Tactics of Treatment for Patients with Ulcerative Gastroduodenal Hemorrhages

The research is dedicated to the development of a treatment tactic for patients with ulcerative gastroduodenal hemorrhages. The study analyzes modern approaches to treating this pathology, the role of endoscopic diagnostic and hemostatic methods, and the impact of the severity of the patient's condition on the prognosis of bleeding recurrence and the outcome of the disease. The author developed and implemented a diagnostic-treatment algorithm based on the endoscopic signs of bleeding activity according to the Forrest classification and the objective assessment of the severity of the condition using the SAPS scale.

The problem of treating patients with acute ulcerative gastroduodenal hemorrhages, despite the introduction of new surgical, endoscopic, and pharmacological treatment methods into practice, has remained an urgent issue of emergency abdominal surgery for over a century.

Annually in Russia, 100–150 patients per 100,000 population are hospitalized for this pathology [Yu. L. Galinger et al., 2000; V.K. Gostishchev et al., 2005; T. J. Savides et al. > 2000, J.J Sung 2003). According to the Chief Surgeon of Moscow (2004), 17,077 patients with ulcerative gastroduodenal hemorrhages were admitted to hospitals over the last 5 years.

This problem is also acute in other countries. For example, in the USA, gastroduodenal hemorrhages annually cause the hospitalization of 300,000 patients (P. Hussain et al., 2000), in Scotland the prevalence of hemorrhages from the upper gastrointestinal tract is 170 cases per 10,000 adult population per year (O. Blaichfbrd et al., 1997), According to some authors, the frequency of ulcerative gastroduodenal hemorrhages has increased from 20% to 40–51% in recent years (E. V. Luceich et al., 1991; V.N. Branchuk et al., 1992; S.G. Grigoriev et al., 1999; Yu.M. Paitsyr'ev et al., 2000; G. Lindell et al., 1994; G.F Longslreht. 1995; S.H. Dcrtinger, 1996; Р Ondrejka et al., 1996).

Currently, UGIB occurs more frequently in elderly patients, which complicates the treatment of this category of patients in the context of the presence of severe concomitant pathology, a decrease in protective elements of the body (S.G. Grigoriev et al., 1994; A.M. Amnrov, 1995; E.M. Blagntko. 1995; P. G. Bryusov et al., 1995; N I Korotkoy et al., 1997; L-I. Kutyavnn et al., 1997; Yu.V. Grubnikh et al., 2002; V, V. Grubnnk et al., 2003; S. Ohmann et al., 2000),

Despite the progress in the development of modern medicine, mortality in UGIB reaches 15–20% (A-S- Balalykin et al., 2000; Yu.Ya. Blokhin et al., 2000; E.D. Fedorov et al., 2002; V.I. Sidorenko et al., 2004; AХ. Bебурншвили et al., 2005; S. Rolihauser et al., 2000). and has no tendency to decrease. Especially high mortality is observed in the recurrence of UGIB, reaching 25%–75% (B.V. Krapivin et al., 1999; R.B. Kuzeyev. 2000; I.I. Zatevakhii et al., 2001: T,A, Sultanayev et al., 2005; V-K- Gostishchev, M L, Kvseyev, 2005; I, Sees et al., 2002).

Currently, one of the main methods for diagnosing sources of bleeding is esophagogastroduodenoscopy (EGDS), the informational value of which reaches 97%–100% (Yu.I. Lomachenko, 2001; V.V. Lgal-zhayi et al., 2002; L.L, Achkekyan et al., 2004; A.M. Khadibayev et al. 2005; S. Sofia et al. 2000). EGDS allows not only to identify the source of bleeding, but also to stop active bleeding using endoscopic technique, to conduct prophylaxis of its recurrence (G.I Demidov. 1995; I.I. Zatevakhii et al., 1998; |O.Ya. Blokhin et al., 2000; I.V. Agafonov et al. 2003; V.V. Lopatminsky et al., 2005; J. Ziemsky et al. 1996).

The results of EGDS allow determining the degree of activity of bleeding, approximate information about the reliability of hemostasis and the prognosis of possible recurrence (E.M. Blagntko. 1995; Yu.I, Lomachenko, 2001; Yu.M. Maiiyrev et al., 2005; D.P Sordia et al., 2005).

Currently, there is no single tactic for choosing a treatment method for hemorrhages from gastric and duodenal ulcers. A number of authors consider a recurrence of UGIB an indication for emergency surgery (I.I. Zatevalin et al., 1977; VV, Rumyantsev, 1981; V.P Verbitsky, 1999; AL. Stanulis et al., 2001; J.S. Bender et al., 1994; GJ. Winkehau et al., 1995),

A number of other authors prefer an actively expectant tactic: initially a conservative method and surgery in case of its ineffectiveness or recurrence of bleeding (A. Scamporino, 1991; K.G.M. Park et al., 1994; L, Cipollena et al, 1998; К Nagayama et al. 1999; A.M, (Severs et al., 2002). The indications for emergency interventions and criteria for the effectiveness of conservative therapy in this tactical approach are today considered quite ambiguous (V.K. Gostishchev, M.A. Evseev, 2005).

With the evolution and formation of gastric surgery in the late 1980s, a so-called "active-individual" tactic was developed. Under this tactic, the timing of surgical interventions is determined by the severity of blood loss, the presence of ongoing bleeding, the effectiveness of endoscopic hemostasis, and the threat of hemorrhage recurrence (A.I. Gorbatko et al., 1987; V.D. Zatolokin 1990; К Nagayama et al., 1999; A. Gevers et al., 2002).

Thus, the problem of timely determination of indications for surgical intervention remains unsolved to this day.

Goal of the research: To develop an individual tactic for the treatment of patients with ulcerative gastroduodenal hemorrhages based on the results of endoscopic research and objective assessment of the severity of the condition.

Tasks:

1. To study the significance of the results of gastroduodenoscopy in determining the treatment tactic for patients with ulcerative gastroduodenal hemorrhages of ulcerative etiology.

2. To demonstrate the role of individual clinical signs and objective assessment of the severity of the condition of patients with ulcerative gastroduodenal hemorrhages of ulcerative etiology in predicting the course of the disease and determining the treatment tactic

3. To develop an algorithm for the treatment of patients with ulcerative gastroduodenal hemorrhages based on the results of gastroduodenoscopy and objective assessment of the severity of the condition according to the SAPS scale.

Scientific novelty

It has been shown that there is a direct dependence of the frequency of hemorrhage recurrence on the type of bleeding identified during primary EGDS according to Forrest and the size of the ulcer.

It is proven that the prognosis for the development of a recurrence of bleeding depends on the characteristics of the bleeding according to Forrest and the method of endoscopic hemostasis

It is proven that the probability of a fatal outcome in ulcerative bleeding increases directly proportional to the age of the patient.

It has been established that with an increase in the severity of blood loss, there is a clear tendency to increase the probability of the development of a hemorrhage recurrence. The severity of blood loss is an important prognostic criterion in the development of a recurrence of bleeding.

It has been shown that with an increase in the severity of the condition (by points on the SAPS scale), the probability of a fatal outcome of the disease increases. The probability of developing a recurrence of bleeding does not depend on the severity of the patient's condition.

It has been established that in determining the treatment tactic for patients with ulcerative gastroduodenal hemorrhages, along with other assessment criteria, it is necessary to take into account the severity of the patient's condition, which largely determines the outcome of the disease.

A diagnostic-treatment algorithm has been developed and introduced into practice based on endoscopic signs of the activity of bleeding according to the Forrest classification and the objective assessment of the severity of the condition of patients according to the SAPS scale,

Practical significance

The prognosis for the development of a recurrence of bleeding depends on the characteristics of the bleeding according to Forrest and the method of endoscopic hemostasis, however, based on any single endoscopic sign of ulcerative bleeding, it is impossible to predict a recurrence of bleeding with sufficient accuracy.

In determining the treatment tactic for patients with ulcerative gastroduodenal hemorrhages, along with other assessment criteria, it is necessary to take into account the severity of the patient's condition, which largely determines the outcome of the disease.

The use of the proposed diagnostic-treatment algorithm taking into account the endoscopic signs of the activity of bleeding according to the Forrest classification and the objective assessment of the severity of the condition of patients according to the SAPS scale allows reducing mortality from acute hemorrhage from 1% to 2.8%, including in the treatment of patients using minimally invasive technologies from 4.5% to 2.2%, and postoperative from 4.5% to 6.8%.

The proposed algorithm allows choosing the optimal diagnostic-treatment tactic directly for this specific patient,

Implementation into practice

The results of the research have been implemented into the practical work of the surgical departments of City Clinical Hospital No. 64.

Validation of the work

The materials and main provisions of the work were reported and discussed at the conferences of young scientists "Vnogradovskiy Chteniya" (Moscow, 2006), at sessions of the department of surgery of the Peoples' Friendship University of Russia, together with surgeons of GKB No. 64.

The validation of the dissertation was conducted at a joint session of the department of faculty surgery of the Peoples' Friendship University of Russia and the staff of City Clinical Hospital No. 64,

Publications of the research results

5 printed works have been published on the topic of the dissertation.

Provisions submitted for defense

The prognosis for the development of a recurrence of bleeding depends on the characteristics of the bleeding according to Forrest and the method of endoscopic hemostasis,

In determining the treatment tactic for patients with ulcerative gastroduodenal hemorrhages, along with other assessment criteria, it is necessary to take into account the severity of the condition of the patient, which largely determines the outcome of the disease.

The use of the proposed diagnostic-treatment algorithm taking into account the endoscopic signs of the activity of bleeding according to the Forrest classification and the objective assessment of the severity of the condition of patients according to the SAPS scale allowed reducing mortality from acute hemorrhage from 6.1% to 2.8%, including in the treatment of patients using minimally invasive technologies from 4.5% to 2.2%, and postoperative from 14.5% to 6.8%. When statistically comparing the groups, we identified a significant difference in the level of general, postoperative mortality, as well as a statistically significant difference when using conservative treatment (p < 0.05, Fisher's exact test).

The proposed algorithm allows choosing the optimal diagnostic-treatment tactic directly for this specific patient.

Volume and structure of the dissertation

The dissertation is presented on 147 pages of typed text, consists of an introduction, 5 chapters, conclusion, findings, practical recommendations, and a list of references, illustrated with 44 tables, 9 diagrams, 5 figures, and photographs. The list of references contains 260 sources, of which 161 are domestic and 99 are foreign authors.