Clinical Aspects of Bleeding Gastroduodenal Ulcers

The research is dedicated to the clinical aspects of the treatment of bleeding gastroduodenal ulcers. The work analyzes the frequency and severity of ulcerative hemorrhages, metabolic disorders in the peri-ulcerative zone, the state of the vegetative nervous system, and develops criteria for forecasting the recurrence of hemorrhage using neural network models. The quality of life of patients in the remote period after treatment is studied.

Peptic ulcer of the stomach and duodenum occupies one of the leading places among diseases of the gastrointestinal tract. In recent years, there has been a major breakthrough in studying the etiological and pathogenetic aspects of gastroduodenal ulcers, and new treatment methods have been proposed, both conservative and surgical. However, despite this, the morbidity of peptic ulcer of the stomach and duodenum remains high and, according to various authors, ranges from 5 to 20% (V.T. Ivashkin, 2004; V.V. Osipov et al., 2004).

The prevalence of peptic ulcer of the stomach and duodenum increased from 1556.6 patients per 100,000 population in 1997 to 1611.3 in 1999. The number of patients with gastrointestinal hemorrhages increased 2.6 times from 1990 to 2001. This increase corresponds to the dynamics of the frequency of gastrointestinal hemorrhages worldwide (V.T. Ivashkin, 2001, 2004; N.N. Krylov, 2001; A.I. Lobakov, 2006; A. Ruigomez et al., 2000).

Trends toward a decrease in ulcerative gastroduodenal hemorrhages are not observed (Yu.M. Pancyrev et al., 2000; G.P. Swain, 2000). According to various authors, over the last time, surgical activity in chronic ulcers has decreased by more than 2 times. At the same time, the number of patients with bleeding ulcers has increased 1.4 to 5 times (V.N. Shilenok et al., 1999; G.A. Bulgakov and V.A. Kubyshkin, 2001; V.P. Petrov, 2001; O.Ch. Khadzhiev, V.N. Lupal'tsev, 2001; M.I. Kuzin, 2001; G.A. Bulgakov et al., 2002; Yu.M. Shantser'ev et al., 2003; V.S. Savel'ev, 2004; V.M. Lobankov, 2005, S.A. Afendulov et al., 2006, M.J. Legrand et al., 1996; L. Aabakken, 2001).

The problem of treating gastroduodenal ulcers complicated by hemorrhages remains one of the most complex problems in surgical gastroenterology (A.A. Polynsky et al., 2003, V.P. Sazhin et al., 2003, A.M. Khadzhibayev et al., 2003, Yu.G. Shapkin and I.I. Matveeva, 2003; V.I. Onopriev et al., 2006). Firstly, this is associated with the fact that no unified tactical approach has been developed in the treatment of patients with ulcerative gastroduodenal hemorrhages, the role of endoscopic hemostasis is overestimated, which leads to the postponement of necessary operations. The optimal surgical intervention has not been determined, there are no specific solutions regarding optimal timing of operations and, especially, the volume of intervention. There is a rather high indicator of general (4-7%) and postoperative (15-25%) mortality, mainly during profuse hemorrhages and during episodes of its recurrence (I.I. Zatevakhin et al., 1997; G.L. Ratner et al., 1999; A.S. Ermolov et al., 2000; Yu.M. Shantser'ev et al., 2000; Yu.G. Shapkin et al., 2000; J.Y.W. Lau, S.C.S. Chung, 2002; S.F. Bagnenko et al., 2003; P.S. Vetchev et al., 2006).

In this context, studies aimed at identifying predispositions that can lead to damage to the stomach or duodenal wall with all the resulting consequences are gaining importance. However, it should be recognized that, despite the extraordinary significance of this direction, the available results mainly characterize the concretization of variants of treatment tactics (A.K. Babalich, 1999; V.N. Shilenok et al., 1999; B.I. Miroschnikov and N.S. Chechurin, 2000; Yu.G. Kadychev, 2001).

The processes of metabolic changes in peptic ulcer and their influence on the degree of destruction of the organ wall are insufficiently studied, especially during ulcerative hemorrhages (Ya.S. Zimmerman, 2000, V.A. Romenskaya, 2006; A.F. Chernovusov et al., 2006).

In recent years, risk factors and prognostic criteria for the course of gastroenterological profile diseases are actively studied. The main risk factors of peptic ulcer exert a pronounced influence on the prognosis of the disease (V.N. Satsukevich and D.V. Satsukevich, 1999; V.V. Osipov et al., 2004). In this regard, forecasting the course of peptic ulcer at the stage of the threat of developing a recurrence of hemorrhage based on objective disease criteria can serve as an additional argument for optimizing the treatment tactics.

The stated moments were the starting point for conducting this research.

Research goal:

Improving the results of treatment for patients with ulcerative gastroduodenal hemorrhages.

Research tasks:

1. To study the frequency of ulcerative hemorrhages depending on the localization of the ulcer and determine the degree of their severity.

2. To study the degree of metabolic disorders in the blood and the peri-ulcerative zone mucosa depending on the degree of blood loss and hemostasis.

3. To study the state of the vegetative nervous and sympathoadrenal systems in patients with ulcerative gastroduodenal hemorrhages.

4. To develop criteria for forecasting the recurrence of hemorrhage and an algorithm of actions based on a comprehensive assessment of clinical, endoscopic, and metabolic indicators.

5. To assess the quality of life of patients with gastroduodenal hemorrhages in the remote period.

Scientific novelty

1. It has been established that in case of ulcerative hemorrhages, with an increase in the severity of blood loss, disorders of connective tissue metabolism indicators in the blood plasma and the peri-ulcerative zone increase. The presence of hemostasis does not have a significant effect on their normalization. In case of a recurrence of hemorrhage, the concentration of serum free hydroxyproline increases.

2. It has been established that the severity of disorders of the vegetative nervous system in ulcerative hemorrhages is determined by the severity of blood loss and hemorrhagic shock. With their progression, sympathetic activity increases. This is accompanied by an increase in the content of catecholamines, serotonin, and histamine in the blood plasma.

3. It has been established that the use of neural network forecasting of the recurrence of ulcerative hemorrhages increases the surgical activity in this pathology. The number of urgent surgical interventions increases, and postoperative mortality decreases.

Practical significance

1. As a result of the conducted studies, the effectiveness of endoscopic hemostasis has been determined.

2. Existing representations about developing disorders during ulcerative hemorrhages, which must be taken into account when conducting corrective therapy, have been supplemented.

3. Clinical criteria for the use of neural network forecasting of the recurrence of hemorrhage have been identified and its capabilities have been studied.

4. Based on the clinical assessment of the research results, indications for urgent surgical interventions in ulcerative hemorrhages have been expanded.

5. The quality of life of patients with ulcerative hemorrhages in the remote period has been assessed.

Main provisions for defense

1. In ulcerative hemorrhages, ulcers of the body of the stomach and the anterior wall of the duodenum prevail. The frequency of hemorrhage recurrences is most likely in the first three days of the post-hemorrhagic period. The operation of choice in this pathology is gastrectomy.

2. The degree of disorders of connective tissue metabolites in the blood plasma and the neurohumoral status in ulcerative hemorrhages is determined by the severity of blood loss. The influence of endoscopic hemostasis on their normalization is insignificant.

3. The neural network model for forecasting the recurrence of hemorrhage has high classification capabilities. Its application allows performing the operative procedure under more favorable conditions and reducing postoperative mortality. The quality of life of patients does not depend on the duration of the ulcer history.

Work validation

The main provisions of the work were reported and discussed at the following conferences, meetings, and congresses: Plenum of the Interdepartmental Scientific Council on the problems of emergency medical care and the problem commission "Emergency Surgery" RAMN (Omsk, 2000), 2nd Russian conference of young scientists of Russia "Fundamental Sciences and Progress of Clinical Medicine" (Moscow, 2001), KhUPG Jubilee Scientific-Practical Conference of doctors of the medical-sanitary unit NYa NPZ, dedicated to the 45th anniversary of MSU NPZ (Yaroslavl, 2001); Road seminar "Tactics of managing patients with gastrointestinal hemorrhages" (Yaroslavl, 2001); XVIII Scientific-Practical Conference "Improving continuity as an important condition for increasing the quality and efficiency of diagnostic and treatment work of medical institutions of the Yaroslavl city healthcare" (Yaroslavl, 2001); Scientific-Practical Conference of doctors of Russia "Uspensky Readings", dedicated to the 100th anniversary of the surgical service of the Tver region (Tver, 2002); 18th All-Russian conference with international participation "Physiology and Pathology of Digestion" (Gelendjik, 2002); City Scientific-Practical Conference dedicated to the 100th anniversary of Professor A.K. Shilov (Yaroslavl, 2003); Yaroslavl Regional Society of Surgeons (2003); 7th Moscow International Congress of Endoscopic Surgery (Moscow, 2003); V Russian Scientific Forum "Surgery 2004" (Moscow, 2004); All-Russian conference with international participation "Peptic Ulcer of the Stomach and Duodenum" (Sochi, 2006).

Publications

As a result of the research, 17 printed works have been published, including 9 in the central press, including 1 in a journal included in the VAK List of the Ministry of Education and Science of Russia.