Choice of Treatment Strategy in Patients with Acute Ulcerative Gastroduodenal Hemorrhages

The study is dedicated to the development and substantiation of a comprehensive diagnostic and treatment program for patients with acute ulcerative gastroduodenal hemorrhages. The work analyzes modern approaches to choosing a management strategy for patients depending on the activity of the hemorrhage and the general condition of the patient. Special attention is paid to the effectiveness of various methods of endoscopic hemostasis, the role of acid-reducing therapy, and anti-helicobacter treatment in preventing the recurrence of hemorrhages.

The work has a direct practical focus, as during the research a methodology acceptable for surgeons for providing assistance to patients with gastroduodenal hemorrhages of ulcer etiology has been created and tested. The generalization and evaluation of the clinical material allowed the development of an algorithm for decision-making in patients with ulcers complicated by hemorrhage and the substantiation of indications for various variants of hemorrhage cessation.

Relevance of the Problem

The relevance of the problem of treating acute gastroduodenal hemorrhages is primarily determined by a high overall mortality rate, which reaches 10–14% [Panzyrev Yu.M., 2003]. Despite the generally recognized high effectiveness of anti-ulcer (acid-reducing) drugs and the overall decrease in the number of planned surgeries for ulcer disease, according to Zittel T.T. et al. (2000), in the 1980s, the percentage of planned surgeries for gastric ulcer decreased by more than 70%, against the backdrop of an increase of more than 80% in the number of emergency surgeries.

At the same time, the number of patients with ulcerative gastroduodenal hemorrhages is increasing and amounts to 90–103 [Swain S.R., 2000] to 150 per 100,000 population [Schoenberg M.N., 2001].

According to Yu.M. Panzyrev et al. (2003), the number of patients admitted to the clinic for gastroduodenal hemorrhage has recently increased by 1.4 times.

According to the selective data of domestic authors, in 5–25% of patients suffering from ulcer disease, the disease is complicated by hemorrhage, while in every fifth patient this complication is the first manifestation of the disease, and mortality is 10–15% [Tkachev A.V., 2002].

Despite the fact that spontaneous hemostasis occurs in approximately 80–85% of patients with ulcerative gastroduodenal hemorrhages [Ye.I. S., Stabile V.E., 1993; Laine L., 1994; Chung S.C.S., 1997], the percentage of hemorrhage recurrences is 20% (from 9 to 42%) [Schoenberg M.N., 2001].

Over the course of its history, three main approaches have formed in the therapy of gastroduodenal hemorrhages: active (Yudin S.S., 1933; Finsterer N., 1939), active-waiting (Dzhanelidze Yu.Yu., 1933; Struchkov V.I. and Luchevich E.V., 1961), and finally, waiting (Berezov Ye.L., 1935; Rabinovich B.K., 1939). Recently, most surgeons have adhered to an active individualized tactic, according to which a patient with a high risk of hemorrhage recurrence is operated on in an urgent order before the recurrence occurs [Krylov Grigoryev S.G., 1999].

Existing data may suggest that this problem has been solved and there is no need to return to it. However, the remaining consistently high (10% and above) mortality rate, a fairly high percentage of recurrences, the absence of a unified treatment and rehabilitation program force surgeons and gastroenterologists to repeatedly return to this problem.

Thus, the problem of providing assistance to patients with ulcerative gastroduodenal hemorrhages is relevant and requires further consideration.

Goal of the Study:

Improving the immediate and long-term results of treatment of patients with ulcerative gastroduodenal hemorrhages by developing and implementing a comprehensive diagnostic and treatment program for each clinical variant of hemorrhage.

Tasks of the Work

1. To conduct a comparative evaluation of the most common methods of endoscopic hemostasis, to assess their effectiveness and safety of use.

2. To study the effectiveness of modern antisecretory drugs and anti-helicobacter therapy and to substantiate the indications for their use in ulcerative gastroduodenal hemorrhages.

3. To substantiate the choice of surgical treatment method for patients with gastroduodenal hemorrhages.

4. To determine the role and place of therapeutic endoscopy and conservative therapy in hemorrhages from gastric and duodenal ulcers.

5. To develop diagnostic algorithms and patient care for acute ulcerative gastroduodenal hemorrhages depending on the activity of the hemorrhage, the condition of the patient, and the effectiveness of endoscopic hemostasis.

Scientific Novelty

Based on the analysis of a large clinical material, a diagnostic and treatment algorithm for providing assistance to patients with acute gastroduodenal hemorrhages has been developed, and indications and contraindications for the use of various variants of hemorrhage cessation have been determined.

The role of endoscopic ultrasonography in predicting the recurrence of hemorrhage from gastroduodenal ulcers has been demonstrated for the first time, which allows for the detailing of the tactics of patient management.

Indications for the use of modern methods of endoscopic hemostasis, including injection-coagulation therapy, argon-plasma coagulation, and the method of endoscopic clipping of the bleeding vessel, have been developed and substantiated.

The causes of recurrences of ulcerative gastroduodenal hemorrhages have been studied, and the role of acid-reducing drugs and anti-helicobacter therapy in preventing repeated hemorrhages has been shown.

Practical Value of the Results

The work has a direct practical focus, as during the research a methodology acceptable for surgeons for providing assistance to patients with gastroduodenal hemorrhages of ulcer etiology has been created and tested. The generalization and evaluation of the clinical material allowed the development of an algorithm for decision-making in patients with gastroduodenal ulcers complicated by hemorrhage.

Among the obtained results, an important practical significance has the recommendations on the choice of treatment strategy for patients with hemorrhage depending on the degree of hemorrhage activity, the general condition of the patient, and the presence of recurrence hemorrhage stigmata. The expediency and necessity of timely performing radical operations in the presence of continuing hemorrhage and a high risk of its recurrence have been substantiated.

Testing of the Work

The main provisions of the dissertation were reported and discussed: at the 2nd Scientific and Practical Conference "Rodinskie Chteniya" (g. Seversk, 2006), and the Tomsk Regional Society of Surgeons (2006).

As a result of the research, 11 scientific papers have been published in journals and collections, a monograph and a methodological guide have been released.

Implementation of the Work. The provisions of the dissertation are used in the educational process and in the treatment of patients with ulcer disease in the clinic of the Research Institute of Gastroenterology of SibGMU, the Department of General Surgery with a course of surgical diseases of the Advanced Training and Professional Retraining (FPK and PPK) of SibGMU, and the Regional Clinical Hospital (g. Tomsk).

MAIN PROVISIONS SUBMITTED FOR DEFENSE

1. Endoscopic hemostasis is the method of choice in the primary cessation of hemorrhage, and the most effective is considered to be coagulation with the use of argon.

2. Gastrectomy is the method of choice in the treatment of patients with continuing gastroduodenal hemorrhage, as well as with a high risk of its recurrence. In young patients, against the background of ulcer disease of the duodenal bulb, vagotomy with ulcer resection and duodenoplasty can be performed. The ulcer suturing operation can be applied only in cases of massive hemorrhage in patients with an extremely high risk of surgery.

3. After performing endoscopic hemostasis in patients with hemorrhage F I-A, B, it is necessary to prescribe parenteral forms of acid-reducing drugs that allow controlling gastric secretion and significantly reduce the risk of early recurrence of hemorrhage.

4. Conducting eradication therapy in patients with ulcer disease associated with H. pylori contributes to faster epithelialization of ulcers, providing better conditions for the cure of ulcer disease.

Volume and Structure of the Dissertation. The dissertation is presented on 143 pages of typed text. The work consists of an introduction, five chapters, conclusion, conclusions, and a list of references, illustrated with 29 tables and 15 figures. The reference index contains 213 works, of which 88 are domestic and 125 are foreign authors.