Complications of the ulcer disease of the (bleeding, pylorostenosis) stomach and duodenum (bleeding, pylorostenosis)

Complications of the ulcer disease perforation bleeding penetration Pylorostenosis malignization

Blood circulation of the stomach

Ulcer bleedings Types of bleeding hidden significant arterial venous capillar

«centralization» - at the blood circulation system At the loss of VCB to 15% Without acute haemodynamical breaches Spasm of the vessels: Pallor of skin Breach of the microcirculation of the organs of the abdominal cavity 2. opening of the arteriovenous shunts State of the vessel Before the bleeding State of the vessel after the bleeding «centralization» - at the blood circulation system

At the loss of VCB more than 15% Reduction of BP Spasm of the vessels opening of the arteriovenous shunts Tachycardia Liberation of the among cellular liquid and limfa into the circulated blood Increasing of the concentration of the corticosteroids: aldosteron, Antidiuretic hormon Stopping of the liquid in the organism Increasing of the BP

Main breaches at the GDB: Hypovolemic shock (reduction of the VCB). Renal insufficiency (hypoxia of the parenchima of kidney and hypofiltration) Liver insufficiency (breach of the blood circulation in the liver and its hypoxia) Infarct and hypostasis of brain Intoxication (suction of the toxins through the intestine) Functional breachees of the Na и К pomps

Breaches, appear after GDB depend on :     volume of bleeding     speed of bleeding      state before bleeding (additional pathology, VCB, gender and other)

Organs-dartboards brain

Stages of posthemorragic shock I – compensation – REVERSIBLE SHOCK II - subcompensation– HARD REVERSIBLE SHOCK III - decompensation - NOT REVERSIBLE SHOCK

Other reasons of the GIB: Errosive defeat of the mucous of the GIP Breakup of the aorta’s aneurism into the in GIP angiodysplasy of the vessels of GIP (syndrome Of Veber-Osler-Randu) Blood diseases Traumas. Mellory-Vays syndrome. Bleeding from the VEVE tuberculosis and siphylus of the stomach Hypertrophic polyadenomatous gastritis (Menetrie syndrome) Gastrinoma Polyposis of the stomach

Lately signs of the bleeding Early signs of the bleeding dizziness, tachycardia, loss of the consciousness , pallor of the skin, weakness. Lately signs of the bleeding : retching «coffee lees» “tar” excrement or melena, reduction or disappearance of pain

Classification of the ulcer bleeding by Forrest 1 stage а – pulsing arterial bleeding 1 stage b – active venous bleeding 2 stage а – visible thrombed vessel 2 stage b – fixed thromb or clot 2 stage v – hemorragic imbibition of the fundus of the ulcer 3 stage – ulcer defect without thromb.

F-I A – pulsing arterial bleeding; F-I B – venous bleeding; Active bleeding F-I A – pulsing arterial bleeding; F-I B – venous bleeding;

F-II B – fixed thromb or clot; F-II A – visible thrombed vessel; Happened bleeding F-II B – fixed thromb or clot; F-II A – visible thrombed vessel;

F-II C – hemorragic imbibition of the ulcer’s fundus; Happened bleeding F-II C – hemorragic imbibition of the ulcer’s fundus; F-III pure ulcer’s fundus, absence of the direct visual signs of bleeding

Main principles of therapy: Urgent hospitalization Bed mode Cold, hungry Local and general haemostatic therapy Reconstruction of the VCB Antoshock therapy Plasmo- and haemotransfusions. Haemostatic therapy: 1% vicasol 3 ml i/m 10% chloride natrium i/v 12,5% aethamzilate natrium (dicinon) i/v or i/m Σ-amino-capron acid 100 ml 5% i/v, every 4-6 hours transfusion every 4 hours 20-30 ml of dry or native plasma

Endoscopic haemostasis Stopping of the continuously bleeding Prevention of the recidivate bleeding

Endoscopic methods of stopping of the bleeding: Electrocoagulation Laser haemostasis Infiltrative haemostasis injective haemostasis diathermocoagulation mechanical method medicine applications criostopping film forming medicines

Method of stopping of the bleeding with the help of electrocoagulation

Meshanical compression of the source of bleeding; Injective method (local pricking of the source of bleeding with the medicines, inducting the stopping of bleeding) Meshanical compression of the source of bleeding; Vasospaspatic effect; Increasing of the local development of thromb

Methods of the mechanical stopping 1. Clipping Visible bleeding or not bleeding vessel (in the fundus of the peptic ulcer, at the ulcers of Delafua, VEVE and other). Bleeding from the bordered surface (acute ulcer, Mallory-Vais syndrome, place of the tumor’s desinteration, leg of the polyp and other. 2. Ligature acute ulcer, ulcers of Delafua, polyps.

Mechanical method of haemostasis

Protection of the ulcer surface application onto the ulcer defect the polymer medicines, form film: lizol, gastrozol, statizol and biological glue on the base of cyanocrilates (MK-6, МК-7, МК-8).

Endovascular haemostasis

Gastrotomy and sewinf of the bleeding ulcer Incision of the ulcer by Djadd Sewing of the ulcer

Differential diagnostic of the GIB Bleeding from the GIP- retching «coffee lees». Pulmonary bleeding – bleeding with the scarlet blood, with the foam, separates at coughing. Estimation of the bleeding by the character of the excrements The black excrement, formed – bleeding from the upper parts of the GIP, the bleeding is stopped Black fluid excrement (melena) – bleeding from the upper parts of the GIP, the bleeding is not stopped Excrement with the scarlet blood – bleeding from the lower parts of the GIP

Depending of death on the degree of common state at the GIB hard degree Death at the GIB 1 stage 14,28% 2 stage 20,06% 3 stage 64,84%

Risk of the recidivate bleeding is more than 90% Prognosis of the recidivate bleeding Collaptoid state Presence of the thromb of clot on the fundus of the ulcer at the endoscopic research The sizes of the ulcer are more than 8 mm at the endoscopic research Risk of the recidivate bleeding is more than 90%

Reasons of the pyloroduodenal stenosis Peryulcer infiltrate Scaring because of the healing of the ulcer Hypostasis Spasm

Degrees of the pyloroduodenal stenosis 1 degree – compensation (to 1,5 sm) 2 degree – subcompensation(tp 1- 1,5 sm) 3 degree – decompensation (to 0,5 --smсм)

Stage of the compensation Evacuation through the narrowed intestine the food passes because of the stomach hypersalivation On the phine of the ulcer clinic the sense of the fullness of the stomach after good feeding Belch with the bad smell, the sense after the retching reliefed Normal sizes of the stomach at the X-ray and constipation of the Ba to 3-4 hours, hypermororic.

Stage of the subcompensation The sense of the fullness in the stomach, belch with the smell of bad eggs, pain, Plural retching, Remainders of the food in the retching masses Deterioration of the general status «Noise of splash» in the epigastria. at hungry X-ray defines the great volume of liquid in the stomach, reducted peristaltic, stopping of Ba to 6-12 hours, breach of the evacuation through the pyloroduodenal cannel because of narrowing

Stage of the decompensation Breach of the evacuation of the content of the stomach Significant deterioration of the general status Stopping of the liquid in the stomach, its dilatation and beginning of the fermentation processes in it. The sense of the fullness in the stomach, belch with the smell of bad eggs, Timely relief after inducted retching Signs of alkalosis, breach of the electrolytes balance, decreasing of the diuresis. X-ray – stopping of Ba after 24 hours

X-ray and endoscopic pictures of the decompensative pylorostenosis

Decompensative pylorostenosis X-ray

X-ray of the pylorostenosis

Resection of the 2\3 of the stomach Radical operation Resection of the 2\3 of the stomach

Pyloroplastic by Geyneke-Mikulich

Pyloroplastic by Finney

GDA by Djabuley

Differential diagnostic Duodenal obstruction at the peryampular tumors Soldering intestinal obstruction Cachexy at the oncological diseases Central anorexy