness.
An inspection, as a rule, gives insignificant information. In many cases on the abdominal skin it is possible to notice hyperpigmentation after application of hot-water bottle. During the pain attack patients often occupy the forced position. At superficial palpation on the abdominal wall determined hyperesthesia in ulcer projection. In the epigastric region, during deep palpation, it is possible to define pain and muscular tension, mostly moderate intensity. There is important symptom of local percussion painful (Mendel’s symptom): percussion by fingers in the symmetric epigastric areas provoke pain in the ulcer, which is increased after the deep breath. The roentgenologic and endoscopic are main diagnostic methods. The symptom of ulcerous “niche” is a classic roentgenologic sign. It is depot of contrast agent, which is corresponded to ulcerous defect, with clear contours and light bank to which converged fold mucus. Cicatricial deformation of bulb of duodenum as a shamrock, butterfly, narrowing, tube, diverticulum and other forms is the important sign of chronic ulcerous process. A roentgenologic method is especially important for determination of configuration and sizes of stomach and duodenum, and also for estimation of motility functions. X-Ray examination is the main method at the peptic ulcer complicated by stenosis, with disturbance of evacuation, duodenostasis, duodenal-gastric reflux, gastroesophageal reflux, diverticulum. But by X-Ray examination is difficult to diagnose small superficial ulcers, acute ulcers, erosions, gastritises and duodenitises. The most informing method in such cases it endoscopy.
During endoscopy examination it is possible to define localization, form, sizes and depth of ulcer. During bleeding grumes, trickle or pulsating of blood are observed. By irrigation by styptic solutions, by cryocoagulation, by laser coagulation endoscopy allows to secure hemostasis. Endoscopy allows to perform the biopsy of ulcer tissues for determination of possible malignization.
Clinical variants and complication
In patients with low postbulbar ulcers the clinical signs are more expressed. It characterized by late (in 2–3 hours after food intake) and intensive “hungry” and nightly pain, that often irradiate to the back and to the right hypochondrium. The postbulbar ulcers are inclined to more frequent exacerbation, and also to more frequent complications, such, as penetration, stenosis and bleeding.
The are more frequent ulcerous bleeding (the bulbous happen in 20–25 % cases, postbulbar — in 50–75 %), perforations (10–15 % cases). Penetration, stenosis and malignization in patients with duodenal ulcers are observed rarely.
Penetration is frequent complication of “low” and postbulbar ulcers of duodenum, which are placed on posterior, posterior superior and posterior inferior walls. Penetrates, usually, deep chronic ulcers, by passing through all layers of duodenum ieighboring organs and tissues (head of pancreas, hepato-duodenal ligament, small and large omentum, gall-bladder, liver). Such penetration is accompanied by development of inflammatory process in the neighboring organs and surrounding tissues and forming of cicatrical adhesions. A pain syndrome becomes more intensive, permanent and often pain irradiated in the back. Sometimes in the area of penetration it is possible to palpate painfully infiltrate.
Diagnostic program
1. Anamnesis and physical examination.
2. Endoscopy.
3. X-Ray examination of stomach and duodenum.
4. General and biochemical blood analysis.
5. Coagulogram.
Pic. Duodenoscopy
Differential diagnostics
The duodenal ulcer must be differentiated from acute and chroniccholecystitis, pancreatitis, gastroduodenitis. Endoscopy is help to diagnose duodenal ulcer.
Tactic and choice of treatment method
Conservative treatment. In most patients after conservative treatment an ulcer heals over in 4–6 weeks. Warning of relapses can be carried out by only supporting therapy during many years.
The best therapy of duodenal ulcer is associated with a helicobacter infection, there is the use of antagonists of Н2- receptors of histamine (renitidine— 300 mg in the evening or 150 mg twice for days; famotidine— 40 mg in the evening or 20 mg twice for days; nisatidine — 300 mg in the evening or 150 mg twice for days; roxatidine — 150 mg in the evening) in combination with sucralfate (venter) — for
In treatment of duodenal ulcer used chinolitics and miolitics (atropine, methacin, platyphyllin), and also mesoprostol (200 mg 4 times per days) and omeprasole (20 or 40 mg on days).
Such treatment of patients with the duodenal ulcer must be 4–6 weeks. If complications absents there is no necessity in the special diet.
Because of appearance of new pharmaceutical preparations and modern therapeutic treatment, indication to the operative methods narrowed. But the number of acute complications of duodenal ulcer does not go down, especially bleeding and perforations which require the urgent surgery.
Indications to the elective operation:
1. Passing of duodenal ulcer with the frequent relapses which could not treated conservatively.
2. Repeated ulcerous bleeding.
3. Stenosis of outcome part of stomach.
4. Chronic penetration ulcers with the pain syndrome.
5. Suspicion for malignization ulcers.
Methods of surgical treatment.
At patients with the duodenal ulcer three types of operations are distinguished:
— organ-saving operations;
— organ-sparing operations;
— resection.
From them the better are: organ-saving operations with vagotomy, excision of ulcer and drainage operation.
Types of vagotomy: trunk (TrV) (Pic.. 3.2.7), selective (SV) (Pic. 3.2.8), selective proximal (SPV) (Pic. 3.2.9). Selective proximal vagotomy is optimal in the elective surgery of duodenal ulcer. However in urgent surgery a trunk, selective or selective proximal is often used in combination with drainage operations.
Drainage of the stomach operations are: Heineke-Mikulicz pyloroplasty, Finney pyloroplasty, submucous pyloroplasty by Diver-Barden-Shalimov, gastroduodenostomy by Jaboulay, gastroenteroanastomosis.
It is necessary to mark that “clean isolated” SPV, performed in patients with duodenal ulcer, often (in 15–20 % cases) results in the relapses. The considerably less number of relapses (8–10 %) is observed after SPV in combinations with drainage operations. Especially dangerous is the relapses of the ulcers placed in the projection of large duodenal papilla, after gastroduodenostomy by Jaboulay.
The least number of relapses of duodenal ulcer is observed after organ-saving operations, that combine SPV and ulcer excision.
If ulcer localized on the anterior surface of duodenal bulb it can be performed by the method Jade (Pic. 3.2.13) with subsequent to the pyloroplasty by Heineke-Mikulich.
At patients with decompensate stenosis and expressed dilatation and by the atony of stomach it is needed to apply the classic resection of stomach depending on possible damping-syndrome by Billroth -I or Billroth -II.
The choice of subtotal resection of stomach needs to be done at suspicion for malignization or at histological confirmed malignization ulcers. In a duodenum this process happens very rarely.
Pic. Trunk vagotomy (TrV)
Pic. Selective vagotomy (SV)
Pic. Selective proximal vagotomy (SPV)
Pic. Heineke-Mikulicz pyloroplasty
Pic. Gastroduodenostomy by Jaboulay
Pic. Finney pyloroplasty
BLEEDING GASTRODUODENAL ULCERS
Bleeding gastroduodenal ulcers are outpouring of blood in the gastrointestinal tract cavity as a result of strengthening and distribution of necrosis process in the ulcer area to vessels with the subsequent melting of their walls.
Complication of peptic or duodenal ulcer by bleeding is critical situation which threatens to life of patient and requires from the surgeon of immediate and decisive actions for clarification of reasons of bleeding and choice of tactic of treatment. The ulcerous bleeding has 60 % of the acute bleeding from the upper parts of gastrointestinal tract.
Etiology and pathogenesis
The origin of the gastrointestinal bleeding at patients with a gastric or duodenal ulcer almost is always related to exacerbation of ulcerous process. The reason of bleeding is a erosive vessel, that is on the bottom of ulcer. The expressed inflammatory and sclerotic processes round the damaged vessel embarrassed its contraction, that diminishes chances on the spontaneous stop of bleeding.
Gastric ulcers, compare with the ulcers of duodenum, complicated by bleeding more frequent. Bleeding at gastric ulcers are more expressed, profuse, with heavy passing.
At the duodenal ulcer bleeding more frequent complicate the ulcers of back wall, which penetrates in the head of pancreas.
At the men ulcer is complicated by bleeding twice more frequent, than at women. It costs to mark that 80 % patients which carried bleeding from an ulcer and treated oneself by conservative preparations, are under the permanent threat of the recurrent bleeding.
Pathomorphology
Strengthening of necrosis process are leading factors in the origin of the ulcerous bleeding in the area of ulcerous crater with distribution of this process to a vessel and subsequent melting of vascular wall; activation of fibrinolysis in tissues of stomach and duodenum; ischemia of tissues of wall of stomach.
Classification
Bleeding gastroduodenal ulcers after the degree of weight of loss of blood (by О.О. Shalimov and V.F.Saenko, 1987) are divided:
I degree is easy — observed at the loss to 20 % volume of circulatory blood (at a patient with weight of body
II degree — middle weight is loss from 20 to 30 % volume of circulatory blood (1000–1500 ml);
The III degree is heavy — is observed at loss of blood more than 30 % volume of circulatory blood (1500–2500 ml).
Clinical management
At patients with an peptic ulcer disease, bleeding pops up, mainly at night. Vomiting can be the first sign of it, mostly, at gastric localization of ulcers. Vomiting masses, as a rule, looks like “coffee-grounds”. Sometimes they are as a fresh red blood or its grume.
The black tar-like emptying are the permanent symptom of the ulcerous bleeding, with an unpleasant smell (“melena”), that can take place to a few times per days.
Bloody vomiting and emptying as “melena” is accompanied by worsening of the general condition of patient. A acute weakness, dizziness, noise in a head and darkening in eyes, sometimes — loss of consciousness. A collapse with the signs of hemorrhagic shock can also develop. Exactly with a such clinical picture the such patients get to the hospital. It is needed to remember, that for diagnostics anamnesis is very important. Find out often, that at a patient an peptic ulcer was already diagnosed once. It appears sometimes, that bleeding is repeated or surgery concerning a perforated ulcer took place in the past. At some patients a gastric or duodenum ulcer is was not diagnosed before, the however attentively collected anamnesis exposed, that at a patient had a stomach-ache. Thus it communication with acceptance of food and seasonality is typical (more frequent appears in spring and in autumn). Patients tell, that pain in overhead part of abdomen which disturbed a few days prior to bleeding suddenly disappeared after first its displays (the Bergmann’s symptom).
At patients with the ulcerous bleeding there are the typical changes of hemodynamic indexes: a pulse is frequent, weak filling and tension, arterial pressure is mostly reduced. These indexes need to be observed in a dynamics, as they can change during the short interval of time.
There is the pallor of skin and visible mucous tunics at a examination. A stomach sometimes is moderately exaggerated, but more frequent is pulled in, soft at palpation. In overhead part it is possible to notice hyperpigmental spots — tracks from the protracted application of hot-water bottle. Painful at deep palpation in the area of right hypochondrium (duodenal ulcer) or in a epigastric area (gastric ulcer) it is possible to observe at penetrated ulcers. Important symptom of Mendel also — painful at percussion in the projection of piloroduodenal area.
At the examination of patients with the gastrointestinal bleeding finger examination of rectum is obligatory. It needs to be performed at the first examination, because information about the presence of black excrement (“melena”) more frequent get according to a patient anamnesis, that can result in erroneous conclusions. Finger examination of rectum allows to expose tracks of black excrement or blood. In addition, it is sometimes possible to expose the tumour of rectum or haemorrhoidal knots which also are the source of bleeding.
The deciding value in establishment of diagnosis has the endoscopic examination. Fiber-gastroduodenoscopy enables not only to deny or confirm the presence of bleeding but also, that it is especially important, to set its reason and source. Often embarrassed the examination of stomach and duodenum present in it blood and content. In such cases it is necessary to remove blood or content, by gastric lavage, and to repeat endoscopic examination. During the examination often exposed the bleeding with fresh blood from the bottom of ulcer or ulcerous defect with one or a few erosive and thrombosed vessels (stopped bleeding). The bottom of ulcer can be covered by the package of blood.
Important information about such pathology is given by haematological indexes also. Diminishment of number of red corpuscles and haemoglobin of blood, decline of haematocritis is observed in such patients. However always needed to remember, that at first time after bleeding haematological indexes can change insignificantly. Conducting of global analysis of blood in a dynamics in every a few hours is more informing.
Variants of clinical passing and complication
It is necessary always to remember that complication of peptic ulcer by bleeding happens considerably more frequent, than is diagnosed. Usually, to 50–55 % moderate bleeding (microbleeding) have the hidden passing. The massive bleeding meet considerably rarer, however almost always run across with the brightly expressed clinical signs which often carries dramatic character. In fact profuse bleeding with the loss 50–60 % to the volume of circulatory blood could stop the heart and cause the death of patient.
The clinical signs and passing of disease depend on the degree of lost of blood (О.О. Shalimov and V.F.Saenko, 1987).
For lost of blood I degree typical there is a frequent pulse to 90–100, decline of arterial pressure of to 90/60 mm Hg. The excitability of patient changes by lethargy, however clear consciousness is, breathing some frequent. After the stop of bleeding and in absent of hemorrhage compensation the expressed disturbances of circulation of blood does not observe.
At patients with the II degree of hemorrhage the general conditioeeds to be estimated as average. Expressed pallor of skin, sticky sweat, lethargy. Pulse — 120–130 per min., weak filling and tension, arterial pressure — 90–80/50 mm Hg. At first hours the spasm of vessels (centralization of circulation of blood) comes after bleeding, that predetermines normal or increased, arterial pressure. However, as a result of the protracted bleeding compensate mechanisms of arterial pressure are exhausted and can acutely go down at any point. Without the proper compensation of hemorrhage the such patients can survive, however almost always there are considerable disturbances of blood circulation with disturbance of functions of liver and kidneys.
The III degree of hemorrhage characterizes heavy clinical passing. There is a pulse in such patients — 130–140 per min., and arterial pressure — from 60 to
But, not always weight of bleeding which is conditioned by the degree of hemorrhage correspond the general condition of patient. On occasion the considerable loss of blood during the set time is accompanied by the relatively satisfactory condition of patient. And vice versa, moderate hemorrhage can bring to the considerable worsening of general condition. It can depend both on compensate possibilities of organism and from the presence of accompanying pathology.
It is needed to remember, that the ulcerous bleeding can accompanying with the perforation of ulcer. During perforation ulcers are often accompanied by bleeding. Correct diagnostics of these two complications has the important value in tactical approach and in the choice of method of surgical treatment. In fact simple suturing of perforated and bleeding ulcer can complicated in postoperative period by the profuse bleeding and cause the necessity of the repeated operation.
Diagnosis program
1. Anamnesis and physical examination.
2. Finger examination of rectum.
3. Gastroduodenoscopy.
4. Global analysis of blood.
5. Coagulogram.
6. 7. Biochemical blood test.
7. X-Ray examination of gastrointestinal tract.
8. Electrocardiography.
Pic. Endoscopy – stopped bleeding.
Differential diagnostics
At wide introduction of gastroduodenoscopy of question of differential diagnostics of bleeding lost the actuality. However much a problem arises up at impossibility to execute this examination through the heavy general condition of patient or taking into account other reasons. Differential diagnostics is conducted with bleeding of unulcerous origin, which arise up in different parts of digestive tract.
For bleeding from the varicose extended veins of esophagus during portal hypertension at patients with the cirrhosis of liver the acute beginning without pain is characteristic, like during exacerbation of ulcerous disease. These bleeding differ by the special massiveness and considerable hemorrhage. Vomiting by fresh blood, expressed tachycardia, falling of arterial pressure are observed. In such patients it is possible to find the signs of cirrhosis of liver and portal hypertension (“head of jelly-fish”, hypersplenism, ascites, often is icterus).
Sliding hernia of the esophagus opening of diaphragm can be accompanied by formation of ulcers in the place of clench of the stomach by the legs of diaphragm and bleeding from them. However for this pathology are more typical microbleeding, that is hidden. In such patients often the present protracted anaemia which can achieve the critical values. Sometimes in them observe more expressed bleeding with “classic” vomiting “coffee-grounds” and melena. During the roentgenologic examination with barium is possible to expose the signs of sliding hernia of the esophagus opening: the obtuse cardial angle, absence or diminishment of gas bubble of stomach or “ringing symptom”.
The cancer tumour of stomach in the destruction stage can be also complicated by bleeding. However, such bleeding are massive, and chronic character is carried mostly with gradual growth of anaemia. For this pathology there are the inherent worsenings of the general condition of patient, loss of weight of body, decline of appetite and waiver of meat food. At the roentgenologic examination the “defect of filling” is exposed in a stomach.
The gastric bleeding can be related to the diseases of the cardio-vascular system (atherosclerosis, hypertensive disease), however such happens mainly in the older years people. Clearly, that in such patients during the endoscopic examination the source of bleeding exposing is not succeeded.
Among other diseases, with which it is necessary to differentiate the ulcerous bleeding, it is needed to remember the Mallory-Weiss syndrome, benign tumours of stomach and duodenum (more frequent leiomyoma), hemorrhagic gastritis, acute (stress) erosive defeats of stomach, arteriovenous fistula of mucous tunic.
Often differential diagnostics performed according to the level of localization of source of bleeding in different parts of gastrointestinal tract. For the upper parts of digestive tract (esophagus and stomach) typical there is vomiting by grume or “coffee-grounds” content and emptying by “melena”. The farther aboral placed source of bleeding, the bloody emptying changes the more so. During the bleeding from a thin bowel excrement looks as “melena”. In case of such pathology of colon (polypuses, tumours, unspecific ulcerous colitis) emptying have the appearance of fresh red blood, mostly as packages.
Tactic and choice of treatment method
The conservative therapy indicated to patients with the stopped bleeding of I degree and bleeding of the II–III degrees at patients which have heavy accompanying pathology, because of operative risk.
Conservative therapy must include:
— prescription of hemostatic preparations (intravenously the aminocapronic acid 5 % — 200–400 ml, chlorous calcium 10 % — 10,0 ml, vicasol 1 % — 3,0 ml);
— addition to the volume of circulatory blood (gelatin, poliglukine, salt blood substitutes);
— preparations of blood (fibrinogen — 2–3 г, cryoprecipitate);
— blood substitutes therapy (red corpuscles mass, washed red corpuscles, plasma of blood);
— antiulcerous preparations — blocker of Н2- receptor (ranitidine, roxatidine, nasatidine— for 150 mg 1–2 times per days);
— antacid and adsorbents (almagel, phosphalugel, maalox— for 1–2 dessert-spoons through 1 hour after food intake).
It is expedient to apply washing of stomach by water with ice and the use 5 % solution of aminocapronic acid inward for to a 1 soupspoon in every 20–30 minutes.
The endoscopic methods of stop of bleeding are used also. Among them most effective is a laser and electro-coagulation.
Absolute indications to surgical treatment are: 1) lasting bleeding I degree; 2) recurrent bleeding after hemorrhage I degree; 3) bleeding of the II–III degrees; 4) stopped bleeding with hemorrhage of the II–III degrees at the endoscopically exposed ulcerous defect with a presence on the ulcer bottom thrombosed vessels or erosive vessels covered by the package of blood.
The choice of method of surgical treatment always needs to be decided individually. On today the best tactic which gives advantage to organ-saving and organоsparing methods of operations. The removing ulcer as sources of bleeding must be an obligatory condition. The methods of sewing of bleeding vessels or edging of ulcer and bandaging of vessels which feed a stomach and duodenum did not justify itself through the real threat of relapse of bleeding already in an early postoperative period (9–12 days).
Palliative operations (cutting of ulcer, forming of roundabout anastomosis) can be justified only taking into account the general condition of patient and on a necessity as possible quick and least traumatically to make off operation.
At the bleeding ulcers of duodenum it is better to apply excision of ulcer or it exteritirization after methods, developed by V.Zajtsev and Velihotskyy. Operation complemented by one of types of vagotomy, it is better by a selective proximal with piliroplastic. The resection of stomach on the second or first method of Bilroth can be realized only in the stable general condition of patient. During the resection of stomach in case of low bleeding duodenal ulcers it is better to execute mobilization of duodenum and suturing of its stump on transcholedochus drainage which formed as transcholedochus duodenotomy (Laqey, 1942). This method warns the possible intraoperative damages of choledoch, that are the possible at low duodenal ulcers. Transcholedochus duodenotomy by performing the decompression of stump of duodenum, warns insufficiency of its stitches, that can arise up in an early postoperative period.
In case of bleeding gastric ulcers, the resection methods of operations are also usable. Only on occasion, when patients has the grave general condition, it is possible to assume the wedge cutting of ulcer.
MALLORY-WEISS SYNDROME
Mallory-Weiss syndrome (MWS) is characterised by upper gastrointestinal bleeding (UGIB) from mucosal lacerations in the upper gastrointestinal tract (GIT) (usually at the gastro-oesophageal junction or gastric cardia). Mallory and Weiss described the syndrome in 1929 in patients retching and vomiting after an alcoholic binge.
MWS may also occur with other events, causing a sudden rise in intragastric pressure or gastric prolapse into the oesophagus. Sudden increased pressure within the nondistensible lower oesophagus causes tearing. It is a feature of about 10% (ranging from 1% to 15%) of upper gastrointestinal bleeds and causes significant hypovolaemia in about 10% of these. There appears to be a trend towards less associated blood loss and lower mortality. It is often associated with hiatus hernia and is also associated with alcoholism and dialysis.
Epidemiology
In recent years, MWS may have become more frequent.
The incidence of UGIB is between 47 and 116 per 100,000 population (mostly from ulcers).
Mallory-Weiss tears cause approximately 3-15% of all episodes of haematemesis in adults. Tears can occur in children but are less common.
There is a wide age range. It is most common between age 40 and 50 years.
PatientPlus
Upper Gastrointestinal Bleeding (includes Rockall Score)
Etiology and pathogenesis
The predetermining factors of origin of syndrome are: protracted whooping, attacks of cough, physical overstrain after the surplus food intake, alcohol with vomiting, chronic diseases of stomach, with the acute increase of intaragastric pressure as a result of discoordinated function of cardial and pyloric sphincter, especially at older patients with atrophy gastritis. The increase ofintaragastric pressure causes change of blood flow in the wall of the stretched stomach. Spontaneous break of mucous tunic ofcardial part of stomach, is accompanied by bleeding in the gastrointestinal tract lumen. The break takes not only mucous tunic but also muscular layer, that weight of bleeding is predetermined. Most often the breaks are localized on small curvature, on the back wall of stomach and esophagus.
Classification
(by В.В.Rumjantsev, 1979)
1. By localization of break: a) esophagus; b) cardio-esophageal; c) cardial.
2. By the amount of breaks:
a) single;
b) plural.
3. By the depth of breaks:
a) superficial (I degree), which penetrate to the submucosal layer
b) deep (II degree), which take mucus and submucosal layer;
c) complete break (III degree) which is characterized by the break of all layers of organ.
4. By the degree of hemorrhage:
a) easy;
b) middle;
in) heavy.
5. By clinical passing:
1) simple form;
2) delirious form: a) with the signs of acute hepatic insufficiency; b ) without the signs of acute hepatic insufficiency.
Causes
Excessive alcohol ingestion.
Aspirin ingestion.
Hiatus hernia is a predisposing factor. During retching or vomiting, the transmural pressure gradient is greater within the hiatus hernia than the rest of the stomach.
Other precipitating factors include retching, vomiting, straining, hiccuping, coughing, blunt abdominal trauma and cardiopulmonary resuscitation.
Other gastrointestinal diseases (gastroenteritis, gastric outlet obstruction, malrotation, volvulus).
Hyperemesis gravidarum.
Hepatitis (causes vomiting in 10-20% of patients).
Biliary disease (gallstones and cholecystitis).
Renal disease – vomiting is often associated with diseases affecting the kidneys (from urinary tract infections to renal failure).
Raised intracranial pressure may lead to vomiting (particularly in children).
Cyclical vomiting syndrome.
Other causes include drugs, and severe diabetic ketoacidosis.
Iatrogenic tears are uncommon, even with a high incidence of retching during endoscopy. The reported prevalence is 0.07-0.49%. It has also been reported in transoesophageal echocardiography.
No apparent precipitating factor can be identified in about 25% of patients.
Presentation
History
The classic presentation is of haematemesis following a bout of retching or vomiting. However, a tear may occur after a single vomit.
Other symptoms include melaena, light-headedness, dizziness, or syncope, and features associated with the initial cause of the vomiting, eg abdominal pain.
Examination
There are no specific physical signs.
An assessment of the degree of blood loss should be made. The Rockall scoring system can be used to assess UGIB. A score of less than 3 is associated with an excellent prognosis and 8 or above an extremely poor prognosis. MWS is usually associated with a score of 3 or less.
Differential diagnosis
Haematemesis as a symptom has quite a long differential diagnosis. The following are important to consider (particularly with the retching and sudden bright bleeding associated with MWS):
Boerhaave’s syndrome (oesophageal rupture).
Other causes of UGIB – see separate Upper gastrointestinal bleeding (includes Rockall Score) article.
Investigations
Endoscopy is the primary diagnostic investigation. Other relevant investigations include:
FBC, including haematocrit to assess the severity of the initial bleeding episode and to monitor patients.
Coagulation studies and platelet counts to detect coagulopathies and thrombocytopenias (routine platelet count, prothrombin time, and activated partial thromboplastin time).
Renal function, urea, creatinine, and electrolyte levels (to guide intravenous fluid therapy).
Cross-matching/ blood grouping and antibody screen (potential blood transfusion).
Electrocardiogram and cardiac enzymes (may be indicated if myocardial ischaemia is suspected).
Management
Initial management is described in the separate article Upper gastrointestinal bleeding (includes Rockall Score).
Initial assessment and management
Resuscitation is a priority – maintain airway, provide high-flow oxygen, correct fluid losses (place two wide-bore cannulae and also send bloods at the same time). Initial fluid resuscitation may be with crystalloids or colloids; give intravenous blood when 30% of circulating volume is lost. Major haemorrhage protocols should be in place.
Once the patient is more stable – take a history and perform an examination (as ‘Examination’, above); identify severity of blood loss and treat any comorbid conditions.
MWS usually follows a benign course but occasionally endoscopic treatment is required to stop bleeding. Sclerotherapy, electrocoagulation and nd:YAG laser treatment can all be used to arrest bleeding. Banding and clipping techniques have also been used.
Clinical management
The main symptom of syndrome is “bloody” vomiting which the dyspeptic signs preceded: nausea and “unbloody” vomiting. Sometimes patients complain for pain in a epigastric area, in the lower part of thorax, which is related to sudden cardial and lower part of esophagus distension.
Weight of bleeding depends on length and depth of breaks and caliber of the damaged vessels. In one case at first the some dark blood is excreted and only at the repeated vomiting is a lot of bright red blood. In other case at once there is vomiting by a bright red blood. Sometimes bleeding looked as the tar-like emptying. The degree of hemorrhage and its weight is determined after the generally accepted chart.
Taking into account that a syndrome arises up after acceptance of a plenty of alcohol and food, the clinical forms of passing are distinguished: simple, delirious, with the signs of acute hepatic insufficiency, without the signs of acute hepatic insufficiency, that matters very much for the choice of medical tactic.
Urgent esophagogastroscopy is the basic method of diagnostics of syndrome. During it in the cardial part of stomach or esophagus single or plural fissures are diagnosed by length 0,5–4,0 cm, by width 0,5–0,8 cm which pass longitudinally, bleeding. The edges of mucus round a fissures swelled, elevated, covered by a fibrin. Often the muscular layer of stomach or esophagus is the bottom of fissure.
Diagnosis program
1. Anamnesis and phisical examination.
2. Esophagogastroscopy.
3. Global analysis of blood.
4. Coagulogram.
5. Group and Rhesus factor of blood.
Endoscopy
Ideally, endoscopy should be performed within 24 hours, as tears heal rapidly and may not be readily apparent at endoscopy after 2-3 days. Proton pump inhibitor (PPI) use is not recommended prior to diagnosis by endoscopy.
5-35% of patients require some form of intervention, usually endoscopic.
Most patients (>80%) present with a single tear. The tear is usually just below the gastro-oesophageal junction on the lesser curvature of the stomach.
Tears are usually associated with other mucosal lesions (83% of patients). These may contribute to bleeding and/or cause the retching and vomiting. Endoscopic examination should be thorough because such co-existing lesions are common.
Several endoscopic modalities are effective for treating a bleeding Mallory-Weiss tear. Injection therapy is often regarded as the first-line therapy.
Fasting is restricted to haemodynamically unstable patients and to those who require repeat endoscopy.
Patients can resume oral intake following endoscopy (starting with a liquid diet and advancing as tolerated to a normal diet) within 48 hours (unless nausea or vomiting is a problem).
Post-initial endoscopy
Calculate the full (post-endoscopic) Rockall Score, as described in the Upper gastrointestinal bleeding (includes Rockall Score) separate article – score <3 is associated with low risk of re-bleeding or death and can be considered for early discharge, whereas a score >3 indicates patients need further close observation as an inpatient.
Careful monitoring is needed after endoscopy for UGIB (pulse, blood pressure, urine output). It is imperative to identify re-bleeding or continuing bleeding.
Patients with clinical risk factors for re-bleeding (for example, portal hypertension, coagulopathy) comprise about 10% of cases. These and those with certain endoscopic findings (non-bleeding visible vessel, pigmented protuberance, or adherent clot) should be observed for 48 hours.
If patients are stable 4-6 hours after endoscopy they should be put on a light diet, as there is no benefit in continued fasting.
If re-bleeding occurs, it usually takes place within 48 hours. Shock at initial manifestation and active bleeding at endoscopy are independent risk factors predicting recurrent bleeding in patients with MWS.[3]
Tactic and choice of treatment method
Conservative treatment of the Mallory-Weiss syndrome is indicated at the small rupture of mucus stomach, to the stop of bleeding, absence of bleeding. Treatment of patients is begun with active conservative therapy, which includes blood transfusion, infusion of hemostatic, application of antacid, Meulengracht’s diet. At the rupture of the I–II degrees indicated endoscopy by amonopolar electrocoagulation of the fissure and covering of aerosol film-forming preparation Lifusol. The conservative method of stop of bleeding in such patients is especially perspective, because most of them has the delirious state or acute hepatic insufficiency.
Operative treatment is indicated at the deep large ruptures of mucus and muscular layers, cardial part of stomach, which are complicated by bleeding. In such cases conduct gastrotomy and suturing of raptures by interrupted suture or 8-shaped stitch, applying nonabsorbable filaments. Sewings of ruptures of mucus stomach often supplement with vagotomy with pyloroplasty. At deep, especially plural ruptures which are accompanied by the edema of tissues, sewing of ruptures is supplement with bandaging of left gastric artery.
Complications
These relate to:
Symptoms:
Vomiting (hypokalaemia and other metabolic disturbance, aspiration pneumonia, perforation and mediastinitis).
Severity of bleeding:
Hypovolaemic shock, and death (very rare with good care).
Myocardial ischaemia or infarction.
Comorbidities:
Myocardial ischaemia (precipitating, for example, myocardial infarction).
Hepatitis (precipitating, for example, liver failure).
Renal disease (precipitating, for example, renal failure).
Diabetes (worsening control and diabetic coma).
Treatment or investigation:
Endoscopy (mediastinitis, aspiration pneumonia, perforation or aggravation of bleeding).
Angiotherapy (organ ischaemia and infarction, aggravation of bleeding).
Prognosis
The prognosis is generally excellent. Most patients usually stop bleeding spontaneously and the tears heal rapidly, usually within 48-72 hours.
However, bleeding is variable and can range from a few specks or streaks of blood mixed with mucus to large amounts of fresh blood. Shock occurs in adults in as many as 20% but is much less common in children.
Associated diseases may have a significant effect on prognosis; for example, cirrhosis carries a very poor prognosis.
Prevention
Recurrence is rare but it makes sense to counsel patients about precipitating factors (for example, binge drinking, alcohol consumption, excessive straining and lifting, violent coughing) that may lead to a recurrence and are generally hazardous to health. Risk factors for recurrent bleeding include:
Initial presentation of shock.
Liver cirrhosis.
Decreased haemoglobin and platelet count.
Need for blood transfusion.
Intensive care management.
Active bleeding noted at the time of endoscopy.
CANCER OF STOMACH
The cancer of stomach is a malignant formation, that develops from epithelium tissue of mucus stomach. Among the tumours of organs of digestion this pathology takes first place and is the most frequent, by the reason of death from malignant formations in many countries of world. Frequency of it at the last 30 years considerably diminished in the countries of Western Europe and North America, but yet remains high in Japan, China, countries of East Europe and South America.
Etiology and pathogenesis
Etiology of cancer of stomach is unknown. It is known that, as other diseases of gastrointestinal tract, a cancer damages a stomach. According to statistical information, it meets approximately in 40 % of all localizations of cancer.
The factors of external environment has the substantial influencing on frequency of this pathology. Above all things, feed, smoke food, salting, freezing of products and their contamination of aflatoxin. Consider that a “food factor” can be: a) by a carcinogen; b) by the solvent of carcinogens; c) to grow into a carcinogen in the process of digestion; d) to be instrumental in action of carcinogens; e) not enough to neutralize carcinogens.
In the USA and countries of Western Europe frequency of cancer of stomach in 2 times more large in the lower socio-economic groups of population. Some professional groups also can it (miners, farmers, works of rubber, woodworking and asbestine industry). High correlation communication is set between frequency of cancer of stomach and use of alcohol and smoking. The value of genetic factors (heredity, blood type) is not led to.
The cancer of stomach arises up mainly in age 60 years and above, more frequent men are ill.
Precancer. The precancer diseases of stomach are: a) chronic metaplastic disregenerator gastritis conditioned by helicobacter pylori; b) villous polypuses of stomach and chronic ulcers; c) nutritional anemia due to vitamin B12 deficiency (pernicious); d) resected stomach concerning an ulcer.
The presence of precancer changes of mucous tunic of stomach has substantial influence for frequency of stomach cancer. In those countries, where morbidity on the cancer of stomach is higher, considerably more frequent chronic gastritises are diagnosed. Lately in etiology of chronic gastritises take the important value helicоbacter pylori. In Japan, where the cancer of stomach is in 40 % cases is the reason of death, chronic gastritis appears in 80 % cases of resected stomach, concerning a cancer.
Connection between polypuses, chronic gastric ulcers and possible it malignization comes into question in literature during many decades. Most authors consider that polypuses could be malignant differently. There are three histological types of polypuses: hyperplastic, villous and hamartoma. There are hyperplastic polypuses, but it not malignant.
Hamartoma is accumulation of cells of normal mucous tunic of stomach. They never becomes malignant.
Villous polypuses are potentially malignant in 40 % cases, but it happen in 10 times less, than hyperplastic. The possibility of malignization of chronic gastric ulcers is not proved. The American scientists support a hypothesis, that the cancer of stomach can be ulcerous often, but malignization of ulcers takes place rarely (no more than 3 %). From data of the Japanese scientists, on 50–70th there was higher correlation connection between chronic gastric ulcers and cancer of stomach. The frequent decline of this correlation is lately noticed (70 % on 50–70th and 10 % on 80th).
Frequency of cancer of stomach at patients with pernicious anaemia hesitates within the 5–10 %, that in 20 times higher, compare with control population. In patients with a resected stomach after peptic ulcers is multiplied the risk of origin of stomach cancer in 2–3 times (duration of latent period hesitates from 15 to 40 years). The reason of such dependence is not found out, but there is a version, that this is linked with a gastric epithelium metaplasia by an intestinal type.
Pathomorphology
From all malignant formations of the stomach in 95 % adenocarcinoma is observed. Epidermoid cancer, adeno-acanthoma and carcinoid tumours do not exceed 1 %. Frequency of leiomyosarcoma hesitates within the limits of 1–3 %. Lymphoma of gastrointestinal tract is localized in a stomach.
The prognosis of localization depends on the degree of invasion, histological variants of tumour.
The macroscopic forms of cancer of stomach in different times were described variously. More than 60 years ago the German pathologist Bermann described 5 macroscopic forms of cancer of stomach: 1) polypoid or mushroom-like; 2) saucer-shaped or with ulcerous and expressly salient edges; 3) with ulcerous and infiltration of walls of stomach; 4) diffuse -infiltrate; 5) unclassified.
American pathopsychologs is selected 4 forms. The tumours of stomach with ulcerous are the most frequent macroscopic form of cancer of stomach and arise up on soil of chronic ulcer. The signs suspicious on malignization are: the sizes of ulcer more than
The polypoid tumours of stomach observed only in 10 %. These tumours can achieve considerable sizes without an invasion and metastasis. Scirrhous carcinoma is the third macroscopic type. This category of tumours also does not exceed 10 %. The scirrhous carcinoma is the signs of infiltration by anaplastic cancer cells, diffusely developed connecting tissue which results in the bulge and rigidity of wall of stomach. So called “small cancers” belong to the fourth macroscopic type. It meet comparative rarely (no more than 5 %) and is characterized by superficial accumulation of cancer cells which substitute for normal mucus in such kind: a) superficial flat layer which does not rise above the level of mucus; b) salient (bursting) formation; c) erosions.
Mainly (more than 50 %) tumours arise up in a antral part or in distal (lower) third of stomach, rarer (to 15 %) — in a body and in cardia (to 25 %).
However, lately more often observed cardioesophageal cancers and diminishment of frequency of tumours of distal parts of stomach. In 2 % cases meet the multicentric focuses of growth, but from data of some authors, this percent could be multiplied in 10 times after carefully histological inspection of the resected stomaches. This assertion is based on the theory of the “tumour field” (D.I. Holovin, 1992). Especially this typically for patients which has pernicious anaemia or chronic metaplastic disregenerative gastritis.
Metastasis is carried out by lymphogenic, hematogenic and implantation ways mostly. Three (from data of some authors, four) pools of lymphogenic metastasis are selected: left gastric (knots on passing of small curvature of stomach in a gastro-subgastric ligament and pericardial); splenic (mainly, suprainfrapancreatic knots); hepatic (knots in a hepato-duodenal ligament, right gastric omentum that lower pyloric groups, right gastric and supraраpyloric groups, pancreatoduodenal group).
However, the such way of lymphogenic metastasis is conditional and incomplete, as at presence of block lymph flow passes retrograde metastasis, so called “jumping metastases” which predetermine the origin of remote lymphogenic metastases in left supraclavicular lymph nodes (Virhov metastasis) appear, in Lymph nodes of left axillar and inguinal areas, metastases in a umbilicus.
Direct distribution: small and large omentum, esophagus and duodenum; liver and diaphragm; pancreas, spleen, bile ducts.
Front wall of stomach: colon bowel and mesocolon; organs and tissues of retroperitoneal space.
Lymphogenic metastasis: regional lymph nodes, remote lymph nodes, left supraclavicular lymph node (Virhov), lymph node of axillar area (Irish); in a umbilicus (sisters Joseph).
Hematogenic metastasis: liver, lungs, bones, cerebrum.
Peritoneal metastasis: peritoneum, ovarium (the Krukenberg metastasis), Duglas space (the Shnicler metastasis).
Classification (by system of ТNM)
Т— primary tumour.
Т0 is a primary tumour is not determined.
Тх — not enough data for estimation of primary tumour.
Тis is invasive carcinoma: intraepithelial tumour without the invasion of own shell mucus (Carcinoma in situ).
Т1 is a tumour infiltrate the wall of stomach to the submucous layer.
Т2 is a tumour damages mucus, submucous and muscular layers.
Т3 is a tumour germinates in a serous shell.
Т4 is a tumour passes to the neighbouring structures.
N are regional lymphatic nodes.
Nх — not enough information for the damage assessment of lymphatic nodes.
Nо — metastases in regional lymph nodes are not present.
N1 are damaged perigastral lymph nodes in the distance no more than
N2 are damaged perigastral lymph nodes in the distance more than
М is remote metastases.
Мх — not enough information for estimation of remote metastases.
Мо — remote metastases are not present.
М1 is presence of remote metastases.
Groupment by stages
Stage 0 Т No Mo.
Stage I Т1-2 No Mo.
Stage II T2-3 No Mo.
Stage III T1-4 N1-2 Mo.
Stage IV any T, any N M1.
Except for clinical classification (ТNM or сTNM), for the most detailed study pathological classification (postsurgical, posthistological) which is signed рТNМ.
G — histopathological differentiation:
G1 is the well differentiated tumour;
G2 is the moderately differentiated tumour;
G3-4 — it is badly or undifferentiated tumour.
Clinical management
All authors which are engaged in the study of problem of cancer of stomach underline absence or vagueness, no specificity of symptoms, especially on the early stages of disease. The displays of cancer of stomach are very various and depend on localization of tumour, character of its growth, morphological structure, distribution on contiguous organs and tissues. At localization of tumour in a cardial part patient complains firstly, as a rule, for appearance of dysphagy.
At careful, purposeful collection of anamnesis it is not succeeded to expose some other, most early symptoms, which precedes to dysphagy and forces a patient to appeal to the doctor. The unpleasant feeling behind a breastbone and feeling of unpassing of hard food on a esophagus appear at the beginning of disease. After some time (as a rule, it is enough quickly, during a few weeks, sometimes even days) a hard food does not pass (it is to wash down by water or other liquid). This period can be during 1–3 months. Patients address a doctor exactly in this period. Other symptoms appear to this time: regurgitation, pain behind a breastbone, loss of mass of body, sometimes even exhaustion, the grey colouring of person, a skin is dry, quickly grows general weakness. Sometimes patients address a doctor, when already with large effort a spoon-meat passes only or complete stenosis came.
At localization of tumour in the antral part of stomach the first complaints, as a rule, are up to appearance of feeling of weight in epigastric region after the reception of food (even in a two-bit), “feeling of saturation” (after the reception of glass of water), belch (at first it is simple by air, and then with a smell). Feeling of weight grows for a day, patients forced to cause vomiting. In the morning there can be vomiting by mucus with the admixtures of “coffee-grounds” (so called “cancer” water). Patients loses weight (mass of body is lost), a weakness, anaemia grows.
Tumours localized in the body of stomach show up either a pain syndrome or syndrome of so called “small signs” (А.I. Savitskyy, 1947), which is characterized by appearance of amotivational general weakness, decline of capacity, rapid fatigueability, depression (by the loss of interest to the environment), proof decline of appetite, gastric discomfort, making progress weight lost.
The carried chronic diseases of stomach, for which typical seasonality, can influence on the clinical sign of cancer of stomach. At appearance of “gastric” complaints out of season or in absent of effect from the got therapy concerning the exacerbation of “gastritis”, “ulcers” must guard a patient and doctor (symptom of “precipice” of gastric anamnesis).
In case of occurring of “gastric” symptoms first in persons in age 50 years and older it is foremost necessary to eliminate the cancer of stomach.
In parts of patients cancer of stomach shows up only the metastatic damage of other organs or complications. More than twenty so called “atypical” forms, which are characterized by “causeless” anaemia, ascites, icterus, fever, edemata, hormonal disturbances, changes of carbohydrate exchange, intestinal symptoms, are distinguished.
During the examination of patients with the cancer of stomach the pallor of skin covers (at anaemia) is observed, ieglected case is “frog” stomach (sign of ascites).
During palpation determined painful in a epigastric area, sometimes possible to palpate the tumour.
During auscultation of patients with pylorostenosis it is possible to define “noise of splash”.
Laboratory information: hypochromic anaemia, neutrophilic leukocytosis, megascopic ESR; during examination of gastric secretion: hypo- and anacidity and achlorhydria.
Gastroduodenoscopy enables to diagnose a tumour even smaller
Roentgenoscopy and roentgenography examination of stomach. Basic signs: defect of filling, local absence of peristalsis, “malignant” relief of mucous tunic (Pic. 3.2.18).
Ultrasonic examination: presence of metastases in a liver, pancreas.
Computer tomography allows to estimate the basic parameters of tumour, germination ieighbouring organs and presence of metastases.
It is expedient to apply laparoscopy, mainly, for the decision of question about operable of tumour (diagnostics of metastatic defeat of organs of abdominal cavity).
Diagnosis program
1. Anamnesis and physical methods of examination.
2. Roentgenologic examination of stomach.
3. Endoscopic examination with a biopsy (if necessary from a few places and even repeatedly), cytologic and histological examination.
4. Sonography, computer tomography.
5. Laboratory, radioisotope methods of examination.
6. Laparoscopy.
7. Diagnostic (therapeutic) laparotomy.
Differential diagnostics
At an early cancer complaints depend on the previous gastric diseases. Therefore, on the basis of clinical information, suspecting a tumour is possible only on occasion, when in patients next to clear pain symptoms an appetite goes down, appear anaemia, general weakness. In practice an early cancer is recognized at purposeful screening, and also in the process of endoscopic or roentgenologic examination of gastric patients.
A differential diagnosis is conducted with an peptic ulcer, gastritis, polyposis, other gastric and ungastric diseases. For a cancer there is typical firmness of symptoms, instead of their seasonality (typical syndrome of “precipice” of gastric anamnesis) or tendency to their gradual progress.
The row of diseases, with which the cancer of stomach is to differentiate to the doctor, depends from character of complaints of patients.
Five basic clinical syndromes are selected:
1) pain;
2) gastric discomfort;
3) anaemic;
4) dysphagic;
5) disturbance of evacuation from a stomach.
At patients, at what cancer of stomach shows up a pain syndrome and syndrome of gastric discomfort, a differential diagnosis is conducted with the peptic ulcer, gastritis, cancer of body of pancreas.
It is oriented on features dynamics of development of pain syndrome, ingravescent of the general condition, change of character of complaints.
A question about character of anaemia, source and nature of bleeding decides at an anaemic syndrome. In the process of examination attention is paid to the state of bottom of stomach, where bleeding malignant formations can be.
At a dysphagic syndrome a differential diagnosis is conducted with the cicatrical narrowing, achalasia of esophagus. For malignant formations testify short anamnesis, gradual progress of symptoms, signs of gastric discomfort, general weakness, weight lost.
At disturbance of evacuation from a stomach during stenosis of pyloric part, absence of ulcerous anamnesis, declining years of patients, relatively quick (weeks, months) growth of stenosis testify for tumor.
Tactic and choice of method of surgical treatment
The presence of cancer of stomach is a indications for surgical treatment. However, counting on success is possible only at presence of the limited tumours (within the limits of the 0–II stages). At the III stage of disease implementation of the widespread combined operations in a radical volume is possible, however most patients die during 1–2 years. A distal or proximal subtotal resection (Pic. 3.2.19) and total gastrectomy (Pic. 3.2.20) is performed with removing of large and small omentumes and regional areas of metastasis with obligatory histological examination of stomach on the lines of resections.
During the combined operations organs which are pulled in to the pathological process are removed.
In case of IV stage of disease and satisfactory state of patient palliative operations which improve quality of life of patient are performed.
In case of presence of complications (mainly stenosis) and grave common condition of patient perform symptomatic operative treatments.
Symptomatic is operations which will liquidate one of symptoms of cancer of stomach. In this group of operations include: 1) roundabout gastrojejunoanastomosis (Pic. 3.2.21) and jejunostoma (in case of the stenosis tumours of stomach output); 2) gastrostoma (Pic. 3.2.22) in case of the cancer of cardial part of stomach with disturbance of patency; 3) edging of bleedingх vessels in case of complication of cancer by bleeding; 4) tamponade by omentum during the perforation of tumour.
The value of radial therapy and chemotherapy, as independent methods of treatment of cancer of stomach, is limited. Radial therapy is indicated for patients with cardial cancer as preoperative course or as palliative treatment. Adjuvant mono- or polychemotherapy (mainly by 5-phtoruracil) is conducted in a postoperative period as combined therapy and in case of dissemination of the tumours.
Prognosis. The indexes of five-year survival of patients with the cancer of stomach hesitate within the limits of 5–30 %, but, from data of most authors, they do not exceed 10 %.
Hemorrhagic erosive gastritis
Hemorrhagic erosive gastritis is diffuse bleeding from mucous tunic stomach as a result of single or plural superficial defects (erosions) of mucous tunic. The gastrointestinal bleeding during erosive gastritis meet in a clinic in 13–17 % cases of acute hemorrhage in a gastrointestinal tract and take first place among bleeding of unulcerous etiology. The disease is met both at men and at women, but more frequent observe in declining years.
Etiology and pathogenesis
The spasm of large vessels in the deep layers of gastric wall, which results in disturbance of local microcirculation, hypoxia and increases of permeability of vascular wall, matters in etiology and pathogenesis of hemorrhage erosive gastritis. The local reaction causes strengthening of reverse diffusion of hydrogen ions, liberation of pepsin, histamine. Such process often is consequence of local damaging factor — action of medicinal or toxic factors for the vessels of mucus. Damaging factor could be the matters which violate a blood flow in mucus stomach (aspirin, reserpine, hormones of adrenal glands cortex). The large value in formation of erosions is had by the anatomic features of blood flow of stomach in a cardial part on small curvature. In connection with absence of submucosal vascular plexus, eventual vessels on small curvature are disposed in relation to mucus tangentially. It results in shelling of epithelium, origin of erosions. Veins damaged at first, that predetermines a hemorrhage and then bleeding. In the origin of acute hemorrhage gastritis matter also acute damage of mucus stomach by mechanical, chemical (burns) and other factors, accompanying diseases (uremia and others like that).
Clinical management
For hemorrhage erosive gastritis there are typical two clinical syndromes: ulcerous and hemorrhagic. The ulcerous syndrome is the most frequent sign of hemorrhage gastritis. “Typical ulcerous pain” is observed in such patients. A hemorrhagic syndrome shows up by the repeated gastric bleeding and moderately increasing anaemia. Bleeding are capillary and are not such catastrophic, as at gastric ulcers.
The clinical picture of hemorrhage gastritis is characterized by dull pain in a epigastric area, which appears at faults in a food, reception of alcohol. Patients disturbs vomiting like “coffee-grounds”, “melena”, which arise up among a complete health, symptoms of hemorrhage (dizziness, general weakness, acceleration of pulse, decline of arterial pressure). The decline of amount of red corpuscles is observed in the blood test, haemoglobin, haemathokritis, leukocytosis. During the roentgenologic examination observed the thickened winding folds of mucus stomach with the small depots of barium. At endoscopic diagnostics of bleeding the presence of single or plural erosions on mucus up to 5–7 mm in diameter are noticed, symptom of “morning dew” (“weeps” all mucus stomach).
Diagnosis program
1. Anamnesis and phisical examination.
2. X-Ray examination of stomach.
3. Endoscopy.
4. Global analysis of blood.
5. Coagulograma.
6. Group and rhesus -belonging of blood.
Tactic and choice of treatment method
Treatment of hemorrhage erosive gastritis, mainly, is conservative. Washing of stomach an effective by cold water or by 5 % solution of aminocapronic acid with subsequent irrigation of mucous tunic by film-forming preparations through endoscope and introduction of hemostatic. It is important the neutralization of hydrochloric acid in a stomach (antacid, additional introduction of atropine of sulfate, aspiration of gastric content), setting of preparations which stimulate reparative processes in a mucous tunic (methyluracyl, sayotek, sea-buckthorn oil), antihelicobacter preparation (de-nol). If under the endoscopy control effect from conservative treatment is absent and it is the obvious threat of life of the patients, operative treatment is indicated.
Surgical treatment must be minimum. Sewing and edging of bleeding areas, selective vagotomy with pyloroplasty in most cases is effective. Only at bleeding from arising acute erosions after submucosal telangiectasia, indicated resection of stomach. It is needed to remember, that the additional focus of bleeding can be in fundal and cardial part of stomach. Without their edging and localhemostasis operation caot be radical. At the considerable damage of stomach by an erosive process, for a patient indicated resection of stomach or gastrectomy.
Tactics at bleeding from the varicose veins of esophagus
(Fig.7.)
Fig.7. Variceal hemorrhage
Treatment of patients at bleeding from the varicose veins of esophagus needs to be begun with the tamponade internal surface of esophagus and cardial part of stomach by the special double-balloon Sengstaken-Blakemore tube (Fig.8; Fig.9.). Some other conservative measures directed on the stop of bleeding without the use of this probe are considered ineffective and tactically wrong.
Fig.8. Sengstaken-Blakemore tube
Fig.9. Method of application of the Sengstaken-Blakemore tube
The Sengstaken-Blakemore tube has three ducts, two of which are connected with rubber bulbs, one — with the cavity of stomach. Before application of probe by introduction of air the volume of bulbs is measured. Probe through a nose and in a distal (gastric) bulb is inserted, the necessary amount of air is forced (about 150,0 ml). After this by drawing out of it a round (distal) gastric bulb is pinned outside against cardia. Farther prolonged esophagus bulb is inflated to appearance at the patients feeling of arching (volume about 120,0 ml) and it is obturated. Then to the proximal end of probe through the block, the load is suspended weighing about 1 kg It warns reverse advancement of probe in stomach and by this provides stability of compression of the varicose extended veins. The control after hemostasis is carried out through the third, connected with stomach, duct of probe. By such method it can be succeeded to attain to hemostasis in 80–90 % cases. The probe in such position is held 2–3 days. After this decompression of repeated bleeding can come almost in half of patients. Therefore deleting the probe is not needed. Taking this into account, it is expedient to carry out decompression of bulbs in the light intervals of days and inflate bulbs at night, when the control after the possible bleeding is complicated.
Conservative treatment is reasonable: 1) at the easy degree of loss of blood and I degree of hepatic insufficiency (basic biochemical indexes either are not changed or with insignificant deviations from a norm; ascites and encephalopathy are absent); 2) at the III degree of hepatic insufficiency, progressive ascites and encephalopathy, regardless of degree of loss of blood.
Conservative therapy of bleeding from the varicose veins of esophagus must engulf the whole volume of medical measures, as at similar pathology of ulcerous genesis (hemostatic therapy, antacid, Н2- blocker histamine receptors).
For the decline of portal pressure pituitrin is entered. The endoscopic methods of stop of bleeding are applied also (imposition of clips on veins, sclerosis therapy — 76 % ethyl alcohol, Varicocide, 66 % solution of glucose, endovascular occlusion of veins, laser coagulation of veins). It is needed to count setting of preparations for stimulation of regeneration of liver (esenciale, lif-52 and others like that), application of disintoxication therapy.
Surgical treatment is considered applicable at bleeding of middle and heavy degrees with the I and the II degrees of hepatic insufficiency (general bilirubin not more large 50 mcmol/L, general albumen not more small 60 g/л, prothrombin index not more low 60 %, present transient ascites) in the cases when the valuable conservative treatment directed on the stop of bleeding is not effective during 24–48 hours.
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Prepared ass. Romaniuk T.
