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Stomachandduodenum
BLEEDINGFROMTHEDIGESTIVETRACT.CAUSES,DIAGNOSTICAND
DIFFERENTIALDIAGNOSTIC,TREATMENTTACTIC.
GASTRICANATOMYANDPHYSIOLOGY
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ACUTEGASTROINTESTINALBLEEDINGS.
Theeffluxofabloodinacavityofagastrointestinaltractisunitedina
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stomachatanangiostaxis,leukoses,illnessofVerlgoff,generaldiseasesof
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
bleedingoccursfromarrosivedlargevesselsinthefieldofanulcer,inothers
fromsmallarteriesbothveinsofwallsandfundusofanulcer,inthird
thereisaparenchymatousbleedingfromamucouscoatofstomachoutside
of an ulcer, where alongside with a hyperpermeability of a vascular wall
multiple small arrosions, being a source of a profuse bleeding, quite often
arefoundout.Plentifulmealofraspingnutrition,especiallyunderconditions
ofdifficultyofitsevacuationfromastomach,physicalstrain,theblunttrauma
of a stomach, especially at the filled stomach provoke gastrointestinal
bleedingsatapepticulcer.
Atableedingowingtoanarrosionofawallofalargebloodvesselinthe
field of an ulcer, arising as a result of a necrosis and the subsequent
influenceofagastricchymeonawallofanakedbloodvessel(moreoftenof
an artery), destruction of a vascular wall and the occurrence of a bleeding
usuallyoccursinaphaseofanexacerbationofapepticulcerandthelumen
ofanarrosivedvesselfrequentlyremainsopen,asthedestructionoftissue
framesprevailsaboveproliferativeprocessesinazoneofableedingpoint.
The local factors of a hemostasis, including a retraction of a vessel (rather
circumscribedowingtodegenerativechangesofavascularwallandfibrosis
ofenvironmentaltissues),aggregationofelementsofablood,theformation
ofathrombus,areinsufficientforspontaneousstoppingofableedingandit
quiteoftenacceptsprofusecharacter.
Ataslowlyprogressingulceroutsideofaphaseofanexacerbationthe
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
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frames,thereforeclottageofsuchvesselcanbesufficientforaspontaneous
stoppingofableeding.Howeverinawallofchroniculcerstherecanbefocal
degenerativechangesofbloodvesselswithformationofarterialaneurysms
inthefieldofedgesandfundusofanulcer.Thedestructionofthinwallsof
theseaneurysmalexpansionsisaccompaniedbyseriousprofusebleedings.
Thepathogenyofbleedingsislessinvestigatedatmicroscopicaldefects
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,
inherenttoaphaseofanexacerbationofdisease,hasthedecisivemeaning
inapathogenyofableeding.Apathogenyofbleedingsfromamucosaofa
stomach outside of an ulcer also is unsufficiently found out. On the data of
seriesofresearches,thebasicpathogeneticmechanismsofsuchbleedings
canbe:
Apermanentplethoraofallvascularsystemofastomach,especially
superficial capillaries and veins causing a hypoxia and disorder of a
vasculartissue permeability, that results to massive erythropedesis and
hemorrhage
Expresseddystrophiaofsuperficiallayersofamucosaanddecrease
ofanexchangeofnucleicacidspromotingtoformationofmicroerosion
Accumulation of neutral mucopolysaccharides as a consequence of
disintegrationoftissuepepticcarbohydratebondsandincreaseofavascular
permeability
Disorderofrhythmsofpolymerizationanddepolymerizationofacidic
mucopolysaccharidesinawallofbloodvessels,changeofapermeabilityof
hematoparenchymatousframes
Hyperplastic and dystrophic processes, reorganization and
pathologicalneogenesisofGlandsofallgastricsystems,breakingsecretory
activity of a stomach, bolstering a vasodilatation and tissue hypoxia (V.D.
Bratus)
Theappreciableroleinapathogenyofacutegastroduodenalbleedings
atapepticulcerisplayedalsobydisordersinsystemofahemostasis.They
arereducedtodecreaseandcompletelossbyanarrosivedvesselofability
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fibrinmoreconcentratedinthefieldofafundusofanulcer,thanitsedges.
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
fibrousconnectivetissue,poorforcellularelements,andtheinfiltrationwith
lymphoplasmocytesisexpressedmainlyonacourseofbloodvesselsandin
itssuperficiallayers.
CLASSIFICATION.
The acute gastroduodenal bleedings are differed basically to two
classificationattributes:bleedingsowingtoapepticulcerofastomachboth
duodenal intestine and bleeding of a not ulcerative etiology. Bleedings also
are distinguished on localization of its source (stomach, duodenal intestine
andtheiranatomicdepartments).Theratherlargepracticalimportancethere
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
definitionofmedicaltacticsandcontentsoftransfusiontherapy.
Clinic.Theacutegastroduodenalbleedingsusuallyarisesuddenlyona
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
commonsignsofanacutehemorrhageoccurpalenessofseenmucous
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
bleedingscanbeascoffee,thatusuallyspecifiesaslowbleeding,andthe
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givenventbloodhastimeinalumenofastomachtoreactwithacidicgastric
contents,thereforethehaemoglobinturnstoahydrochloridehematinhaving
darkbrowncolour.Ataplentifulbleeding,especiallyifitssourceisposedin
astomachthegivenventbloodhasnottimetoreactwithagastricchyme,it
is coagulated and forms blood clots which are filling lumen of a stomach.
Theseclotsonappearancesometimesremindacrudeliverandthepatients
quite often mark a vomiting with pieces of a liver*. At a very intensive
bleedingtheoverflowofastomachandthevomitiveactarisesearlier,than
bloodclotshavetimetobeformedandthereisavomitingbyascarletblood,
that is. as well as vomiting with blood clots, attribute of a serious bleeding
fromthetopdepartmentsofagastrointestinaltract.Thevomitingreplicating
in short intervals of time, specifies continuation of a bleeding, and the
occurrenceofavomitinginalongintervaltestifiestoarelapseofableeding.
Ataslowandnotintensivebleeding,especiallyifthesourcelocatedina
duodenal intestine, on a background of the moderately expressed signs of
anacutehemorrhagethedarkstoolscanappear,theimpurityofabloodin
whichiseasilyfoundoutbytheexpressedpositivereactionofGregerson.In
case of an anamnestic bleeding shown by a melena, at inspection of the
patientitisnecessarytocarryoutdigitalresearchofarectum,thatallowsto
determinecharacterofitscontentsandpresenceofanimpurity,undergone
todecomposingwithformationofsulfurousFerrilactasofablood,thatgives
darkcolourtosuchclots.Atmoreintensivebleedingowingtoexaltationby
thegivenventbloodofperistalticactivityofanintestineoccursaliquidtarry
stools,andataveryintensivebleedingstools,sometimesconsensual,can
looklikecherryjamorconsistfromsmalltransformedblood.
The acute gastrointestinal bleedings, shown only by a melena, have
more favorable prognosis in comparison with bleedings, shown by a
hematemesis.Thereisthemostadverseprognosisatbleedings,shownbya
hematemesisandamelena.
Atamilddegreeofahemorrhageitscommonattributesareunstable,as
they are caused not by an oligemia, but reflex reactions and pathological
depositionofablood.Thecreationofconditionsofphysicalandmentalrest
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oferythrocytesandthedecreaseofahaemoglobincontentcanbeabsentor
tobeconsiderablylessexpressedincomparisonwithsizeofahemorrhage,
therepeatedbloodanalysiseswithsimultaneouslydefinitionofapulserate
and level of arterial pressure are necessary for judgement about its sizes,
quiteoftenafterahemorrhagethereisaleukocytosis,risingofESR.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
segmentST,thatmoreprobableisconnectedtoahypoxiaofamyocardium
(F.I. Komarov). At serious bleedings there can be psychic disfunction as
exaltationandhallucinations.Theoccurrenceofthelistedchangesdepends
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
atscopingofhemorrhagevolumeandbleedingpoint,butthisimportanceis
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.Gastroduodenoscopyatacutegastroduodenalbleedings
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
surveyedpatients.
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
hemodinamicparameters)atseriousbleedings,accompaniedbysyncopeor
collaptiod condition. Other additional methods of diagnostics of acute
gastroduodenal bleedings (hepatolienography, celiacography, external
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radiometryetc.)areappliedseldom.
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
variegratedmoistralecausedbyhitofabloodintracheobronchialtreequite
oftenareauscultatedinlungs.
TREATMENT.
At a prehospital stage the first medical assistance at acute
gastroduodenalbleedingsconsistsinthefollowing:
Strictbedregimen
Antacids inside (almagelum, phospholugelum etc.), thrombostatic
preparations (250 units of thrombinum in 50 ml of water on one spoon 15
mineswithin2hours)
Bubblewithice(heaterfilledbycoldwater)onareaofanepigastrium
Ataserioushemorrhage:inhibitorsofafibrinolysisinside(solutionof
epsilonaminocapronicum 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,
Vicasolum5mlorDicynonum2mlintramuscularly.Change(withregistration
inalistofobservation)ofarterialpressureandpulserateineveryone15
30min.
Thedelayofthepatientataprehospitalstageisinadmissible,andeven
theprovedsuspiciononanacuteesophagealorgastroduodenalbleedingis
theabsoluteindicationforurgenthospitalizationofthepatientinthenearest
surgical hospital.The evacuation of the patient should be made in a laying
positioninsupportofthemedicalpersonnel.
Atenteringofsuchpatientinasurgicalhospitalthegroupofabloodfirst
ofallshouldbedeterminedathimandtheconservativetreatmentbasedon
keepingofthefollowingprincipleshastobecontinued:
replenishment of deficiency of volume of a circulating blood by
transfusion of an integral blood of small terms of a storage and
hemocorrectors(plasma,solutionofAlbuminum,erythrosuspensionetc.)
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Suppressionofagastricsecretionandneutralizationofahydrochloric
acid of a gastric juice by application of antacids, cholinolytics, Hblockers
(Cimetidinum, hystodil. Tagametum, cinaet on 0,4 gr 3 4 times per day,
famotidinononetabletonceperdayetc.),localhypothermia
Localandcommonhemostatictherapy
nasogastral intubation for erasion of gastric contents, control of a
hemostasisandstoppingofableedingbyuseof4mlofNoradrenalinumin
150 ml of an isotonic solution of Sodium chloridum, then the probe is
blockedon2h,ifthisintroductionisnoneffectivetheoperativetreatment
(O.S.Kochnev)isshowntothepatient
Maintenance therapy (cardiovascular preparations, use of
Oxygenium,warmingofextremitiesetc.),cleansingenemaforerasionofthe
givenventandbreakingupbloodfromanintestine.
Inaspecialcardofobservationorthecasehistorybasicparametersofa
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,atwhichthestoppingofableedingismadebyapplicationofan
electrocoagulation,laserandotherwaysofanartificialhemostasis.
Theindicationstourgentoperativemeasureconcerningacutebleedings
atanulcerofastomachorduodenalintestineare:
The serious bleeding, when the intensive care during 6 8 hours
appearsunsuccessful
A serious bleeding stopped at conservative treatment, but when the
occurrence of a relapse even with a small hemorrhage represents real
dangertolifeofthepatient
The relapse or proceeding bleeding irrespective of its intensity,
especially at penetrating ulcers of a stomach and duodenal intestine
confirmedbyanendoscopy
Endoscopicattributesofinstabilityofahemostasis.
The first operations concerning a bleeding ulcer of a stomach were
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GASTRICULCER
Video
The gastric ulcer is the chronic disease with polycyclic passing. The
maintypicalofpepticulceristhepresenceofulcerousdefectinamucous
tunic.Oneofbasicplacesbelongsamongthegastroenterologydiseasesto
this pathology. Such phenomenon explained by not only considerable
distributionofdiseasebutalsothosedangerouscomplicationswhichalways
accompanygastriculcers.
Pic.Thepresenceofulcerousdefectinamucoustunic.
Etiologyandpathogenesis
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Frequencyofmorbidityonthepepticulceramongtheadultpopulation
is about 4 %. More frequent age in patients with gastric ulcers is 5060
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
thefactorsofaggressionanddefenseofmucoustunicarosepepticulcer.To
thefirstfactorsbelong:hydrochloricacid,pepsin,reversediffusionofionsof
hydrogen, products of lipid hyperoxidizing. To the second: mucus and
alkalinecomponentsofgastricjuice,propertyofepitheliumofmucoustunic
to permanent renewal, local blood flow of mucous tunic and submucous
membrane.
Intheterminalstageofmechanismoforiginofgastriculcersimportant
role has the peptic factor and disturbance of trophism of gastric wall as a
resultoflocalischemia.Itconfirmedbydecreasingofbloodflowinthewall
ofstomachatpatientswithulcerson3035%comparedtothenorm.Itis
proved, that a local and functional ischemia more frequent arises up on
smallcurvatureofstomachintheareasofectopyoftheantralmucoustunic
inacidforming.Exactlythereulcersappear.
Importantpartinulcerogenesisisactedbyduodenogastricrefluxand
gastritis. Also, gastrostasis can provoke hypergastrinaemia and
hypersecretionandformedgastriculcers.
Numeral scientific developments of the last years testify to the
important infectious factor in the mechanism of origin of peptic ulcer
conditioned,mainly,byhelicobacterpylori.
Pathomorphology
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Classification
Clinicalmanagement
Thecomplaintsofpatientswiththegastriculceralwaysgivevaluable
information about the disease. The detailed analysis of their anamnesis
allowstopayattentiontothepossiblereasonsoforiginofulcer,timeofthe
firstcomplaints,tothechangesofsymptoms.
Pain. A pain symptom in the peptic ulcer disease is very important.
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There are typical passing for this disease: hunger pain food intake
facilitation again hunger pain food intake facilitation (so during all
days).Nightpainforthegastriculcerisnottypical.Thesuchpatientsrarely
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
foodandappearanceofpainitistheshorter,thanthehigherplacedgastric
ulcer.Thus,atpatientswithacardialulcerpainarisesatonceafterthefood
intake, with the ulcers of small curvature in 5060 minutes, at pyloric
localizationapproximatelyintwohours.Howeverthisfeatureitisenough
relative and some patients in general do not mark dependence between
foodintakeandpain.Inotherpatientsthepainattackisaccompaniedbythe
salivation.
A epigastric region near the xiphoid process is typical localization of
pain.Theirradiationofpainisnotusualforgastriculcers.Irradiationoccurin
patients with penetration and depended from organ, in which an ulcer
penetrates.
Attheexaminationofulcerouspatientitisexpedienttodeterminethe
specialpainpoints:Boas(painatpressureontheleftoftheIIpectoral
vertebrae),Mendel(painatpercussiononthelefttoepigastricregion).
Vomiting,thesignofdisturbanceofmotilityfunctionofstomach,isthe
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
organischemia.Vomitingcouldarisesbothonemptystomachandafterfood
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
precedesofpainarising(initialheartburn)oraccompaniesapainsymptom.
Mostlyheartburnarisesafterthefoodintake,butcanappearindependently.
it is observed not only at hypersecretion of the hydrochloric acid, but at
normalsecretion,evenreducedacidityofgastricjuice.
The belching at gastric ulcers is examined rarely, more frequent in
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Clinicalvariantsandcomplication
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Thegastriculcerpassingcanbeacuteandchronic.Acuteulcersarise
as answer for the stress situations, related to the nervous overstrain,
trauma,lossofblood,someinfectiousandsomaticdiseases.Byadiameter
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
andmostlyhealover.
G.J.Burchynskyy(1965)suchvariantsofclinicalflowdistinguished:
1.Chroniculcerwhichdoesnothealoverlongtime.
2. Chronic ulcer which after the conservative therapy heals over
relatively easily, however inclined to the relapses after the periods of
remissionofadifferentduration.
3. Ulcers, which localization are had migrant character. Observed in
peoplewithacuteulcerousprocessofstomach.
4. Special form of gastric ulcer passing after the already carried
disease. Passed with the expressed pain syndrome. Characterized by the
presenceinplaceofulcerousdefectofscarsordeformationsandabsence
ofsymptomofniche.
There are such complications can develop in patients with gastric
ulcer:penetration,stenosis,perforation,bleedingandmalignization.
Diagnosisprogram
1.Anamnesisandphysicalexamination.
2.Endoscopy.
3.XRayexaminationofstomach.
4. Examination of gastric secretion by the method of aspiration of
gastriccontents.
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5.GastricpHmetry.
6.Multipositionbiopsyofedgesofulcerandmucoustunicofstomach.
7.GastricDopplerography.
8.Sonographyofabdominalcavityorgans.
9.Generalandbiochemicalbloodanalysis.
10.Coagulogram.
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Pic.SymptomofHaudek'sniche
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Pic.Pepticulcerofthestomach(endoscopy)
Differentialdiagnostics
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Tacticandchoiceoftreatmentmethod
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reparativedrugs(dalargin,solcoseryl,actovegin)for2ml
12timesperdays
antimicrobialdrugs(clarytromicine500mgtwicedaily,denol,
metronidazole)
Treatmentofpatientwithagastriculcermustcontinuesnotlessthan
68weeks.
Surgicaltreatmentmustperformedincases:
)attherelapseofulcerafterthecourseofconservativetherapy
) in the cases when the relapses arise during supporting antiulcer
therapy
)whenanulcerdoesnothealoverduring1,52monthsofintensive
treatment,especiallyinfamilieswithulcerousanamnesis.
)attherelapseofulcerinpatientswithcomplications(perforationor
bleeding)
)atsuspiciononmalignizationulcers,incaseofnegativecytological
analysis.
Thechoiceofmethodofsurgicaltreatmentofgastriculcerdepended
fromlocalizationandsizesofulcer,presenceofgastroandduodenostasis,
accompanyinggastritis,complicationsofpepticulcer(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,allowstoremoveanulcer,andfromothertosaveconsiderablepart
oforgan,providingitfunctionalability(Pic.3.2.2).Incasewithlargecardial
ulcers, when the vagus nerves pulled in the inflammatory infiltrate and it is
impossible to save integrity even one of them, operation needs to be
complemented by pyloroplasty. It will give possibility to warn pylorospasm
andgastrostasis,whichinanearlypostoperativeperiodcanbethereason
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ofanastomosisinsufficiencyandothercomplications.
At the choice of method of surgical treatment of gastric ulcers with
subcardiallocalizationon small curvature without duodenostasis it is better
toapplythemethodsofstomachresectionwithsavingofpassagethrougha
duodenum.
Forthispurposewearedevelopedthemethodofsegmentalresection
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 acidforming part of stomach
comes after introduction of preparation. The functional scopes of stomach
partsaredetermined.Theborderbetweenacidformingandantralpartsare
themostfrequentlocalizationofgastriculcers.
During this operation middle laparotomy is performed, intravenously
entered 1,0 ml 0,1 % solution of atropine, then the scopes of functional
stomachpartsareidentifiedandbystitchesholdersismarkedaintermedial
segment. Selective proximal vagotomy is performed. After mobilization of
large curvature of stomach within the limits of intermedial segment it
resectionisperformed.Afterthatgastrogastroanastomosisendtoendis
formed(Pic.3.2.3).
Theanalysisofsupervisionsofthepatientsoperatedbysuchmethod
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
Latarjetdamaging.
The operation of choice in patients with subcardial ulcers and
duodenostasisisgastricresectionbyBillrothII.
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
suchfactors,asabsenceofpenetrationinasmallomentumandabsenceof
the duodenostasis. In such patients is performed segmental resection of
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Attheborderofgastricresectionnearpyloricsphinctercanbespasm
and gastrostasis in a postoperative period . Avoiding such complication is
possible,ifthisborderofgastricresectionpassesnomorethan1,5cmfrom
a pyloric sphincter (M.M. Risaev, 1986). So, at a resection, that passes
higherthan2,0cmfromapylorus,integrityofbothloopsiskept.
Patients with antral ulcers without the duodenostasis performed the
gastricresectionbyBillrothI(Pic.3.2.6),andonpresenceofduodenostasis
BillrothII.
Prepiloriculcersissimilartotheulcersofduodenum.Suchlocalization
of gastric ulcers without malignization allow to perform selective proximal
vagotomy. However, at large prepyloric ulcers with penetration without
duodenostasisisbettertoperformthegastricresectionbyBillrothIandon
presenceofduodenostasisbyBillrothII.
Bycontraindicationtooperationswithsavingoffoodpassingthrough
the duodenum are also decompensated pylorostenosis , functional
gastrostasis and duodenostasis. In such patients it is better to perform
gastricresectionbyBillrothII.
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Pic.BillrothIandBillrothIIresection
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Pic.BillrothIreconstruction
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Pic.BillrothIIrecontruction
DUODENALULCER
Etiologyandpathogenesis
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geneticinclination,presenceofchronicgastroduodenitis,disturbanceofdiet
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
hyperproductionofhydrochloricacidandpepsin,andalsoreversediffusion
oftheions+,actionofbiliousacidsandisoleucine,toxinsandenzymesof
helicobacter pylori (HP). There are factors which are contribute to
ulcerogenic action: disturbance of motility of stomach and duodenum,
ischemiaofduodenum,andmetaplasiaoftheepithelium.
Pathomorphology
Classification
(byA.L.Hrebenev,A.O.Sheptulin,1989)
Theduodenalulcerisdivided:
I.Byetiology:
.Trueduodenalulcer.
.Symptomaticulcers.
II.Bypassingofdisease:
1.Acute(firstexposedulcer).
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2.Chronic:
a)withtherareexacerbation
b)withtheannualexacerbation
c) with the frequent exacerbation (2 times per a year and
morefrequent).
III.Bythestagesofdisease:
1.Exacerbation.
2.Scarring:
a)stageofredscar
b)stageofwhitescar.
3.Remission.
IV.Bylocalization:
1.Ulcersofbulbofduodenum.
2.Lowpostbulbarulcers.
3.Combinedulcersofduodenumandstomach.
V.Bysizes:
1.Smallulcersupto0,5cm.
2.Middleup1,5cm.
3.Largeupto3cm
4.Giantulcersover3cm.
VI.Bythepresenceofcomplications:
1.Bleeding.
2.Perforation.
3.Penetration.
4.Organicstenosis.
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5.Periduodenitis.
6.Malignization.
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Clinicalvariantsandcomplication
In patients with low postbulbar ulcers the clinical signs are more
expressed. It characterized by late (in 23 hours after food intake) and
intensivehungryandnightlypain,thatoftenirradiatetothebackandtothe
right hypochondrium. The postbulbar ulcers are inclined to more frequent
exacerbation,andalsotomorefrequentcomplications,such,aspenetration,
stenosisandbleeding.
Thearemorefrequentulcerousbleeding(thebulboushappenin20
25 % cases, postbulbar in 5075 %), perforations (1015 % cases).
Penetration,stenosisandmalignizationinpatientswithduodenalulcersare
observedrarely.
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
alllayersofduodenuminneighboringorgansandtissues(headofpancreas,
hepatoduodenal ligament, small and large omentum, gallbladder, liver).
Such penetration is accompanied by development of inflammatory process
intheneighboringorgansandsurroundingtissuesandformingofcicatrical
adhesions.Apainsyndromebecomesmoreintensive,permanentandoften
pain irradiated in the back. Sometimes in the area of penetration it is
possibletopalpatepainfullyinfiltrate.
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Diagnosticprogram
1.Anamnesisandphysicalexamination.
2.Endoscopy.
3.XRayexaminationofstomachandduodenum.
4.Generalandbiochemicalbloodanalysis.
5.Coagulogram.
Pic.Duodenoscopy
Differentialdiagnostics
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Tacticandchoiceoftreatmentmethod
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3.Stenosisofoutcomepartofstomach.
4.Chronicpenetrationulcerswiththepainsyndrome.
5.Suspicionformalignizationulcers.
Methodsofsurgicaltreatment.
At patients with the duodenal ulcer three types of operations are
distinguished:
organsavingoperations
organsparingoperations
resection.
From them the better are: organsaving operations with vagotomy,
excisionofulceranddrainageoperation.
Typesofvagotomy:trunk(TrV)(Pic..3.2.7),selective(SV)(Pic.3.2.8),
selectiveproximal(SPV)(Pic.3.2.9).Selectiveproximalvagotomyisoptimal
intheelectivesurgeryofduodenalulcer.Howeverinurgentsurgeryatrunk,
selective or selective proximal is often used in combination with drainage
operations.
Drainage of the stomach operations are: HeinekeMikulicz
pyloroplasty,Finneypyloroplasty,submucouspyloroplastybyDiverBarden
Shalimov,gastroduodenostomybyJaboulay,gastroenteroanastomosis.
ItisnecessarytomarkthatcleanisolatedSPV,performedinpatients
with duodenal ulcer, often (in 1520 % cases) results in the relapses. The
considerably less number of relapses (810 %) is observed after SPV in
combinationswithdrainageoperations.Especiallydangerousistherelapses
of the ulcers placed in the projection of large duodenal papilla, after
gastroduodenostomybyJaboulay.
The least number of relapses of duodenal ulcer is observed after
organsavingoperations,thatcombineSPVandulcerexcision.
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
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pyloroplastybyHeinekeMikulich.
Atpatientswithdecompensatestenosisandexpresseddilatationand
by the atony of stomach it is needed to apply the classic resection of
stomachdependingonpossibledampingsyndromebyBillrothIorBillroth
II.
The choice of subtotal resection of stomach needs to be done at
suspicionformalignizationorathistologicalconfirmedmalignizationulcers.
Inaduodenumthisprocesshappensveryrarely.
Pic.Trunkvagotomy(TrV)
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Pic.Selectivevagotomy(SV)
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Pic.Selectiveproximalvagotomy(SPV)
Pic.HeinekeMikuliczpyloroplasty
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Pic.GastroduodenostomybyJaboulay
Pic.Finneypyloroplasty
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BLEEDINGGASTRODUODENALULCERS
Etiologyandpathogenesis
Theoriginofthegastrointestinalbleedingatpatientswithagastricor
duodenalulceralmostisalwaysrelatedtoexacerbationofulcerousprocess.
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
spontaneousstopofbleeding.
Gastriculcers,comparewiththeulcersofduodenum,complicatedby
bleeding more frequent. Bleeding at gastric ulcers are more expressed,
profuse,withheavypassing.
Attheduodenalulcerbleedingmorefrequentcomplicatetheulcersof
backwall,whichpenetratesintheheadofpancreas.
Atthemenulceriscomplicatedbybleedingtwicemorefrequent,than
atwomen.Itcoststomarkthat80%patientswhichcarriedbleedingfroman
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Pathomorphology
Classification
Clinicalmanagement
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Itisnecessaryalwaystorememberthatcomplicationofpepticulcerby
bleedinghappensconsiderablymorefrequent,thanisdiagnosed.Usually,to
5055%moderatebleeding(microbleeding)havethehiddenpassing.The
massive bleeding meet considerably rarer, however almost always run
acrosswiththebrightlyexpressedclinicalsignswhichoftencarriesdramatic
character. In fact profuse bleeding with the loss 5060 % to the volume of
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circulatorybloodcouldstoptheheartandcausethedeathofpatient.
Theclinicalsignsandpassingofdiseasedependonthedegreeoflost
ofblood(..ShalimovandV.F.Saenko,1987).
ForlostofbloodIdegreetypicalthereisafrequentpulseto90100,
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 condition
needs to be estimated as average. Expressed pallor of skin, sticky sweat,
lethargy. Pulse 120130 per min., weak filling and tension, arterial
pressure 9080/50 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
oftheprotractedbleedingcompensatemechanismsofarterialpressureare
exhausted and can acutely go down at any point. Without the proper
compensationofhemorrhagethesuchpatientscansurvive,howeveralmost
always there are considerable disturbances of blood circulation with
disturbanceoffunctionsofliverandkidneys.
The III degree of hemorrhage characterizes heavy clinical passing.
Thereisapulseinsuchpatients130140permin.,andarterialpressure
from60to0mmHg.Consciousnessisalmostalwaysdarkened,acutely
expressedadynamy.Centralveinpressureislow.Oliguriaisobserved,that
canchangebyanuria.Withoutactiveanddirectedcorrectionofhemorrhage
apatientcandie.
But,notalwaysweightofbleedingwhichisconditionedbythedegree
ofhemorrhagecorrespondthegeneralconditionofpatient.Onoccasionthe
considerable loss of blood during the set time is accompanied by the
relatively satisfactory condition of patient. And vice versa, moderate
hemorrhagecanbringtotheconsiderableworseningofgeneralcondition.It
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Diagnosisprogram
1.Anamnesisandphysicalexamination.
2.Fingerexaminationofrectum.
3.Gastroduodenoscopy.
4.Globalanalysisofblood.
5.Coagulogram.
6.7.Biochemicalbloodtest.
7.XRayexaminationofgastrointestinaltract.
8.Electrocardiography.
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Pic.Endoscopystoppedbleeding.
Differentialdiagnostics
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Tacticandchoiceoftreatmentmethod
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use5%solutionofaminocapronicacidinwardfortoa1soupspooninevery
2030minutes.
The endoscopic methods of stop of bleeding are used also. Among
themmosteffectiveisalaserandelectrocoagulation.
Absolute indications to surgical treatment are: 1) lasting bleeding I
degree2)recurrentbleedingafterhemorrhageIdegree3)bleedingofthe
IIIIIdegrees4)stoppedbleedingwithhemorrhageoftheIIIIIdegreesat
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
organsavingandorgansparingmethodsofoperations.Theremovingulcer
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
threatofrelapseofbleedingalreadyinanearlypostoperativeperiod(912
days).
Palliative operations (cutting of ulcer, forming of roundabout
anastomosis)canbejustifiedonlytakingintoaccountthegeneralcondition
of patient and on a necessity as possible quick and least traumatically to
makeoffoperation.
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
betterbyaselectiveproximalwithpiliroplastic.Theresectionofstomachon
the second or first method of Bilroth can be realized only in the stable
generalconditionofpatient.Duringtheresectionofstomachincaseoflow
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
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MALLORYWEISSSYNDROME
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
gastrointestinalbleedsandcausessignificanthypovolaemiainabout10%of
these.Thereappearstobeatrendtowardslessassociatedbloodlossand
lower mortality. It is often associated with hiatus hernia and is also
associatedwithalcoholismanddialysis.
Epidemiology
Inrecentyears,MWSmayhavebecomemorefrequent.
TheincidenceofUGIBisbetween47and116per100,000population
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(mostlyfromulcers).
MalloryWeiss tears cause approximately 315% of all episodes of
haematemesisinadults.Tearscanoccurinchildrenbutarelesscommon.
Thereisawideagerange.Itismostcommonbetweenage40and50
years.
PatientPlus
UpperGastrointestinalBleeding(includesRockallScore)
Etiologyandpathogenesis
Thepredeterminingfactorsoforiginofsyndromeare:protractedwhooping,
attacks of cough, physical overstrain after the surplus food intake, alcohol with
vomiting,
chronic
diseases
of
stomach,
with
the
acute
increase
Classification
(by..Rumjantsev,1979)
1.Bylocalizationofbreak:a)esophagusb)cardioesophagealc)cardial.
2.Bytheamountofbreaks:
a)single
b)plural.
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3.Bythedepthofbreaks:
a)superficial(Idegree),whichpenetratetothesubmucosallayer
b)deep(IIdegree),whichtakemucusandsubmucosallayer
c) complete break (III degree) which is characterized by the break of all
layersoforgan.
4.Bythedegreeofhemorrhage:
a)easy
b)middle
in)heavy.
5.Byclinicalpassing:
1)simpleform
2)deliriousform:a)withthesignsofacutehepaticinsufficiencyb)without
thesignsofacutehepaticinsufficiency.
Causes
Excessivealcoholingestion.
Aspiriningestion.
Hiatusherniaisapredisposingfactor.Duringretchingorvomiting,the
transmuralpressuregradientisgreaterwithinthehiatusherniathantherest
ofthestomach.
Other precipitating factors include retching, vomiting, straining,
hiccuping, coughing, blunt abdominal trauma and cardiopulmonary
resuscitation.
Other gastrointestinal diseases (gastroenteritis, gastric outlet
obstruction,malrotation,volvulus).
Hyperemesisgravidarum.
Hepatitis(causesvomitingin1020%ofpatients).
Biliarydisease(gallstonesandcholecystitis).
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Boerhaave'ssyndrome(oesophagealrupture).
OthercausesofUGIBseeseparateUppergastrointestinalbleeding
(includesRockallScore)article.
Investigations
Endoscopy is the primary diagnostic investigation. Other relevant
investigationsinclude:
FBC,includinghaematocrittoassesstheseverityoftheinitialbleeding
episodeandtomonitorpatients.
Coagulation studies and platelet counts to detect coagulopathies and
thrombocytopenias (routine platelet count, prothrombin time, and activated
partialthromboplastintime).
Renal function, urea, creatinine, and electrolyte levels (to guide
intravenousfluidtherapy).
Crossmatching/ blood grouping and antibody screen (potential blood
transfusion).
Electrocardiogram and cardiac enzymes (may be indicated if
myocardialischaemiaissuspected).
Management
Initial management is described in the separate article Upper
gastrointestinalbleeding(includesRockallScore).
Initialassessmentandmanagement
Resuscitationisaprioritymaintainairway,providehighflowoxygen,
correctfluidlosses(placetwowideborecannulaeandalsosendbloodsat
thesametime).Initialfluidresuscitationmaybewithcrystalloidsorcolloids
give intravenous blood when 30% of circulating volume is lost. Major
haemorrhageprotocolsshouldbeinplace.
Once the patient is more stable take a history and perform an
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Diagnosisprogram
1.Anamnesisandphisicalexamination.
2.Esophagogastroscopy.
3.Globalanalysisofblood.
4.Coagulogram.
5.GroupandRhesusfactorofblood.
Endoscopy
Ideally,endoscopyshouldbeperformedwithin24hours,astearsheal
rapidlyandmaynotbereadilyapparentatendoscopyafter23days.Proton
pump inhibitor (PPI) use is not recommended prior to diagnosis by
endoscopy.
535% of patients require some form of intervention, usually
endoscopic.
Mostpatients(>80%)presentwithasingletear.Thetearisusuallyjust
below the gastrooesophageal 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
existinglesionsarecommon.
Several endoscopic modalities are effective for treating a bleeding
MalloryWeiss tear. Injection therapy is often regarded as the firstline
therapy.
Fasting is restricted to haemodynamically unstable patients and to
thosewhorequirerepeatendoscopy.
Patients can resume oral intake following endoscopy (starting with a
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transfusion,
infusion
of
hemostatic,
application
of
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stopofbleedinginsuchpatientsisespeciallyperspective,becausemostofthem
hasthedeliriousstateoracutehepaticinsufficiency.
Operative treatment is indicated at the deep large ruptures of mucus and
muscular layers, cardial part of stomach, which are complicated by bleeding. In
suchcasesconductgastrotomyandsuturingofrapturesbyinterruptedsutureor
8shapedstitch,applyingnonabsorbablefilaments.Sewingsofrupturesofmucus
stomach often supplement with vagotomy with pyloroplasty.At deep, especially
plural ruptures which are accompanied by the edema of tissues, sewing of
rupturesissupplementwithbandagingofleftgastricartery.
Complications
Theserelateto:
Symptoms:
Vomiting (hypokalaemia and other metabolic disturbance, aspiration
pneumonia,perforationandmediastinitis).
Severityofbleeding:
Hypovolaemicshock,anddeath(veryrarewithgoodcare).
Myocardialischaemiaorinfarction.
Comorbidities:
Myocardial ischaemia (precipitating, for example, myocardial
infarction).
Hepatitis(precipitating,forexample,liverfailure).
Renaldisease(precipitating,forexample,renalfailure).
Diabetes(worseningcontrolanddiabeticcoma).
Treatmentorinvestigation:
Endoscopy (mediastinitis, aspiration pneumonia, perforation or
aggravationofbleeding).
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Initialpresentationofshock.
Livercirrhosis.
Decreasedhaemoglobinandplateletcount.
Needforbloodtransfusion.
Intensivecaremanagement.
Activebleedingnotedatthetimeofendoscopy.
CANCEROFSTOMACH
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Etiologyandpathogenesis
Etiology of cancer of stomach is unknown. It is known that, as other
diseases of gastrointestinal tract, a cancer damages a stomach.According
tostatisticalinformation,itmeetsapproximatelyin40%ofalllocalizationsof
cancer.
Thefactorsofexternalenvironmenthasthesubstantialinfluencingon
frequency of this pathology. Above all things, feed, smoke food, salting,
freezing of products and their contamination of aflatoxin. Consider that a
foodfactorcanbe:a)byacarcinogenb)bythesolventofcarcinogensc)
togrowintoacarcinogenintheprocessofdigestiond)tobeinstrumentalin
actionofcarcinogense)notenoughtoneutralizecarcinogens.
In the USA and countries of Western Europe frequency of cancer of
stomach in 2 times more large in the lower socioeconomic groups of
population.Someprofessionalgroupsalsocanit(miners,farmers,worksof
rubber,
woodworking
and
asbestine
industry).
High
correlation
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villouspolypusesofstomachandchroniculcersc)nutritionalanemiadueto
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
gastritisestaketheimportantvaluehelicbacterpylori.InJapan,wherethe
cancerofstomachisin40%casesisthereasonofdeath,chronicgastritis
appearsin80%casesofresectedstomach,concerningacancer.
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.
Therearehyperplasticpolypuses,butitnotmalignant.
Hamartoma is accumulation of cells of normal mucous tunic of
stomach.Theyneverbecomesmalignant.
Villous polypuses are potentially malignant in 40 % cases, but it
happenin10timesless,thanhyperplastic.Thepossibilityofmalignizationof
chronic gastric ulcers is not proved. The American scientists support a
hypothesis, that the cancer of stomach can be ulcerous often, but
malignizationofulcerstakesplacerarely(nomorethan3%).Fromdataof
theJapanesescientists,on5070ththerewashighercorrelationconnection
betweenchronicgastriculcersandcancerofstomach.Thefrequentdecline
ofthiscorrelationislatelynoticed(70%on5070thand10%on80th).
Frequency of cancer of stomach at patients with pernicious anaemia
hesitates within the 510 %, that in 20 times higher, compare with control
population. In patients with a resected stomach after peptic ulcers is
multipliedtheriskoforiginofstomachcancerin23times(durationoflatent
periodhesitatesfrom15to40years).Thereasonofsuchdependenceisnot
foundout,butthereisaversion,thatthisislinkedwithagastricepithelium
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metaplasiabyanintestinaltype.
Pathomorphology
Fromallmalignantformationsofthestomachin95%adenocarcinoma
is observed. Epidermoid cancer, adenoacanthoma and carcinoid tumours
donotexceed1%.Frequencyofleiomyosarcomahesitateswithinthelimits
of13%.Lymphomaofgastrointestinaltractislocalizedinastomach.
The prognosis of localization depends on the degree of invasion,
histologicalvariantsoftumour.
The macroscopic forms of cancer of stomach in different times were
described variously. More than 60 years ago the German pathologist
Bermanndescribed5macroscopicformsofcancerofstomach:1)polypoid
or mushroomlike 2) saucershaped or with ulcerous and expressly salient
edges 3) with ulcerous and infiltration of walls of stomach 4) diffuse
infiltrate5)unclassified.
American pathopsychologs is selected 4 forms. The tumours of
stomachwithulcerousarethemostfrequentmacroscopicformofcancerof
stomach and arise up on soil of chronic ulcer. The signs suspicious on
malignization are: the sizes of ulcer more than 2 cm in a diameter,
appearanceoftheheightenededges.
The polypoid tumours of stomach observed only in 10 %. These
tumourscanachieveconsiderablesizeswithoutaninvasionandmetastasis.
Scirrhouscarcinomaisthethirdmacroscopictype.Thiscategoryoftumours
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
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flatlayerwhichdoesnotriseabovethelevelofmucusb)salient(bursting)
formationc)erosions.
Mainly(morethan50%)tumoursariseupinaantralpartorindistal
(lower)thirdofstomach,rarer(to15%)inabodyandincardia(to25%).
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
histologicalinspectionoftheresectedstomaches.Thisassertionisbasedon
thetheoryofthetumourfield(D.I.Holovin,1992).Especiallythistypically
for patients which has pernicious anaemia or chronic metaplastic
disregenerativegastritis.
Metastasis is carried out by lymphogenic, hematogenic and
implantationwaysmostly.Three(fromdataofsomeauthors,four)poolsof
lymphogenicmetastasisareselected:leftgastric(knotsonpassingofsmall
curvature of stomach in a gastrosubgastric ligament and pericardial)
splenic (mainly, suprainfrapancreatic knots) hepatic (knots in a hepato
duodenal ligament, right gastric omentum that lower pyloric groups, right
gastricandsuprapyloricgroups,pancreatoduodenalgroup).
However, the such way of lymphogenic metastasis is conditional and
incomplete, as at presence of block lymph flow passes retrograde
metastasis,socalledjumpingmetastaseswhichpredeterminetheoriginof
remotelymphogenicmetastasesinleftsupraclavicularlymphnodes(Virhov
metastasis) appear, in Lymph nodes of left axillar and inguinal areas,
metastasesinaumbilicus.
Direct distribution: small and large omentum, esophagus and
duodenumliveranddiaphragmpancreas,spleen,bileducts.
Frontwallofstomach:colonbowelandmesocolonorgansandtissues
ofretroperitonealspace.
Lymphogenicmetastasis:regionallymphnodes,remotelymphnodes,
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leftsupraclavicularlymphnode(Virhov),lymphnodeofaxillararea(Irish)in
aumbilicus(sistersJoseph).
Hematogenicmetastasis:liver,lungs,bones,cerebrum.
Peritoneal metastasis: peritoneum, ovarium (the Krukenberg
metastasis),Duglasspace(theShniclermetastasis).
Classification(bysystemofNM)
primarytumour.
0isaprimarytumourisnotdetermined.
notenoughdataforestimationofprimarytumour.
isisinvasivecarcinoma:intraepithelialtumourwithouttheinvasionof
ownshellmucus(Carcinomainsitu).
1isatumourinfiltratethewallofstomachtothesubmucouslayer.
2isatumourdamagesmucus,submucousandmuscularlayers.
3isatumourgerminatesinaserousshell.
4isatumourpassestotheneighbouringstructures.
Nareregionallymphaticnodes.
Nnotenoughinformationforthedamageassessmentoflymphatic
nodes.
Nmetastasesinregionallymphnodesarenotpresent.
N1aredamagedperigastrallymphnodesinthedistancenomorethan
3cmfromaprimarytumouralongsmallorlargecurvatureofstomach.
N2aredamagedperigastrallymphnodesinthedistancemorethan3
cmfromaprimarytumour,whichcanberemotedduringoperation,including
lymph nodes placed along left gastric, splenic, abdominal and general
hepaticarteries.
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isremotemetastases.
notenoughinformationforestimationofremotemetastases.
remotemetastasesarenotpresent.
1ispresenceofremotemetastases.
Groupmentbystages
Stage0NoMo.
StageI12NoMo.
StageIIT23NoMo.
StageIIIT14N12Mo.
StageIVanyT,anyNM1.
Exceptforclinicalclassification(NMorTNM),forthemostdetailed
study pathological classification (postsurgical, posthistological) which is
signedN.
Ghistopathologicaldifferentiation:
G1isthewelldifferentiatedtumour
G2isthemoderatelydifferentiatedtumour
G34itisbadlyorundifferentiatedtumour.
Clinicalmanagement
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tissues.Atlocalizationoftumourinacardialpartpatientcomplainsfirstly,as
arule,forappearanceofdysphagy.
At careful, purposeful collection of anamnesis it is not succeeded to
exposesomeother,mostearlysymptoms,whichprecedestodysphagyand
forces a patient to appeal to the doctor. The unpleasant feeling behind a
breastboneandfeelingofunpassingofhardfoodonaesophagusappearat
the beginning of disease.After some time (as a rule, it is enough quickly,
duringafewweeks,sometimesevendays)ahardfooddoesnotpass(itis
to wash down by water or other liquid). This period can be during 13
months. Patients address a doctor exactly in this period. Other symptoms
appeartothistime:regurgitation,painbehindabreastbone,lossofmassof
body, sometimes even exhaustion, the grey colouring of person, a skin is
dry,quicklygrowsgeneralweakness.Sometimespatientsaddressadoctor,
when already with large effort a spoonmeat passes only or complete
stenosiscame.
At localization of tumour in the antral part of stomach the first
complaints,asarule,areuptoappearanceoffeelingofweightinepigastric
region after the reception of food (even in a twobit), 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 coffeegrounds (so called cancer water). Patients loses
weight(massofbodyislost),aweakness,anaemiagrows.
Tumours localized in the body of stomach show up either a pain
syndrome or syndrome of so called small signs (.I. Savitskyy, 1947),
which is characterized by appearance of amotivational general weakness,
declineofcapacity,rapidfatigueability,depression(bythelossofinterestto
the environment), proof decline of appetite, gastric discomfort, making
progressweightlost.
Thecarriedchronicdiseasesofstomach,forwhichtypicalseasonality,
can influence on the clinical sign of cancer of stomach. At appearance of
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gastriccomplaintsoutofseasonorinabsentofeffectfromthegottherapy
concerningtheexacerbationofgastritis,ulcersmustguardapatientand
doctor(symptomofprecipiceofgastricanamnesis).
In case of occurring of gastric symptoms first in persons in age 50
yearsandolderitisforemostnecessarytoeliminatethecancerofstomach.
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,intestinalsymptoms,aredistinguished.
During the examination of patients with the cancer of stomach the
pallor of skin covers (at anaemia) is observed, in neglected case is frog
stomach(signofascites).
During palpation determined painful in a epigastric area, sometimes
possibletopalpatethetumour.
During auscultation of patients with pylorostenosis it is possible to
definenoiseofsplash.
Laboratory
information:
hypochromic
anaemia,
neutrophilic
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Diagnosisprogram
1.Anamnesisandphysicalmethodsofexamination.
2.Roentgenologicexaminationofstomach.
3. Endoscopic examination with a biopsy (if necessary from a few
placesandevenrepeatedly),cytologicandhistologicalexamination.
4.Sonography,computertomography.
5.Laboratory,radioisotopemethodsofexamination.
6.Laparoscopy.
7.Diagnostic(therapeutic)laparotomy.
Differentialdiagnostics
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differentiatetothedoctor,dependsfromcharacterofcomplaintsofpatients.
Fivebasicclinicalsyndromesareselected:
1)pain
2)gastricdiscomfort
3)anaemic
4)dysphagic
5)disturbanceofevacuationfromastomach.
Atpatients,atwhatcancerofstomachshowsupapainsyndromeand
syndromeofgastricdiscomfort,adifferentialdiagnosisisconductedwiththe
pepticulcer,gastritis,cancerofbodyofpancreas.
Itisorientedonfeaturesdynamicsofdevelopmentofpainsyndrome,
ingravescentofthegeneralcondition,changeofcharacterofcomplaints.
Aquestionaboutcharacterofanaemia,sourceandnatureofbleeding
decidesatananaemicsyndrome.Intheprocessofexaminationattentionis
paidtothestateofbottomofstomach,wherebleedingmalignantformations
canbe.
Atadysphagicsyndromeadifferentialdiagnosisisconductedwiththe
cicatrical narrowing, achalasia of esophagus. For malignant formations
testify short anamnesis, gradual progress of symptoms, signs of gastric
discomfort,generalweakness,weightlost.
Atdisturbanceofevacuationfromastomachduringstenosisofpyloric
part, absence of ulcerous anamnesis, declining years of patients, relatively
quick(weeks,months)growthofstenosistestifyfortumor.
Tacticandchoiceofmethodofsurgicaltreatment
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limited tumours (within the limits of the 0II stages). At the III stage of
diseaseimplementationofthewidespreadcombinedoperationsinaradical
volumeispossible,howevermostpatientsdieduring12years.Adistalor
proximalsubtotalresection(Pic.3.2.19)andtotalgastrectomy(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
thelinesofresections.
During the combined operations organs which are pulled in to the
pathologicalprocessareremoved.
In case of IV stage of disease and satisfactory state of patient
palliativeoperationswhichimprovequalityoflifeofpatientareperformed.
In case of presence of complications (mainly stenosis) and grave
commonconditionofpatientperformsymptomaticoperativetreatments.
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
stenosistumoursofstomachoutput)2)gastrostoma(Pic.3.2.22)incaseof
thecancerofcardialpartofstomachwithdisturbanceofpatency3)edging
of bleeding vessels in case of complication of cancer by bleeding 4)
tamponadebyomentumduringtheperforationoftumour.
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)isconductedinapostoperativeperiodascombinedtherapyand
incaseofdisseminationofthetumours.
Prognosis.Theindexesoffiveyearsurvivalofpatientswiththecancer
of stomach hesitate within the limits of 530 %, but, from data of most
authors,theydonotexceed10%.
Hemorrhagicerosivegastritis
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Etiologyandpathogenesis
Thespasmoflargevesselsinthedeeplayersofgastricwall,whichresults
indisturbanceoflocalmicrocirculation,hypoxiaandincreasesofpermeabilityof
vascular wall, matters in etiology and pathogenesis of hemorrhage erosive
gastritis.Thelocalreactioncausesstrengtheningofreversediffusionofhydrogen
ions,liberationofpepsin,histamine.Suchprocessoftenisconsequenceoflocal
damagingfactoractionofmedicinalortoxicfactorsforthevesselsofmucus.
Damaging factor could be the matters which violate a blood flow in mucus
stomach(aspirin,reserpine,hormonesofadrenalglandscortex).Thelargevalue
informationoferosionsishadbytheanatomicfeaturesofbloodflowofstomach
in a cardial part on small curvature. In connection with absence
ofsubmucosalvascularplexus,eventualvesselsonsmallcurvaturearedisposed
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.Intheoriginofacutehemorrhagegastritismatteralsoacutedamageof
mucus stomach by mechanical, chemical (burns) and other factors,
accompanyingdiseases(uremiaandotherslikethat).
Clinicalmanagement
For hemorrhage erosive gastritis there are typical two clinical syndromes:
ulcerous and hemorrhagic. The ulcerous syndrome is the most frequent sign of
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of
red
corpuscles
test,
haemoglobin,
is
observed
haemathokritis,
in
leukocytosis.
the
blood
During
Diagnosisprogram
1.Anamnesisandphisicalexamination.
2.XRayexaminationofstomach.
3.Endoscopy.
4.Globalanalysisofblood.
5.Coagulograma.
6.Groupandrhesusbelongingofblood.
Tacticandchoiceoftreatmentmethod
Treatmentofhemorrhageerosivegastritis,mainly,isconservative.Washing
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Fig.7.Varicealhemorrhage
Treatmentofpatientsatbleedingfromthevaricoseveinsofesophagusneeds
tobebegunwiththetamponadeinternalsurfaceofesophagusandcardialpartof
stomach by the special doubleballoon SengstakenBlakemore tube (Fig.8
Fig.9.). Some other conservative measures directed on the stop of bleeding
withouttheuseofthisprobeareconsideredineffectiveandtacticallywrong.
Fig.8.SengstakenBlakemoretube
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Fig.9.MethodofapplicationoftheSengstakenBlakemoretube
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changedorwithinsignificantdeviationsfromanormascitesandencephalopathy
areabsent)2)attheIIIdegreeofhepaticinsufficiency,progressiveascitesand
encephalopathy,regardlessofdegreeoflossofblood.
Conservativetherapyofbleedingfromthevaricoseveinsofesophagusmust
engulfthewholevolumeofmedicalmeasures,asatsimilarpathologyofulcerous
genesis(hemostatictherapy,antacid,2blockerhistaminereceptors).
For
the
decline
of
portal
pressure
pituitrin
is
entered.
Theendoscopicmethodsofstopofbleedingareappliedalso(impositionofclips
on veins, sclerosis therapy 76 % ethyl alcohol, Varicocide, 66 % solution of
glucose,endovascularocclusionofveins,lasercoagulationofveins).Itisneeded
tocountsettingofpreparationsforstimulationofregenerationofliver(esenciale,
lif52andotherslikethat),applicationofdisintoxicationtherapy.
Surgicaltreatmentisconsideredapplicableatbleedingofmiddleandheavy
degreeswiththeIandtheIIdegreesofhepaticinsufficiency(generalbilirubinnot
more large 50 mcmol/L, general albumen not more small 60 g/
,prothrombinindexnotmorelow60%,presenttransientascites)inthecases
whenthevaluableconservativetreatmentdirectedonthestopofbleedingisnot
effectiveduring2448hours.
REFERENCES
1.CheyWD,WongBC.AmericanCollegeofGastroenterologyguideline
onthemanagementofHelicobacterpyloriinfection.AmJ
Gastroenterol.Aug2007102(8):180825.
2.JavidG,ZargarSA,USaifR,KhanBA,YatooGN,ShahAH,etal.
Comparisonofp.o.ori.v.protonpumpinhibitorson72hintragastric
pHinbleedingpepticulcer.JGastroenterolHepatol.Jul
200924(7):123643.
3.LaiKC,LamSK,ChuKM,WongBC,HuiWM,HuWH,etal.
http://intranet.tdmu.edu.ua/data/kafedra/internal/surgery2/classes_stud/en/med/lik/ptn/surgery/6/Topic%2010%20Bleeding%20from%20the%20digestive%20tr
78/84
5/15/2016
Stomachandduodenum
Lansoprazoleforthepreventionofrecurrencesofulcercomplications
fromlongtermlowdoseaspirinuse.NEnglJMed.Jun27
2002346(26):20338.
4.LaiKC,LamSK,ChuKM,HuiWM,KwokKF,WongBC,etal.
LansoprazolereducesulcerrelapseaftereradicationofHelicobacter
pyloriinnonsteroidalantiinflammatorydrugusersarandomizedtrial.
AlimentPharmacolTher.Oct15200318(8):82936.
5.SungJJ,TsoiKK,MaTK,YungMY,LauJY,ChiuPW.Causesof
mortalityinpatientswithpepticulcerbleeding:aprospectivecohort
studyof10,428cases.AmJGastroenterol.Jan2010105(1):849.
6.PietroiustiA,LuzziI,GomezMJ,MagriniA,BergamaschiA,ForliniA,
etal.Helicobacterpyloriduodenalcolonizationisastrongriskfactor
forthedevelopmentofduodenalulcer.AlimentPharmacolTher.Apr1
200521(7):90915.
7.LaineL,CurtisSP,CryerB,KaurA,CannonCP.Riskfactorsfor
NSAIDassociatedupperGIclinicaleventsinalongtermprospective
studyof34701arthritispatients.AlimentPharmacolTher.Nov
201032(10):12408.
8.[BestEvidence]VergaraM,CatalnM,GisbertJP,CalvetX.Meta
analysis:roleofHelicobacterpylorieradicationinthepreventionof
pepticulcerinNSAIDusers.AlimentPharmacolTher.Jun15
200521(12):14118.
9.BerezinSH,BostwickHE,HalataMS,FeerickJ,NewmanLJ,Medow
MS.Gastrointestinalbleedinginchildrenfollowingingestionoflow
doseibuprofen.JPediatrGastroenterolNutr.Apr200744(4):5068.
10.GulmezSE,LassenAT,AalykkeC,DallM,AndriesA,Andersen
BS,etal.Spironolactoneuseandtheriskofuppergastrointestinal
bleeding:apopulationbasedcasecontrolstudy.BrJClinPharmacol.
Aug200866(2):2949.
11.LewisJD,StromBL,LocalioAR,MetzDC,FarrarJT,Weinrieb
http://intranet.tdmu.edu.ua/data/kafedra/internal/surgery2/classes_stud/en/med/lik/ptn/surgery/6/Topic%2010%20Bleeding%20from%20the%20digestive%20tr
79/84
5/15/2016
Stomachandduodenum
RM,etal.Moderateandhighaffinityserotoninreuptakeinhibitors
increasetheriskofuppergastrointestinaltoxicity.Pharmacoepidemiol
DrugSaf.Apr200817(4):32835.
12.AldooriWH,GiovannucciEL,StampferMJ,RimmEB,WingAL,
WillettWC.Aprospectivestudyofalcohol,smoking,caffeine,andthe
riskofduodenalulcerinmen.Epidemiology.Jul19978(4):4204.
13.SonnenbergA,MllerLissnerSA,VogelE,SchmidP,Gonvers
JJ,PeterP,etal.Predictorsofduodenalulcerhealingandrelapse.
Gastroenterology.Dec198181(6):10617.
14.KoivistoTT,VoutilainenME,FrkkilMA.Effectofsmokingon
gastrichistologyinHelicobacterpyloripositivegastritis.ScandJ
Gastroenterol.200843(10):117783.
15.SchubertML,PeuraDA.Controlofgastricacidsecretionin
healthanddisease.Gastroenterology.Jun2008134(7):184260.
16.CaiS,GarcaRodrguezLA,MassGonzlezEL,Hernndez
DazS.UncomplicatedpepticulcerintheUK:trendsfrom1997to
2005.AlimentPharmacolTher.Nov15200930(10):103948.
17.[BestEvidence]LeontiadisGI,SreedharanA,DorwardS,Barton
P,DelaneyB,HowdenCW,etal.Systematicreviewsoftheclinical
effectivenessandcosteffectivenessofprotonpumpinhibitorsinacute
uppergastrointestinalbleeding.HealthTechnolAssess.Dec
200711(51):iiiiv,1164.
18.BardouM,TouboutiY,BenhaberouBrunD,RahmeE,Barkun
AN.Highdoseprotonpumpinhibitiondecreasebothrebleedingand
mortalityinhighriskpatientswithacutepepticulcerbleeding.
Gastroenterology.2003123(suppl1):A625.
19.BardouM,YoussefM,TouboutiY,etal.Newerendoscopic
therapiesdecreasebothrebleedingandmortalityinhighriskpatients
withacutepepticulcerbleeding:aseriesofmetaanalyses[abstract].
Gastroenterology.2003123:A239.
http://intranet.tdmu.edu.ua/data/kafedra/internal/surgery2/classes_stud/en/med/lik/ptn/surgery/6/Topic%2010%20Bleeding%20from%20the%20digestive%20tr
80/84
5/15/2016
Stomachandduodenum
20.GisbertJP,PajaresR,PajaresJM.EvolutionofHelicobacter
pyloritherapyfromametaanalyticalperspective.Helicobacter.Nov
200712Suppl2:508.
21.SvanesC,LieRT,SvanesK,LieSA,SreideO.Adverseeffects
ofdelayedtreatmentforperforatedpepticulcer.AnnSurg.Aug
1994220(2):16875.
22.RamakrishnanK,SalinasRC.Pepticulcerdisease.AmFam
Physician.Oct1200776(7):100512.
23.FordAC,MarwahaA,LimA,MoayyediP.Whatistheprevalence
ofclinicallysignificantendoscopicfindingsinsubjectswithdyspepsia?
Systematicreviewandmetaanalysis.ClinGastroenterolHepatol.Oct
20108(10):8307,837.e12.
24.ZulloA,HassanC,CampoSM,MoriniS.Bleedingpepticulcerin
theelderly:riskfactorsandpreventionstrategies.DrugsAging.
200724(10):81528.
25.UddM,MiettinenP,PalmuA,HeikkinenM,JanatuinenE,
PasanenP,etal.Analysisoftheriskfactorsandtheircombinationsin
acutegastroduodenalulcerbleeding:acasecontrolstudy.ScandJ
Gastroenterol.Dec200742(12):1395403.
26.WangHM,HsuPI,LoGH,ChenTA,ChengLC,ChenWC,etal.
Comparisonofhemostaticefficacyforargonplasmacoagulationand
distilledwaterinjectionintreatinghighriskbleedingulcers.JClin
Gastroenterol.NovDec200943(10):9415.
27.LarssenL,MogerT,BjrnbethBA,LygrenI,KlwNE.
Transcatheterarterialembolizationinthemanagementofbleeding
duodenalulcers:a5.5yearretrospectivestudyoftreatmentand
outcome.ScandJGastroenterol.200843(2):21722.
28.TravisAC,WasanSK,SaltzmanJR.Modeltopredictrebleeding
followingendoscopictherapyfornonvaricealuppergastrointestinal
hemorrhage.JGastroenterolHepatol.Oct200823(10):150510.
http://intranet.tdmu.edu.ua/data/kafedra/internal/surgery2/classes_stud/en/med/lik/ptn/surgery/6/Topic%2010%20Bleeding%20from%20the%20digestive%20tr
81/84
5/15/2016
Stomachandduodenum
29.[BestEvidence]ElmunzerBJ,YoungSD,InadomiJM,
SchoenfeldP,LaineL.Systematicreviewofthepredictorsofrecurrent
hemorrhageafterendoscopichemostatictherapyforbleedingpeptic
ulcers.AmJGastroenterol.Oct2008103(10):262532quiz2633.
30.ChiuPW,NgEK,CheungFK,ChanFK,LeungWK,WuJC,et
al.Predictingmortalityinpatientswithbleedingpepticulcersafter
therapeuticendoscopy.ClinGastroenterolHepatol.Mar20097(3):311
6quiz253.
31.KikkawaA,IwakiriR,OotaniH,OotaniA,FujiseT,SakataY,et
al.Preventionoftherehaemorrhageofbleedingpepticulcers:effects
ofHelicobacterpylorieradicationandacidsuppression.Aliment
PharmacolTher.Jun200521Suppl2:7984.
32.LisbertJP,CalvetX,FeuF,BoryF,CosmeA,AlmelaP,etal.
EradicationofHelicobacterpyloriforthepreventionofpepticulcer
rebleeding.Helicobacter.Aug200712(4):27986.
33.BoparaiV,RajagopalanJ,TriadafilopoulosG.Guidetotheuseof
protonpumpinhibitorsinadultpatients.Drugs.200868(7):92547.
34.BarkunA,BardouM,MarshallJK.Consensusrecommendations
formanagingpatientswithnonvaricealuppergastrointestinalbleeding.
AnnInternMed.Nov182003139(10):84357.
35.CotGA,HowdenCW.Potentialadverseeffectsofprotonpump
inhibitors.CurrGastroenterolRep.Jun200810(3):20814.
36.LaineL,ShahA,BemanianS.IntragastricpHwithoralvs
intravenousbolusplusinfusionprotonpumpinhibitortherapyin
patientswithbleedingulcers.Gastroenterology.Jun
2008134(7):183641.
37.ChanWH,KhinLW,ChungYF,GohYC,OngHS,WongWK.
Randomizedcontrolledtrialofstandardversushighdoseintravenous
omeprazoleafterendoscopictherapyinhighriskpatientswithacute
pepticulcerbleeding.BrJSurg.May201198(5):6404.
http://intranet.tdmu.edu.ua/data/kafedra/internal/surgery2/classes_stud/en/med/lik/ptn/surgery/6/Topic%2010%20Bleeding%20from%20the%20digestive%20tr
82/84
5/15/2016
Stomachandduodenum
38.[BestEvidence]AndriulliA,LoperfidoS,FocaretaR,LeoP,
FornariF,GarripoliA,etal.Highversuslowdoseprotonpump
inhibitorsafterendoscopichemostasisinpatientswithpepticulcer
bleeding:amulticentre,randomizedstudy.AmJGastroenterol.Dec
2008103(12):30118.
39.SariYS,CanD,TunaliV,SahinO,KocO,BenderO.Hpylori:
Treatmentforthepatientonlyorthewholefamily?.WorldJ
Gastroenterol.Feb28200814(8):12447.
40.KonnoM,YokotaS,SugaT,TakahashiM,SatoK,FujiiN.
PredominanceofmothertochildtransmissionofHelicobacterpylori
infectiondetectedbyrandomamplifiedpolymorphicDNAfingerprinting
analysisinJapanesefamilies.PediatrInfectDisJ.Nov
200827(11):9991003.
41.SinghV,MishraS,MauryaP,RaoG,JainAK,DixitVK,etal.
DrugresistancepatternandclonalityinH.pyloristrains.JInfectDev
Ctries.Mar120093(2):1306.
42.[Guideline]LanzaFL,ChanFK,QuigleyEM.Guidelinesfor
preventionofNSAIDrelatedulcercomplications.AmJGastroenterol.
Mar2009104(3):72838.
43.ChanFK,HungLC,SuenBY,WuJC,LeeKC,LeungVK,etal.
Celecoxibversusdiclofenacandomeprazoleinreducingtheriskof
recurrentulcerbleedinginpatientswitharthritis.NEnglJMed.Dec26
2002347(26):210410.
44.ChanKL,ChingYL,HungCY.Clopidogrelversusaspirinand
esomeprazoletopreventulcerbleeding.NEngJMed.2005352:238
44.
45.LaiKC,ChuKM,HuiWM,WongBC,HungWK,LooCK,etal.
Esomeprazolewithaspirinversusclopidogrelforpreventionof
recurrentgastrointestinalulcercomplications.ClinGastroenterol
Hepatol.Jul20064(7):8605.
http://intranet.tdmu.edu.ua/data/kafedra/internal/surgery2/classes_stud/en/med/lik/ptn/surgery/6/Topic%2010%20Bleeding%20from%20the%20digestive%20tr
83/84
5/15/2016
Stomachandduodenum
46.HsuPI,LaiKH,LiuCP.Esomeprazolewithclopidogrelreduces
pepticulcerrecurrence,comparedwithclopidogrelalone,inpatients
withatherosclerosis.Gastroenterology.Mar2011140(3):791798.e2.
47.TalleyNJ,VakilN.Guidelinesforthemanagementofdyspepsia.
AmJGastroenterol.Oct2005100(10):232437.
48.TajimaA,KoizumiK,SuzukiK,HigashiN,TakahashiM,
ShimadaT,etal.Protonpumpinhibitorsandrecurrentbleedingin
pepticulcerdisease.JGastroenterolHepatol.Dec200823Suppl
2:S23741.
49.McConnellDB,BabaGC,DeveneyCW.Changesinsurgical
treatmentofpepticulcerdiseasewithinaveteranshospitalinthe
1970sandthe1980s.ArchSurg.Oct1989124(10):11647.
50.GisbertJP,CalvetX,CosmeA,AlmelaP,FeuF,BoryF,etal.
LongTermFollowUpof1,000PatientsCuredofHelicobacterpylori
InfectionFollowinganEpisodeofPepticUlcerBleeding.AmJ
Gastroenterol.May222012
51.BerneTV,DonovanAJ.Nonoperativetreatmentofperforated
duodenalulcer.ArchSurg.Jul1989124(7):8302.
52.DonovanAJ,BerneTV,DonovanJA.Perforatedduodenalulcer:
analternativetherapeuticplan.ArchSurg.Nov1998133(11):116671.
53.LaiKC,LamSK,ChuKM,WongBC,HuiWM,HuWH,etal.
Lansoprazoleforthepreventionofrecurrencesofulcercomplications
fromlongtermlowdoseaspirinuse.NEnglJMed.Jun27
2002346(26):20338.
54.WangensteenOH.Nonoperativetreatmentoflocalized
perforationsoftheduodenum.ProcMinnAcadMed.193518:477480.
Preparedass.RomaniukT.
http://intranet.tdmu.edu.ua/data/kafedra/internal/surgery2/classes_stud/en/med/lik/ptn/surgery/6/Topic%2010%20Bleeding%20from%20the%20digestive%20tr
84/84