ulcer bleeding
Introduction
Introduction to ulcer bleeding The amount and rate of bleeding depends on the type and diameter of the eroded blood vessel, the vasomotor state of the blood vessel, and the patient's coagulation mechanism. The so-called massive bleeding refers to the clinical occurrence of hypovolemic shock, hemoglobin is less than 8g/100ml, and the red blood cell count is less than 3 million/mm3. Generally, there is often a small amount of bleeding on the ulcer surface, which is caused by corrosion and destruction of the capillaries at the bottom of the ulcer. When the blood vessels at the bottom of the ulcer are eroded, the arteries or veins may be eroded and ruptured, and the bottom tissue is constantly progressing during the progress of the ulcer. It is eroded, the ulcers continue to deepen, and finally penetrate the serosal layer of the stomach or duodenal wall to cause perforation. basic knowledge The proportion of illness: 0.02% Susceptible people: people with ulcers Mode of infection: non-infectious Complications: syncope shock
Cause
Ulcer bleeding cause
(1) Causes of the disease
Whether it is gastric ulcer or duodenal ulcer can be combined with blood, especially large ulcers and deep ulcers often corrode the blood vessels in the base of the ulcer and cause bleeding. Pyloric ulcer and duodenal ampullary ulcer are more likely to cause bleeding. It is often difficult to stop bleeding after bleeding.
(two) pathogenesis
Generally, there is often a small amount of bleeding on the ulcer surface, which is caused by corrosion and destruction of the capillaries at the bottom of the ulcer. When the blood vessels at the bottom of the ulcer are eroded, the arteries or veins may be eroded and ruptured, and the bottom tissue is constantly progressing during the progress of the ulcer. It is eroded, the ulcer is deepened, and finally it can penetrate the serosa layer of the stomach or duodenal wall to cause perforation. Acute perforation is common in the anterior wall ulcer, and the duodenum or stomach contents flow into the abdominal cavity, resulting in acute diffuseness. Peritonitis; Chronic ulcer penetration is common in posterior wall ulcers, anterior pyloric area, pyloric or duodenal ulcer can form a large number of scars during healing, due to scar tissue contraction can cause pyloric stenosis, but also around the ulcer Secondary inflammation, edema or pyloric tendon lead to functional pyloric obstruction.
Prevention
Ulcer bleeding prevention
All patients with a history of ulcers should be treated actively, standardizedly, and systematically to prevent the occurrence of ulcer complications - ulcer bleeding. Pay attention to proper rest, do not master the combination of movement and rest, rest well, is conducive to the recovery of the body; exercise can enhance physical strength and enhance disease resistance, and the combination of the two can better recover.
Complication
Ulcer bleeding complications Complications
1. Acute hemorrhage, such as more than 1000ml, may appear palpitations, dizziness, cold sweat, syncope, skin cold, heart rate, pulse speed and other signs of hemorrhagic peripheral circulatory failure, and even irritability, convulsions, heart rate often exceeds 120 times /min, blood pressure is significantly reduced, shock can occur.
2. Fever, patients may have low fever, body temperature often does not exceed 38.5 °C.
Symptom
Ulcer bleeding symptoms Common symptoms Anxiety tension Nausea palpitations Dizziness Hypotension Hypertension Stomach pain Compensatory effect Esophageal bleeding
The clinical manifestation of ulcer bleeding depends on the amount and speed of blood loss, whether bleeding continues, the age of the patient, whether there is anemia and dehydration, and mental state, generally healthy adults, the amount of bleeding does not exceed 500ml, without any symptoms The blood volume can be recovered from the tissue fluid within 36 hours, but the protein content is low, and the blood is diluted. The red blood cells and hemoglobin must be recovered within 2 weeks. The normal spleen reserves are small and cannot play a big role.
Loss of blood above 1000ml, can appear palpitations, nausea, weakness, more than 1500ml, can occur hypotension, depending on the speed of bleeding and dizziness, fainting and shock, etc., if lost 2000ml within 15min, it is inevitable Deep shock, even death, lost half of the circulation within 10h, 10% of untreated patients died; if the same amount of blood was lost more than 24h, very few deaths occurred.
The amount of blood loss is large, the blood volume is reduced, the blood volume is reduced, and the cardiac output is also reduced. By the action of sympathetic adrenaline, reflex vasoconstriction is caused; mainly small arteries and veins contract, thereby skin, skeletal muscle and internal organs. Reduced blood flow can increase cardiac output by 25% to meet the blood supply to the vital center of the life. Vasoconstriction facilitates venous return. In fact, blood is transferred from the venous pool to the circulating arterial part to increase tissue perfusion. It is the performance of pre-compensation function before shock. Especially when the bleeding is slow, the compensatory effect is more prominent. Therefore, in chronic bleeding, the blood pressure is not a good indicator of the amount of bleeding, especially in young people; diastolic blood pressure reflects the blood volume compared with systolic blood pressure. Reduction is more valuable, except for patients with hypertension, whose diastolic blood pressure is easier to maintain than normal blood pressure. When blood volume decreases, heart rate increases often before arterial pressure drops, so changes in pulse rate may provide more blood loss. The hint of meaning, but the pulse is affected by mental state and rapid infusion, the central venous pressure is reflected back to the blood flow By signs, urine volume per unit time to reflect tissue perfusion case, it should exclude the possibility of high-ranked nephrotic syndrome and renal failure.
Hypovolemic shock is the main manifestation of major hemorrhage. The pulse is fast, the systolic blood pressure is below 10.7 kPa (80 mmHg), the skin of the limbs is cold and wet, pale, breathing is shallow, and thirst, nausea, anxiety, and anxiety are characteristic. Insufficient perfusion can lead to less urine and hypoxia; anaerobic metabolism produces a large amount of pyruvate and lactic acid. In the case of metabolic acidosis, the vascular tone gradually disappears, and the inner adrenaline and norepinephrine are also Gradually lose the reaction, and finally the blood vessels dilate, and the patient can die due to circulatory failure.
Examine
Examination of ulcer bleeding
Blood picture
White blood cell and neutrophil counts are often slightly elevated, and hemoglobin and red blood cell counts decrease (early may not be obvious).
2. Blood urea nitrogen
After hemorrhage, enterogenous azotemia can occur due to elevated intestinal nitrogen. If the patient's renal function is normal, the degree of blood urea nitrogen elevation can reflect the amount of bleeding.
3. X-ray gastrointestinal barium meal angiography
It has an accuracy of 70% to 90% for the diagnosis of ulcer disease. However, in the state of shock, when the patient can't stand or the blood clot accumulates in the stomach, it is not suitable. Generally, it is recommended that the condition be stable after 48 hours and then check. It is not suitable to press, the presence of tincture in the gastrointestinal tract is obstructive to observe the results, should be considered in advance, currently in the diagnosis of acute upper gastrointestinal bleeding is not the preferred method of examination, and the choice of emergency gastroscopy.
4. Gastroscopic examination
The positive rate can reach 80%~95%. It is superior to X-ray gastrointestinal sputum angiography in diagnosing upper gastrointestinal bleeding. Gastroscopic examination can not only see the nature of the lesion, but also can see the reliable signs of activity or recent bleeding, that is, fresh. Bleeding or oozing, the lesion area is dark brown or with clots. According to the experience of 248 cases of emergency gastroscopy in 8 major hospitals in Beijing, it is considered that it does not increase the risk of major bleeding. If necessary, it can be performed under endoscopy. Hemostasis treatment, as long as the patient's blood pressure is stable and close to normal, after the patient's concerns and tensions are eliminated, it is carried out at the bedside or on the operating table. The examination process should be light and rapid, avoiding rough insertion, and the inspection time should be 24 after bleeding. ~48h, otherwise some superficial mucosal lesions such as erosion, shallow ulcers, mucosal tears, etc., may lose the diagnosis signs due to partial or complete repair, do not need gastric lavage before the examination, if observed due to the impact of blood, Before the examination, the stomach is washed with ice water through the stomach tube. The observation should be comprehensive. Do not be satisfied with finding a lesion. Conclusion: The esophagus, stomach and duodenum should be carefully examined. After that, make a diagnosis, if necessary, take a living body for pathological examination, but be wary of the varicose veins at the bottom of the stomach sometimes appear gray nodular bulge, but the soft and elastic touch, easy to take biopsy has a serious bleeding risk.
5. Selective celiac angiography
Acute upper gastrointestinal hemorrhage also contributes to the localization diagnosis. The positive rate of chronic small amount of bleeding is not high. Some hospitals use this as the primary diagnostic step, and then make a barium meal or other examination after failure.
6. Swallowing test
The swallowing test method is simple, generally using ordinary white line, 30 minutes after swallowing one end. After taking out, the bleeding is judged according to the area of the incisors. Pittman introduces the fluorescent band test to diagnose upper gastrointestinal bleeding; After one end, fluorescein was injected intravenously, and then the band was observed under ultraviolet light to observe the blood stained portion of fluorescein, and the length of the incisor was calculated to determine the location of the bleeding.
7. Other tests
For example, if Miller-Abbott (MA) double lumen tube is used, after insertion into the gastrointestinal tract, it is continuously sucked. When the tube is sucked out of blood, it is fixed with a tape, and the X-ray film is used to examine the tube end portion. Where the bleeding is located, it is effective for slow bleeding positioning, and there are red blood cells labeled with chromium. After intravenous injection, each radiograph sampled by the MA tube is used to measure the radioactivity, and the most radioactive specimen contains 51 chromium. The location of the bleeding, this test is of little value in the diagnosis of small amount of intestinal bleeding, so it is rarely used.
8. Radionuclide scanning
Commonly used 99mTc labeled red blood cells, after intravenous injection, overflow in the bleeding and gathered in the gastrointestinal tract, scan to detect the radioactive signal in the gastrointestinal tract, indicating the location of gastrointestinal bleeding, but sometimes difficult to accurately locate.
Diagnosis
Diagnosis and diagnosis of ulcer disease
Diagnostic criteria
History of ulcers, history of salicylic acid preparations or hormones, combined with the performance of bleeding, is helpful in diagnosing this disease. 90% of patients with ulcer disease have "stomach pain", but after bleeding, the pain disappears, and should be avoided when checking Necessary manual examination, the abdomen should not be overweight, in order to further understand the bleeding and electrolyte imbalance caused by blood loss and heart and kidney function, blood should be taken to check hemoglobin, red blood cell and platelet count, hematocrit, sodium, potassium, chlorine, urea nitrogen Or non-protein nitrogen, pH or carbon dioxide binding, and coagulation factors, etc., if necessary, should measure oxygen and carbon dioxide partial pressure, blood volume, and ECG, measure central venous pressure to understand the state of the circulatory system, indwell the catheter to observe The amount of urine per hour, the insertion of the stomach tube has diagnostic and therapeutic significance, first inserted into the 40cm, pumping whether there is blood to exclude esophageal hemorrhage, and then inserted into the stomach, can be confirmed as gastric or duodenal hemorrhage, and by observation The bleeding dynamics, in order to further determine the diagnosis, should be considered as an auxiliary examination.
Differential diagnosis
1. Acute erosive gastritis or stress ulcer and bleeding
Common causes of acute erosive gastritis or stress ulcers, such as taking non-steroidal anti-inflammatory drugs, brain trauma, severe burns, multiple organ failure, etc., gastroscopy can confirm gastric mucosal congestion, edema, erosion and bleeding Or stress ulcers.
2. Cirrhosis of esophageal varices bleeding
Patients often have a history of cirrhosis, physical examination can be found in spider mites, liver palm, hepatosplenomegaly, ascites and edema, laboratory tests often have liver damage, complete blood cell reduction, etc., barium meal or gastroscopy can be found in the lower esophagus and stomach Bottom varicose veins.
3. Gastric cancer bleeding
The general condition of the patient is poor, the appetite is diminished, and the weight loss is obvious. In the middle and advanced gastric cancer patients, the swollen lymph nodes can often be touched on the left clavicle, the upper abdomen can be swollen and the mass, the barium meal and the gastroscopy combined with the mucosal biopsy pathological examination can be clear. diagnosis.
