Prediction, Prevention, and Treatment of Acute Erosions and Ulcers of the Gastrointestinal Tract Mucous Membrane in Wounded and Injured Patients

The dissertation is dedicated to the development of methods for predicting, preventing, and treating acute erosive-ulcerative lesions of the gastric and duodenal mucosa in wounded and injured patients with severe mechanical injuries and gunshot wounds. The research is based on identifying trauma-related risk factors and studying the morphological and functional features of the formation and course of the post-traumatic period. The work analyzes the frequency, timing of formation, complications, and localization of acute erosions and ulcers, as well as evaluating the effectiveness of pharmacological and surgical methods of prevention and treatment for this category of patients.

Acute erosive-ulcerative lesions of the mucous membrane of the gastrointestinal tract organs arise sufficiently frequently in wounded and injured patients with severe mechanical injuries and gunshot wounds (Basalevich G.P. et al., 1998; Kobiashvili M.G. et al., 2003; Kotaev A.Yu., 2006; Brzozowski Т. et al., 2000; Stollman N., Matz D.C., 2005). Previously their occurrence was considered a relatively rare phenomenon (Khokhlya V.P., 1985). However, with the development of surgery, resuscitation, and the emergence of the ability to fight for the lives of these patients, a new problem arose — acute erosions and ulcers of the mucous membrane, which often complicate with bleeding or perforation, and sometimes their combination, aggravating the already severe condition of patients and often posing a greater threat to their lives than the injury itself (Cook O.J. et al., 2001). Their formation frequency reaches, according to various data, from 40 to 100% (Gelfand B.R., Guryanov V.A., 2005; Lewis J.D. et al., 2005), and mortality from complications of acute ulcers reaches up to 75% (Kobiashvili M.G. et al., 2003).

Given that the clinical signs of the appearance of acute erosive-ulcerative lesions and their complications are masked by the severity of the trauma, most of them are diagnosed late (Galustyan A.S., 1999; Bokeria I.A. et al., 2004; Kotaev A.Yu., 2006; Franciosi С.М. et al., 2002). Taking this into account, the necessity of conducting preventive measures is beyond doubt. However, the methods of prevention remain unclear, and the categories of wounded or injured patients for whom prevention is extremely necessary, desirable, or unnecessary have not been defined. In other words, a system for predicting the formation of acute erosive-ulcerative lesions of the mucous membrane in wounded and injured patients, their prevention, and treatment has not been created.

Objective of the research.

Development of methods for predicting, preventing, and treating acute erosive-ulcerative lesions of the mucous membrane of the stomach and duodenum in cases of injuries and trauma based on the identification of risk factors, studying the morphological and functional features of their formation and the course of the post-traumatic period.

Tasks of the research.

1. To determine the trauma-related risk factors that allow predicting the formation of acute erosions and ulcers. To assess their influence on the frequency, timing of onset, localization, and spread of lesions of the mucous membrane of the stomach and duodenum in wounded and injured patients.

2. To identify the presence of morphological features (macro- and microscopic), characteristic of acute erosive-ulcerative lesions of the mucous membrane of the upper gastrointestinal tract in cases of injuries and trauma.

3. To study the effect of trauma on intragastric acidity and determine its role in the pathogenesis of the formation of acute erosions and ulcers in wounded and injured patients.

4. To evaluate the effectiveness of the use of various antisecretory drugs in wounded and injured patients with severe and extremely severe trauma for the development of recommendations on the prevention and treatment of acute erosions and ulcers of the mucous membrane of the stomach, duodenum, and their complications.

Scientific novelty.

For the first time, the main trauma-related risk factors have been determined, the accounting for which allows predicting the formation of acute erosions and ulcers of the mucous membrane of the stomach and duodenum in wounded and injured patients. The dependence of the frequency of their occurrence, spread, and localization on the severity of the received trauma, the condition of the injured at admission (calculated using objective trauma severity scales: ISS-P, ISS-S, ISS-SS), and the period of the traumatic disease has been demonstrated.

Based on the study of the dynamics of intragastric acidity in the early post-traumatic period, its dependence on the severity of trauma and its influence on the frequency of formation and spread of acute erosions and ulcers in wounded and injured patients has been revealed for the first time.

The effect of the main antisecretory drugs (famotidine and omeprazole) under severe trauma has been studied for the first time. The necessity has been substantiated and the effectiveness proven for their use in the prevention and treatment of acute erosions and ulcers of the mucous membrane of the upper gastrointestinal tract, including complicated ones, in this category of injured patients.

Practical significance.

The developed principles for predicting the formation of acute erosions and ulcers in wounded and injured patients, taking into account the identified trauma-related risk factors, will help surgeons make timely and rational tactical decisions in the treatment of this category of patients, avoid additional investigations and untimely diagnosis of complications. A comparative assessment of the effectiveness of antisecretory drugs of various groups will allow the selection of optimal pharmacological prevention and treatment schemes for acute erosions and ulcers, including complicated ones, in wounded and injured patients with severe and extremely severe trauma. Overall, the implementation in clinical practice of the proposed system for predicting, preventing, and treating acute erosive-ulcerative lesions of the mucous membrane of the upper gastrointestinal tract will substantially improve treatment outcomes in cases of injuries and trauma.

Basic provisions to be defended:

1. The trauma-related risk factors for the formation of acute erosive-ulcerative changes of the mucous membrane in wounded and injured patients are: the severity of the received injury and the condition at admission, the nature of the trauma, and the development of purulent complications. In addition, the risk of acute erosions and ulcers formation increases with age and the presence of concomitant pathology.

2. Morphological changes in acute erosive-ulcerative lesions of the mucous membrane of the stomach and duodenum in wounded and injured patients have no specific features and do not depend on the type of underlying pathological process that led to their occurrence.

3. Injury or trauma leads to a reversible, proportional to the severity of the damage, increase in intragastric acidity, which is directly associated with the occurrence and spread of acute erosive-ulcerative changes of the mucous membrane of the upper gastrointestinal tract in wounded and injured patients.

4. The most effective drugs for the prevention and treatment of acute erosions and ulcers of the mucous membrane of the upper gastrointestinal tract and their complications in wounded and injured patients with severe and extremely severe trauma are antisecretory drugs such as H2-histamine receptor blockers of the III generation or proton pump inhibitors.

Presentation and implementation of the results.

Seven scientific works have been published on the dissertation topic (including 2 journal articles and 1 methodological guide). The results of the dissertation research have been implemented in the practice of the 442nd Interdistrict Military Clinical Hospital named after Z.P. Solovyov, the 1st Naval Clinical Hospital, and the I.I. Dzhanelidze Research Institute of Emergency Medicine. The dissertation materials are used in the educational process at the departments of advanced surgical training №2 and naval hospital surgery at the S.M. Kirov Military Medical Academy.

The main materials of the dissertation were presented at the All-Russian Scientific Conference «Actual Questions of Pathogenesis, Diagnosis, and Treatment of Peritonitis» (Saint Petersburg, January 24, 2006) and the 8th International Slavic-Baltic Scientific Forum «Saint Petersburg — Gastro-2006» (Saint Petersburg, May 18, 2006).

Volume and structure of the dissertation.

The dissertation materials are presented across 120 pages. The dissertation consists of an introduction, a literature review, a description of patients and research methods, two chapters of original research, a conclusion, conclusions, practical recommendations, a list of references, and one appendix. The work contains 20 tables and 14 figures, and the reference list includes 132 domestic and 53 foreign authors.