Stomach and Duodenum

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BLEEDINGFROMTHEDIGESTIVETRACT.CAUSES,DIAGNOSTICAND
DIFFERENTIALDIAGNOSTIC,TREATMENTTACTIC.
GASTRICANATOMYANDPHYSIOLOGY
Pic. The anatomic relationships in the upper abdomen. The stomach is

bounded on its left by the spleen, posteriorly (dorsally) by the pancreas,
inferiorly(caudally)bythecolon,andtoitsrightbytheduodenumalongthe
liver'sedge.
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Pic. 1 lig. hepatogastricum 2 lien 3 gaster 4 lig. gastro

colicum 5 duodenum 6 lig. hepatorenale 7 foramen epiploicum
(Winslovi)8lig.hepatoduodenale9vesicafellea10hepar11
lig.tereshepatis
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Pic. 1 lien 2 aa. et vv. gastricae breves 3 a. et v. gastrica

sinistra 4 truncuscoeliacus 5. lienalis 6. hepatica communis 7
a.etv.gastroepiploicasinistra8gaster9omentummajus10a.et
v.gastroomentalisdextra11duodenum12a.etv.gastricadextra 13,
et v. gastroduodenalis14ductuscholedochus15v.cava inferior 16
v.portae17a.hepaticapropria18hepar19vesicafellea
Pic. Anatomically, the stomach is divided into several segments.

Functionally, the cardia and the antrum differ from the body in that they
contain no acid secretory properties.The incisura is an area on the lesser
curvature,whichmarkstheantrumbodyjunctionandisofteneasilyseenon
bariumupperintestinalseries.
video
ACUTEGASTROINTESTINALBLEEDINGS.
Theeffluxofabloodinacavityofagastrointestinaltractisunitedina
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syndrome of gastrointestinal bleedings, which can be acute, arising

suddenly, and chronic, beginning imperceptibly and quite often proceeding
for long time. Besides the gastrointestinal bleedings can be obvious and
concealed.Atconcealedhemorrhagestheimpurityofabloodincontentsof
agastrointestinaltract(vomitivemasses,stools)canbefoundoutonlywith
the help of laboratory methods of research (for example, reaction of
Gregerson), and such bleedings are not included into group of acute
gastrointestinalbleedings.Atobviousbleedingsthebloodisfoundoutinnot
changed kind together with contents of a gastrointestinal tract and its
presence is found out at usual survey of vomitive masses or stools. In
clinical current of a peptic ulcer of a stomach and duodenal intestine the
gastrointestinalbleedingscanariseinanyofthelistedabovevariants.
At an ulcer of a stomach and duodenal intestine the gastrointestinal
bleeding arises at each fourth fifth patient with these diseases.
Approximatelyathalfofpersons,diedfromapepticulcerofastomachand
duodenal intestine a gastrointestinal bleeding was an immediate cause of
death.
ETIOLOGY.
Morethan100diseasesofthemanareknownnow,duringwhichthere
can be an acute gastrointestinal bleeding. In frame of the reasons of such
bleedings about 60 % are made by an ulcer of a stomach and duodenal
intestineothers40%otherdiseases:tumoursofastomach(1517%),
errosiveandhemorrhagicgastritis(1015%),syndromeofMelloryVase
(8 10 %), syndrome of a portal hypertension (7 8 %), tumours of an
intestine,ulcerativecolitis,divertuculosisandotherdiseases(710%).
Pathogenesis of acute gastrointestinal bleedings at various diseases is
various: at malignant neoplasms the reason of bleedings usually is the
disintegration and ulceration of a tumour at a syndrome of a portal
hypertensiontrophicchangesofmucosa,ulcerationandbreaksofwallsof
theextendedveinsofastomachandesophagusowingtoaportalcrisisata
syndromeofMelloryVasedestructionofwallsofbloodvesselsowingto
breakmainlyofmucousandsubmucouslayersofacardialdepartmentofa
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stomachatanangiostaxis,leukoses,illnessofVerlgoff,generaldiseasesof
a blood and hemorrhagic diathesises the pathogeny of bleedings is
connected to change of coagulative properties of a blood, disorders of a
capillary permeability and quantitative or (and) qualitative failure of
thrombocytes.
The pathogeny of acute gastrointestinal bleedings at an ulcer of a
stomach and duodenal intestine is rather complex, as in one cases the
bleedingoccursfromarrosivedlargevesselsinthefieldofanulcer,inothers
fromsmallarteriesbothveinsofwallsandfundusofanulcer,inthird
thereisaparenchymatousbleedingfromamucouscoatofstomachoutside
of an ulcer, where alongside with a hyperpermeability of a vascular wall
multiple small arrosions, being a source of a profuse bleeding, quite often
arefoundout.Plentifulmealofraspingnutrition,especiallyunderconditions
ofdifficultyofitsevacuationfromastomach,physicalstrain,theblunttrauma
of a stomach, especially at the filled stomach provoke gastrointestinal
bleedingsatapepticulcer.
Atableedingowingtoanarrosionofawallofalargebloodvesselinthe
field of an ulcer, arising as a result of a necrosis and the subsequent
influenceofagastricchymeonawallofanakedbloodvessel(moreoftenof
an artery), destruction of a vascular wall and the occurrence of a bleeding
usuallyoccursinaphaseofanexacerbationofapepticulcerandthelumen
ofanarrosivedvesselfrequentlyremainsopen,asthedestructionoftissue
framesprevailsaboveproliferativeprocessesinazoneofableedingpoint.
The local factors of a hemostasis, including a retraction of a vessel (rather
circumscribedowingtodegenerativechangesofavascularwallandfibrosis
ofenvironmentaltissues),aggregationofelementsofablood,theformation
ofathrombus,areinsufficientforspontaneousstoppingofableedingandit
quiteoftenacceptsprofusecharacter.
Ataslowlyprogressingulceroutsideofaphaseofanexacerbationthe
productive inflammation of a vascular wall can handicap to a massive
bleeding even at an arrosion of a large vessel, which lumen frequently
appears narrowed owing to a proliferation of an intima and subendothelial
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frames,thereforeclottageofsuchvesselcanbesufficientforaspontaneous
stoppingofableeding.Howeverinawallofchroniculcerstherecanbefocal
degenerativechangesofbloodvesselswithformationofarterialaneurysms
inthefieldofedgesandfundusofanulcer.Thedestructionofthinwallsof
theseaneurysmalexpansionsisaccompaniedbyseriousprofusebleedings.
Thepathogenyofbleedingsislessinvestigatedatmicroscopicaldefects
in walls of small blood vessels of a fundus and edges of an ulcer, but in
these cases, apparently, a progressing necrosis in a crater of an ulcer,
inherenttoaphaseofanexacerbationofdisease,hasthedecisivemeaning
inapathogenyofableeding.Apathogenyofbleedingsfromamucosaofa
stomach outside of an ulcer also is unsufficiently found out. On the data of
seriesofresearches,thebasicpathogeneticmechanismsofsuchbleedings
canbe:
Apermanentplethoraofallvascularsystemofastomach,especially
superficial capillaries and veins causing a hypoxia and disorder of a
vasculartissue permeability, that results to massive erythropedesis and
hemorrhage
Expresseddystrophiaofsuperficiallayersofamucosaanddecrease
ofanexchangeofnucleicacidspromotingtoformationofmicroerosion
Accumulation of neutral mucopolysaccharides as a consequence of
disintegrationoftissuepepticcarbohydratebondsandincreaseofavascular
permeability
Disorderofrhythmsofpolymerizationanddepolymerizationofacidic
mucopolysaccharidesinawallofbloodvessels,changeofapermeabilityof
hematoparenchymatousframes
Hyperplastic and dystrophic processes, reorganization and
pathologicalneogenesisofGlandsofallgastricsystems,breakingsecretory
activity of a stomach, bolstering a vasodilatation and tissue hypoxia (V.D.
Bratus)
Theappreciableroleinapathogenyofacutegastroduodenalbleedings
atapepticulcerisplayedalsobydisordersinsystemofahemostasis.They
arereducedtodecreaseandcompletelossbyanarrosivedvesselofability
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to a retraction, which posesses a rather essential role in mechanisms of a

local spontaneous hemostasis. In acidic medium there is an inactivation of
Thrombinum, that results in decrease of coagulant ability of a blood, and
than above acidity of a gastric juice, especially is oppressed coagulant
system of a blood in the intragastric center of a bleeding. Simultaneously
with dropping of a coagulability of a blood immediately in the field of a
locating of a bleeding point, under influence of acidic medium of a gastric
chyme and chemically active proteolytic enzymes, contained in it, the
fibrinolytic activity raises. This is promoted also by trypsinums, discharged
withatissueofapancreas,ifthebleedingulcerpenetratesinthisorgan.
Inprocessofincreaseofgravityofahemorrhagethereareattributesof
ahypercoagulationofablood,itsfibrinolyticactivityevenmoreamplifiesand
reologic property are worsened owing to progressing aggregation of
elementsofblood(V.V.Rumantsev).
ThedeficiencyofvitaminsP,C,K,especiallyinthewinterspringperiod,
whentheexacerbationsofapepticulcerarisemostfrequently,alsobreaks
mechanisms of a hemostasis. For these reasons, despite of decrease of
bloodypressureinbleedingvessels,owingtoanoligemiaandcollapsethe
independentspontaneousstoppingofagastroduodenalbleedingatanulcer
ofastomachandduodenalintestineisalwaysproblematic.Aswellasatany
acute hemorrhage, the condition of the patient is characterized by the
followingchanges:decreaseofmassofacirculatingblood,centralizationof
a circulation and disorder of cardiac activity, that at the end results in an
oxygenstarvationfirstofallofcardiacmuscle,parenchymatousorgansand
brain.
PATHOLOGICALANATOMY.
Most frequently morphological changes at acute
gastroduodenal bleeding specify the roughly progressing necrosis reaching
deeplocatedbloodvesselswithanecrosisoftheirwallsatakept lumen. In
othercasesonasurfaceofanulcerthereisathinlayerofnecrosedtissue
consistingofunstructuredbasis,inwhichpartsofnucleardisintegrationare
nonuniformlyposed.Quiteofteninunstructuredbasistherearestringsofa
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fibrinmoreconcentratedinthefieldofafundusofanulcer,thanitsedges.
Less often zone of a necrosis is absent and surface of an ulcer is covered
only with strings of a fibrin containing in a plenty the rests of breaking up
nucleuses of leucocytes and lymphocytes. More often zone of a necrosis
penetrates in deeper located connective tissue, which at a chronic ulcer is
usually covered with granulations, is plentiful infiltrated by leucocytes,
hystiocytes, plasma cells. The fundus of an ulcer, as a rule, consists of a
fibrousconnectivetissue,poorforcellularelements,andtheinfiltrationwith
lymphoplasmocytesisexpressedmainlyonacourseofbloodvesselsandin
itssuperficiallayers.
CLASSIFICATION.
The acute gastroduodenal bleedings are differed basically to two
classificationattributes:bleedingsowingtoapepticulcerofastomachboth
duodenal intestine and bleeding of a not ulcerative etiology. Bleedings also
are distinguished on localization of its source (stomach, duodenal intestine
andtheiranatomicdepartments).Theratherlargepracticalimportancethere
is a classification of gastroduodenal bleedings by gravity of a hemorrhage.
Thus, the application of these simple classification attributes provides an
establishment of the etiological and topical diagnoses in aggregate with
definition and degree of gravity of a hemorrhage, that is necessary for
definitionofmedicaltacticsandcontentsoftransfusiontherapy.
Clinic.Theacutegastroduodenalbleedingsusuallyarisesuddenlyona
background of habitual for the patient an exacerbation of a peptic ulcer or
other of the listed above diseases. Quite often after the begun
gastrointestinal bleeding at peptic ulcers pains in epigastric area, available
up to it, disappear (sign of Bergmann). Simultaneously with it or earlier
commonsignsofanacutehemorrhageoccurpalenessofseenmucous
and dermal integuments, giddiness, hum in a head, ears, quite often
syncopal condition, and then in 15 20 minutes and later occur a
hematemesis and melena. The vomitive masses at acute gastroduodenal
bleedingscanbeascoffee,thatusuallyspecifiesaslowbleeding,andthe
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givenventbloodhastimeinalumenofastomachtoreactwithacidicgastric
contents,thereforethehaemoglobinturnstoahydrochloridehematinhaving
darkbrowncolour.Ataplentifulbleeding,especiallyifitssourceisposedin
astomachthegivenventbloodhasnottimetoreactwithagastricchyme,it
is coagulated and forms blood clots which are filling lumen of a stomach.
Theseclotsonappearancesometimesremindacrudeliverandthepatients
quite often mark a vomiting with pieces of a liver*. At a very intensive
bleedingtheoverflowofastomachandthevomitiveactarisesearlier,than
bloodclotshavetimetobeformedandthereisavomitingbyascarletblood,
that is. as well as vomiting with blood clots, attribute of a serious bleeding
fromthetopdepartmentsofagastrointestinaltract.Thevomitingreplicating
in short intervals of time, specifies continuation of a bleeding, and the
occurrenceofavomitinginalongintervaltestifiestoarelapseofableeding.
Ataslowandnotintensivebleeding,especiallyifthesourcelocatedina
duodenal intestine, on a background of the moderately expressed signs of
anacutehemorrhagethedarkstoolscanappear,theimpurityofabloodin
whichiseasilyfoundoutbytheexpressedpositivereactionofGregerson.In
case of an anamnestic bleeding shown by a melena, at inspection of the
patientitisnecessarytocarryoutdigitalresearchofarectum,thatallowsto
determinecharacterofitscontentsandpresenceofanimpurity,undergone
todecomposingwithformationofsulfurousFerrilactasofablood,thatgives
darkcolourtosuchclots.Atmoreintensivebleedingowingtoexaltationby
thegivenventbloodofperistalticactivityofanintestineoccursaliquidtarry
stools,andataveryintensivebleedingstools,sometimesconsensual,can
looklikecherryjamorconsistfromsmalltransformedblood.
The acute gastrointestinal bleedings, shown only by a melena, have
more favorable prognosis in comparison with bleedings, shown by a
hematemesis.Thereisthemostadverseprognosisatbleedings,shownbya
hematemesisandamelena.
Atamilddegreeofahemorrhageitscommonattributesareunstable,as
they are caused not by an oligemia, but reflex reactions and pathological
depositionofablood.Thecreationofconditionsofphysicalandmentalrest
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results in series of cases in disappearance of these attributes. The

appreciable disorders of a hemodynamics caused by bleedings, usually
occuratahemorrhagemorethan0,5I,astherateofableedingevenatan
arrosionofalargevesselinanulcerdoesnotexceedrateofahemorrhage
atexfusionofabloodatthedonor.Besidesapproximatelyin15minaftera
hemorrhage the compensatoric hydremia develops, and quite often on a
background shortterm reflex arterial hypertension, therefore in early terms
from a beginning of a bleeding the hemodinamic changes can be less
expressed in comparison with due at this degree of a hemorrhage. In
subsequent, at an appreciable hemorrhage, there is a thirst, dryness of
mucosas of an oral cavity, the diuresis is reduced, that specifies a
dehydrationowingtoahemorrhage.Thesesignsusuallyarisealreadyona
background of hemodinamic changes tachycardia, decrease of arterial
pressure,compensatorictachypneaetc.
Diagnostics of acute gastroduodenal bleedings is carried out on the
basis of the clinical and laboratory data. An anamnesis has the essential
importance in an establishment of the reason and location of a bleeding
point,whichcanbefoundoutfromtheoverwhelmingmajorityofthepatients
rather in details, however approximately at one third of patients the arisen
bleeding is the first clinical sign of disease. It is necessary also to find out,
whetherthepatientusesmedicineswhichcancauseableeding(aspirinum,
steroidpreparations,derivativeofpyrosolonetc.).
Thebleedingswithahemorrhageupto0,5Iessentiallyarenotreflected
in a common condition of the patient and only sometimes are shown by
shorttermcommondelicacy,giddiness,andthentheoccurrenceofablack
stools is found out.At a plentiful hemorrhage there are expressed signs of
anacuteanemiawiththesubsequentoccurrenceofahematemesisandtar
likestools.Thedurationoftheperiodbetweenoccurrenceofcommonsigns
ofanacutehemorrhageandhematemesisormelenachangesfromseveral
minutes up to day and more, that depends on intensity of a bleeding. At
bleedings owing to a peptic ulcer decrease of intensity of pains is marked
(signofBergmann).Atabloodanalysisinearlytermsdecreaseofquantity
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oferythrocytesandthedecreaseofahaemoglobincontentcanbeabsentor
tobeconsiderablylessexpressedincomparisonwithsizeofahemorrhage,
therepeatedbloodanalysiseswithsimultaneouslydefinitionofapulserate
and level of arterial pressure are necessary for judgement about its sizes,
quiteoftenafterahemorrhagethereisaleukocytosis,risingofESR.These
changes, as well as fervescence, apparently, are caused by toxic action of
products of disintegration of a blood, absorptived from an intestine. The
changes in a muscle of heart are expressed by decrease of wave T and
segmentST,thatmoreprobableisconnectedtoahypoxiaofamyocardium
(F.I. Komarov). At serious bleedings there can be psychic disfunction as
exaltationandhallucinations.Theoccurrenceofthelistedchangesdepends
on intensity of a bleeding and size of a hemorrhage, which can be
determined under the formula: V = 37x( 1,064 d), where V size of a
hemorrhage in litres, d densities of a blood, determined on a method of
G.A.Barashkov.The character of vomitive masses and stools also matters
atscopingofhemorrhagevolumeandbleedingpoint,butthisimportanceis
rather. Last years the establishment of the etiological and topical diagnosis
at acute gastroduodenal bleedings became more perfect due to more and
more wide application of gastroduodenoscopy with the help of
fibrogastroscopes.Gastroduodenoscopyatacutegastroduodenalbleedings
is carried out as urgent research and at an individualization of a
premedication there are practically no contraindications to its. The
application of an endoscopy allows to establish the correct etiological and
topical diagnosis of a gastrointestinal bleeding more than at 90 % of the
surveyedpatients.
At impossibility of endoscopic research the radiopaque research of a
stomach in a horizontal position of the patient can be applied for an
establishment of localization and character of a bleeding point, but this
research is considered counterindicative (before steady stabilization of
hemodinamicparameters)atseriousbleedings,accompaniedbysyncopeor
collaptiod condition. Other additional methods of diagnostics of acute
gastroduodenal bleedings (hepatolienography, celiacography, external
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radiometryetc.)areappliedseldom.
At differential diagnostics with pulmonary bleedings it is necessary to
have in view, that at bleedings from the top respiratory ways the
hematomesis has foamy character, is accompanied by tussis, and
variegratedmoistralecausedbyhitofabloodintracheobronchialtreequite
oftenareauscultatedinlungs.
TREATMENT.
At a prehospital stage the first medical assistance at acute
gastroduodenalbleedingsconsistsinthefollowing:
Strictbedregimen
Antacids inside (almagelum, phospholugelum etc.), thrombostatic
preparations (250 units of thrombinum in 50 ml of water on one spoon 15
mineswithin2hours)
Bubblewithice(heaterfilledbycoldwater)onareaofanepigastrium
Ataserioushemorrhage:inhibitorsofafibrinolysisinside(solutionof
epsilonaminocapronicum acidum 5 % 60,0 on one spoon in 15 mines
within 2 hours to raise the foot end of a bed or to give a position of
Trendelenburg, 10 ml of 10 % solution of calcium chloridum intravenously,
Vicasolum5mlorDicynonum2mlintramuscularly.Change(withregistration
inalistofobservation)ofarterialpressureandpulserateineveryone15
30min.
Thedelayofthepatientataprehospitalstageisinadmissible,andeven
theprovedsuspiciononanacuteesophagealorgastroduodenalbleedingis
theabsoluteindicationforurgenthospitalizationofthepatientinthenearest
surgical hospital.The evacuation of the patient should be made in a laying
positioninsupportofthemedicalpersonnel.
Atenteringofsuchpatientinasurgicalhospitalthegroupofabloodfirst
ofallshouldbedeterminedathimandtheconservativetreatmentbasedon
keepingofthefollowingprincipleshastobecontinued:
replenishment of deficiency of volume of a circulating blood by
transfusion of an integral blood of small terms of a storage and
hemocorrectors(plasma,solutionofAlbuminum,erythrosuspensionetc.)
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Suppressionofagastricsecretionandneutralizationofahydrochloric
acid of a gastric juice by application of antacids, cholinolytics, Hblockers
(Cimetidinum, hystodil. Tagametum, cinaet on 0,4 gr 3 4 times per day,
famotidinononetabletonceperdayetc.),localhypothermia
Localandcommonhemostatictherapy
nasogastral intubation for erasion of gastric contents, control of a
hemostasisandstoppingofableedingbyuseof4mlofNoradrenalinumin
150 ml of an isotonic solution of Sodium chloridum, then the probe is
blockedon2h,ifthisintroductionisnoneffectivetheoperativetreatment
(O.S.Kochnev)isshowntothepatient
Maintenance therapy (cardiovascular preparations, use of
Oxygenium,warmingofextremitiesetc.),cleansingenemaforerasionofthe
givenventandbreakingupbloodfromanintestine.
Inaspecialcardofobservationorthecasehistorybasicparametersofa
hemodynamics, peripheric blood and diuresis are recorded (better graphic
way).
The importance of purposeful both intensive hemostatic and
maintenance therapy considerably grows with application of a medical
endoscopy,atwhichthestoppingofableedingismadebyapplicationofan
electrocoagulation,laserandotherwaysofanartificialhemostasis.
Theindicationstourgentoperativemeasureconcerningacutebleedings
atanulcerofastomachorduodenalintestineare:
The serious bleeding, when the intensive care during 6 8 hours
appearsunsuccessful
A serious bleeding stopped at conservative treatment, but when the
occurrence of a relapse even with a small hemorrhage represents real
dangertolifeofthepatient
The relapse or proceeding bleeding irrespective of its intensity,
especially at penetrating ulcers of a stomach and duodenal intestine
confirmedbyanendoscopy
Endoscopicattributesofinstabilityofahemostasis.
The first operations concerning a bleeding ulcer of a stomach were
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made in Russia by prof. S.P. Fedorov in 1903. Now concerning acute

gastroduodenal bleedings at an ulcer of a stomach and duodenal intestine
thevagotomy(usuallytruncal)withaligationorunderrunningofableeding
vessel (ulcer) and one of variants of draining operations or resection of a
stomachtogetherwitherasionofanulcerareevenmoreoftencarriedout.
GASTRICULCER
Video
The gastric ulcer is the chronic disease with polycyclic passing. The
maintypicalofpepticulceristhepresenceofulcerousdefectinamucous
tunic.Oneofbasicplacesbelongsamongthegastroenterologydiseasesto
this pathology. Such phenomenon explained by not only considerable
distributionofdiseasebutalsothosedangerouscomplicationswhichalways
accompanygastriculcers.
Pic.Thepresenceofulcerousdefectinamucoustunic.
Etiologyandpathogenesis
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Frequencyofmorbidityonthepepticulceramongtheadultpopulation
is about 4 %. More frequent age in patients with gastric ulcers is 5060
years.
To development mechanism of disease is still not enough studied.
From a plenty of different theories in relation to genesis of peptic ulcer no
one able to explain the disease. So, each of such factors as neurogenic,
mechanical, inflammatory, vascular is present in the mechanism of
development of peptic ulcer. Consider for today, that disturbance between
thefactorsofaggressionanddefenseofmucoustunicarosepepticulcer.To
thefirstfactorsbelong:hydrochloricacid,pepsin,reversediffusionofionsof
hydrogen, products of lipid hyperoxidizing. To the second: mucus and
alkalinecomponentsofgastricjuice,propertyofepitheliumofmucoustunic
to permanent renewal, local blood flow of mucous tunic and submucous
membrane.
Intheterminalstageofmechanismoforiginofgastriculcersimportant
role has the peptic factor and disturbance of trophism of gastric wall as a
resultoflocalischemia.Itconfirmedbydecreasingofbloodflowinthewall
ofstomachatpatientswithulcerson3035%comparedtothenorm.Itis
proved, that a local and functional ischemia more frequent arises up on
smallcurvatureofstomachintheareasofectopyoftheantralmucoustunic
inacidforming.Exactlythereulcersappear.
Importantpartinulcerogenesisisactedbyduodenogastricrefluxand
gastritis. Also, gastrostasis can provoke hypergastrinaemia and
hypersecretionandformedgastriculcers.
Numeral scientific developments of the last years testify to the
important infectious factor in the mechanism of origin of peptic ulcer
conditioned,mainly,byhelicobacterpylori.
Pathomorphology
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Such stages of disease are distinguished: erosion, acute and chronic

ulcers.
Erosions, mainly, are plural. Their bottom as a result of formation of
muriatic haematine is black, edges infiltrated by leucocytes. A defect
usually does not penetrate outside muscular tissue of the mucous tunic. If
necrosis gets to more deep layers of wall of stomach, a acute ulcer
develops. It has a funnelshaped form. Bottom is also black, edges is
swelled. Chronic ulcers are mainly single, sometimes arrive to the serous
layer.Abottomissmooth,sometimeshilly,edgesislikeelevation,dense.
Classification
For today the most known classification of gastric ulcers by Johnson

(1965).Therearethreetypesofgastriculcersaredistinguished:Iulcersof
smallcurvature(for3cmhigherfromagoalkeeper)IIdoublelocalization
of ulcers simultaneously in a stomach and duodenum III ulcers of
goalkeeperpartofstomach(notfartheras3cmfromagoalkeeper).Inthe
areaofsmallcurvatureofbodyofstomachislocalized70,9%ulcers,ona
back wall, nearer to small curvature 4,8 %, in the area of cardial part
12,9 %, in a goalkeeper part 11,4 %. The ulcers of large curvature of
stomacharecasuistryandmeetinfrequently.
Clinicalmanagement
Thecomplaintsofpatientswiththegastriculceralwaysgivevaluable
information about the disease. The detailed analysis of their anamnesis
allowstopayattentiontothepossiblereasonsoforiginofulcer,timeofthe
firstcomplaints,tothechangesofsymptoms.
Pain. A pain symptom in the peptic ulcer disease is very important.
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There are typical passing for this disease: hunger pain food intake
facilitation again hunger pain food intake facilitation (so during all
days).Nightpainforthegastriculcerisnottypical.Thesuchpatientsrarely
wake up in order to take a food. For diagnostics of ulcer localization it is
important to know the time of appearance of pain. Between acceptance of
foodandappearanceofpainitistheshorter,thanthehigherplacedgastric
ulcer.Thus,atpatientswithacardialulcerpainarisesatonceafterthefood
intake, with the ulcers of small curvature in 5060 minutes, at pyloric
localizationapproximatelyintwohours.Howeverthisfeatureitisenough
relative and some patients in general do not mark dependence between
foodintakeandpain.Inotherpatientsthepainattackisaccompaniedbythe
salivation.
A epigastric region near the xiphoid process is typical localization of
pain.Theirradiationofpainisnotusualforgastriculcers.Irradiationoccurin
patients with penetration and depended from organ, in which an ulcer
penetrates.
Attheexaminationofulcerouspatientitisexpedienttodeterminethe
specialpainpoints:Boas(painatpressureontheleftoftheIIpectoral
vertebrae),Mendel(painatpercussiononthelefttoepigastricregion).
Vomiting,thesignofdisturbanceofmotilityfunctionofstomach,isthe
second typical symptom of gastric ulcer. More frequent gastrostasis arises
as a result of failure of stomach muscular, it atony which can be effect of
organischemia.Vomitingcouldarisesbothonemptystomachandafterfood
intake.
Heartburn is one of early symptoms of gastric ulcer, however at the
prolonged passing of disease it can be hidden or quite disappear. Often it
precedesofpainarising(initialheartburn)oraccompaniesapainsymptom.
Mostlyheartburnarisesafterthefoodintake,butcanappearindependently.
it is observed not only at hypersecretion of the hydrochloric acid, but at
normalsecretion,evenreducedacidityofgastricjuice.
The belching at gastric ulcers is examined rarely, more frequent in
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patients with cardial and subcardial ulcers. It is necessary to bind to

disturbanceoffunctionofcardialvalve.
Thegeneralconditionofpatientswiththeuncomplicatedgastriculcer
usually satisfactory, and in a period between the attacks even good.
Howeverformostpatientslostofthebodyweightandpalloraretypical.Ina
epigastric region hyperpigmental spots are examined after the prolonged
application of hotwater bottle. At palpation of stomach in this area
sometimes appears local painful. It is needed also to check up noise of
splash,thepresenceofwhichcanbethesignofpossiblegastrostasis.
At the examination of mouth cavity a tongue has whiteryellow
incrustation. In patients with penetration ulcers and disturbances
evacuationsfromastomachexamineddrynessoftongue.
Stomach, as a rule, regular rounded shape, however during the pain
attackispulledin.Thereisantiperistalsisarisesduringthepylorostenosis.
The increased secretion of hydrochloric acid in patients with gastric
ulcers observed rarely and, mainly, at prepyloric ulcer localizations. Mostly
secretionisnormal,andinsomepatientsisevenreduced.
XRay examination. The direct signs of ulcer at XRay examinations
are: symptom of Haudek's niche (Pic. 3.2.1), ulcerous billow and
convergenceoffoldsofmucoustunic.Indirectsigns:symptomofforefinger
(circularspasmofmuscles),segmentalhyperperistalsis,pylorospasm,delay
ofevacuationfromastomach,duodenogastricreflux,disturbanceoffunction
ofcardialpart(gastroesophagealreflux).
Gastroscopy can give important information about localization, sizes,
kindofulcer,dynamicsofitscicatrization,andalsoallowtoperformbiopsy
withsubsequenthistologicalexamination.
Clinicalvariantsandcomplication
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Thegastriculcerpassingcanbeacuteandchronic.Acuteulcersarise
as answer for the stress situations, related to the nervous overstrain,
trauma,lossofblood,someinfectiousandsomaticdiseases.Byadiameter
ulcers has from a few millimeters to centimeter, a round or oval form with
even edges. Thus in most cases clinically observed clear ulcerous clinical
signs. If complications is absent (bleeding, perforation) such ulcers treated
andmostlyhealover.
G.J.Burchynskyy(1965)suchvariantsofclinicalflowdistinguished:
1.Chroniculcerwhichdoesnothealoverlongtime.
2. Chronic ulcer which after the conservative therapy heals over
relatively easily, however inclined to the relapses after the periods of
remissionofadifferentduration.
3. Ulcers, which localization are had migrant character. Observed in
peoplewithacuteulcerousprocessofstomach.
4. Special form of gastric ulcer passing after the already carried
disease. Passed with the expressed pain syndrome. Characterized by the
presenceinplaceofulcerousdefectofscarsordeformationsandabsence
ofsymptomofniche.
There are such complications can develop in patients with gastric
ulcer:penetration,stenosis,perforation,bleedingandmalignization.
Diagnosisprogram
1.Anamnesisandphysicalexamination.
2.Endoscopy.
3.XRayexaminationofstomach.
4. Examination of gastric secretion by the method of aspiration of
gastriccontents.
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5.GastricpHmetry.
6.Multipositionbiopsyofedgesofulcerandmucoustunicofstomach.
7.GastricDopplerography.
8.Sonographyofabdominalcavityorgans.
9.Generalandbiochemicalbloodanalysis.
10.Coagulogram.
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Pic.SymptomofHaudek'sniche
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Pic.Pepticulcerofthestomach(endoscopy)
Differentialdiagnostics
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Chronic gastritis, as well as at an gastric ulcer, characterized by the

pain syndrome, that arises after the food intake. In such patients it is
possibletoobservenauseaandvomitingbygastriccontent,heartburnand
belch. However, unlike an gastric ulcer, for gastritis typical symptom of
quicksatiationbyafood.Unsteadyemptying,diarrheaalsomoreinherent
to gastritises. At gastric ulcer more frequent the delays are observed,
constipationfor45days.
The cancer of stomach, it is comparative with an gastric ulcer, has
considerably more short anamnesis. The most typical clinical signs of this
pathology are: absence of appetite, weight loss, rapid fatigability,
depression, unsociability, apathy. In such patients XRay examination
exposethedefectoffilling,relatedtoexophytictumoranddeformationof
wallsoforgan.Afinaldiagnosisissetaftertheresultsofmultipositionbiopsy
ofshadyareasofmucoustunicofstomach.
Differentialdiagnosticsalsoneedstobeconductedwiththesocalled
precancerous states: gastritis with the achlorhydria chronic, continuously
recurrenceulcers,poliposisandAddisonBiermeranemia.
Tacticandchoiceoftreatmentmethod
Conservative treatment of gastric ulcer always must be complex,

individually differentiated, according to the etiology, pathogeny, localization
of ulcer and character of clinical signs (disturbance of functions of
gastroduodenalorgans,complication,accompanyingdiseases).
Conservativetherapymustinclude:
Omeprazole20mg2timeperdayor2blockerhistamine
receptor(ranitidine)150mgintheevening,famotidine40
mgatnight,
roxatidine150mgintheevening
antiaciddrugsinaccordancewiththeresultsofpHmetry
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reparativedrugs(dalargin,solcoseryl,actovegin)for2ml
12timesperdays
antimicrobialdrugs(clarytromicine500mgtwicedaily,denol,
metronidazole)
Treatmentofpatientwithagastriculcermustcontinuesnotlessthan
68weeks.
Surgicaltreatmentmustperformedincases:
)attherelapseofulcerafterthecourseofconservativetherapy
) in the cases when the relapses arise during supporting antiulcer
therapy
)whenanulcerdoesnothealoverduring1,52monthsofintensive
treatment,especiallyinfamilieswithulcerousanamnesis.
)attherelapseofulcerinpatientswithcomplications(perforationor
bleeding)
)atsuspiciononmalignizationulcers,incaseofnegativecytological
analysis.
Thechoiceofmethodofsurgicaltreatmentofgastriculcerdepended
fromlocalizationandsizesofulcer,presenceofgastroandduodenostasis,
accompanyinggastritis,complicationsofpepticulcer(penetration,stenosis,
perforation, bleeding, malignization), age of patient, general condition and
accompanying diseases. In patients with cardial localization of ulcer the
operation of choice is the proximal resection of stomach, which, from one
side,allowstoremoveanulcer,andfromothertosaveconsiderablepart
oforgan,providingitfunctionalability(Pic.3.2.2).Incasewithlargecardial
ulcers, when the vagus nerves pulled in the inflammatory infiltrate and it is
impossible to save integrity even one of them, operation needs to be
complemented by pyloroplasty. It will give possibility to warn pylorospasm
andgastrostasis,whichinanearlypostoperativeperiodcanbethereason
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ofanastomosisinsufficiencyandothercomplications.
At the choice of method of surgical treatment of gastric ulcers with
subcardiallocalizationon small curvature without duodenostasis it is better
toapplythemethodsofstomachresectionwithsavingofpassagethrougha
duodenum.
Forthispurposewearedevelopedthemethodofsegmentalresection
of stomach with addition selective proximal vagotomy.The redistribution of
gastric blood flow between the functional parts of stomach as reply to
medicinal vagotomy (intravenous introduction 1,0 ml 0,1 % solution of
atropine of sulfate) is studied. Hyperemia of acidforming part of stomach
comes after introduction of preparation. The functional scopes of stomach
partsaredetermined.Theborderbetweenacidformingandantralpartsare
themostfrequentlocalizationofgastriculcers.
During this operation middle laparotomy is performed, intravenously
entered 1,0 ml 0,1 % solution of atropine, then the scopes of functional
stomachpartsareidentifiedandbystitchesholdersismarkedaintermedial
segment. Selective proximal vagotomy is performed. After mobilization of
large curvature of stomach within the limits of intermedial segment it
resectionisperformed.Afterthatgastrogastroanastomosisendtoendis
formed(Pic.3.2.3).
Theanalysisofsupervisionsofthepatientsoperatedbysuchmethod
in postoperative period has good results. It allows to recommend this
operation for clinical practice, in case of gastric ulcers of subcardial
localizations, without duodenostasis, penetration, malignization or nerves
Latarjetdamaging.
The operation of choice in patients with subcardial ulcers and
duodenostasisisgastricresectionbyBillrothII.
At the choice of method of surgical treatment of ulcers which are
localized in upper and middle third of stomach, it is necessary to consider
suchfactors,asabsenceofpenetrationinasmallomentumandabsenceof
the duodenostasis. In such patients is performed segmental resection of
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stomach with ulcer removing with selective proximal vagotomy. In case of

penetration ulcer in a small omentum with involvement in infiltrate Latarjet
nerves,suchoperationisimpossiblebecauseoffuturespasmofpylorusand
gastrostasis.Ifduodenostasisisabsencethanbettertoapplypylorussaving
resection by MakiShalimov. In patients with duodenostasis better to apply
gastricresectionbyBillrothII.
Attheborderofgastricresectionnearpyloricsphinctercanbespasm
and gastrostasis in a postoperative period . Avoiding such complication is
possible,ifthisborderofgastricresectionpassesnomorethan1,5cmfrom
a pyloric sphincter (M.M. Risaev, 1986). So, at a resection, that passes
higherthan2,0cmfromapylorus,integrityofbothloopsiskept.
Patients with antral ulcers without the duodenostasis performed the
gastricresectionbyBillrothI(Pic.3.2.6),andonpresenceofduodenostasis
BillrothII.
Prepiloriculcersissimilartotheulcersofduodenum.Suchlocalization
of gastric ulcers without malignization allow to perform selective proximal
vagotomy. However, at large prepyloric ulcers with penetration without
duodenostasisisbettertoperformthegastricresectionbyBillrothIandon
presenceofduodenostasisbyBillrothII.
Bycontraindicationtooperationswithsavingoffoodpassingthrough
the duodenum are also decompensated pylorostenosis , functional
gastrostasis and duodenostasis. In such patients it is better to perform
gastricresectionbyBillrothII.
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Pic.BillrothIandBillrothIIresection
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Pic.BillrothIreconstruction
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Pic.BillrothIIrecontruction
DUODENALULCER
The duodenal ulcer is the chronic recurrent disease which

characterizedbyulcerousdefectonamucoustunicofduodenum.Pathology
oftenmakesprogresswithcomplicationsdevelopment.
There are some etiologic factors of the duodenal ulcer: Helicobacter

pylori, emotion tension and neuropsychic stress overstrain, heredity and
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geneticinclination,presenceofchronicgastroduodenitis,disturbanceofdiet
and harmful habits (alcohol, smoking). In pathogenesis of peptic ulcer a
leading role is played disturbance of equilibrium between aggressive and
projective properties of secret of stomach and it mucous tunic. The
aggressive factors are vagus hyperfunctioning and hypergastrinemia
hyperproductionofhydrochloricacidandpepsin,andalsoreversediffusion
oftheions+,actionofbiliousacidsandisoleucine,toxinsandenzymesof
helicobacter pylori (HP). There are factors which are contribute to
ulcerogenic action: disturbance of motility of stomach and duodenum,
ischemiaofduodenum,andmetaplasiaoftheepithelium.
Pathomorphology
Morphogenesis of duodenal ulcer fundamentally does not differ from

ulcerinastomach.Chroniculcersaremainlysingle,islocalizedonthefront
or back wall of bulb (bulbar ulcer) and only in 78 % cases below it
(postbulbarulcer).Thepluralulcersofduodenumaremetin25%cases.
Classification
(byA.L.Hrebenev,A.O.Sheptulin,1989)
Theduodenalulcerisdivided:
I.Byetiology:
.Trueduodenalulcer.
.Symptomaticulcers.
II.Bypassingofdisease:
1.Acute(firstexposedulcer).
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2.Chronic:
a)withtherareexacerbation
b)withtheannualexacerbation
c) with the frequent exacerbation (2 times per a year and
morefrequent).
III.Bythestagesofdisease:
1.Exacerbation.
2.Scarring:
a)stageofredscar
b)stageofwhitescar.
3.Remission.
IV.Bylocalization:
1.Ulcersofbulbofduodenum.
2.Lowpostbulbarulcers.
3.Combinedulcersofduodenumandstomach.
V.Bysizes:
1.Smallulcersupto0,5cm.
2.Middleup1,5cm.
3.Largeupto3cm
4.Giantulcersover3cm.
VI.Bythepresenceofcomplications:
1.Bleeding.
2.Perforation.
3.Penetration.
4.Organicstenosis.
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5.Periduodenitis.
6.Malignization.
Clinicalmanagement
Pain in the epigastric region is the most expressed symptom of

duodenalulcer,oftenwithdisplacementtotherightintheprojectionareaof
bulb of duodenum and gallbladder. Also for this pathology is typical the
pain,thatarisesin1,52hoursafterfoodintake,hungryandnightlypain.
As a rule, it is acute, sometimes unendurable, and is halted only after the
useoffoodorwater.Suchpatientscomplainsfortheseasonalexacerbation,
morefrequentinspringandinautumn.Howeverexacerbationcanbealsoin
winter or in summer. In the acute period of disease heartburn often
increases. However heartburn is the frequent symptom of cardial
insufficiency and gastroesophageal reflux. For an duodenal ulcer the acute
burning feeling of acid in a esophagus, pharynx and even in the cavity of
mouthisespeciallytypical.Oftenarebelchbyairorsourcontent,excessive
salivation.Vomitingisnotatypicalsymptomforduodenalulcer.Moretypical
sign is nausea. Sometimes for facilitation patients wilfully cause vomiting.
Thesesymptoms,arisesinthelateperiodsofpassingofduodenalulcer.
Intensityofpainanddyspepsiasyndromesdependsbothonthedepth
ofpenetrationandfromdistributionofulcerousandperiulcerousprocesses.
Superficialulcerationwithinthemucoustunic,asarule,doesnotcausethe
pain because it does not have sensible receptors. However, more deep
layers of wall (muscular and especially serous) have plural sensible
vegetative receptors. Therefore, on deepening and distribution of process
arises visceral pain. At evident periulcerous processes and penetration of
ulcerstoneighboringorgansandtissues,usually,aparietalperitoneum,that
has spinal innervation, is pulled in. Pain becomes viscerosomatic, more
intensive.Asuchpainsyndrome(withanirradiationintheback)istypicalfor
lowpostbulbarulcersandbulbousulcersofbackwall,whichpenetratesina
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pancreas and hepatoduodenal ligament. Usually such patients has good

appetite.Someofthemlimitthemselvesinacceptanceofordinaryfood,go
intotothedietaryfeedbysmallportions,andsomeevenholdbackfrom
afood,beingafraidtoprovokepain,andasaresultofitweightislost.Some
ofpatientsfeedsmoreintensiveandoften.
The psychical status of patients often are changed as a
asthenoneurotic syndrome: irritates, decline of working capacity,
indisposition,hypochondria,abusiveness.
Aninspection,asarule,givesinsignificantinformation.Inmanycases
on the abdominal skin it is possible to notice hyperpigmentation after
applicationofhotwaterbottle.Duringthepainattackpatientsoftenoccupy
the forced position. At superficial palpation on the abdominal wall
determinedhyperesthesiainulcerprojection.Intheepigastricregion,during
deep palpation, it is possible to define pain and muscular tension, mostly
moderate intensity. There is important symptom of local percussion painful
(Mendelssymptom):percussionbyfingersinthesymmetricepigastricareas
provoke pain in the ulcer, which is increased after the deep breath. The
roentgenologicandendoscopicaremaindiagnosticmethods.Thesymptom
of ulcerous niche is a classic roentgenologic sign. It is depot of contrast
agent, which is corresponded to ulcerous defect, with clear contours and
lightbanktowhichconvergedfoldmucus.Cicatricialdeformationofbulbof
duodenumasashamrock,butterfly,narrowing,tube,diverticulumandother
forms is the important sign of chronic ulcerous process. A roentgenologic
method is especially important for determination of configuration and sizes
of stomach and duodenum, and also for estimation of motility functions. X
Ray examination is the main method at the peptic ulcer complicated by
stenosis, with disturbance of evacuation, duodenostasis, duodenalgastric
reflux, gastroesophageal reflux, diverticulum. But by XRay examination is
difficult to diagnose small superficial ulcers, acute ulcers, erosions,
gastritises and duodenitises. The most informing method in such cases it
endoscopy.
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During endoscopy examination it is possible to define localization,

form,sizesanddepthofulcer.Duringbleedinggrumes,trickleorpulsating
ofbloodareobserved.Byirrigationbystypticsolutions,bycryocoagulation,
by laser coagulation endoscopy allows to secure hemostasis. Endoscopy
allows to perform the biopsy of ulcer tissues for determination of possible
malignization.
Clinicalvariantsandcomplication
In patients with low postbulbar ulcers the clinical signs are more
expressed. It characterized by late (in 23 hours after food intake) and
intensivehungryandnightlypain,thatoftenirradiatetothebackandtothe
right hypochondrium. The postbulbar ulcers are inclined to more frequent
exacerbation,andalsotomorefrequentcomplications,such,aspenetration,
stenosisandbleeding.
Thearemorefrequentulcerousbleeding(thebulboushappenin20
25 % cases, postbulbar in 5075 %), perforations (1015 % cases).
Penetration,stenosisandmalignizationinpatientswithduodenalulcersare
observedrarely.
Penetration is frequent complication of low and postbulbar ulcers of
duodenum, which are placed on posterior, posterior superior and posterior
inferior walls. Penetrates, usually, deep chronic ulcers, by passing through
alllayersofduodenuminneighboringorgansandtissues(headofpancreas,
hepatoduodenal ligament, small and large omentum, gallbladder, liver).
Such penetration is accompanied by development of inflammatory process
intheneighboringorgansandsurroundingtissuesandformingofcicatrical
adhesions.Apainsyndromebecomesmoreintensive,permanentandoften
pain irradiated in the back. Sometimes in the area of penetration it is
possibletopalpatepainfullyinfiltrate.
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Diagnosticprogram
2.Endoscopy.
3.XRayexaminationofstomachandduodenum.
4.Generalandbiochemicalbloodanalysis.
5.Coagulogram.
Pic.Duodenoscopy
The duodenal ulcer must be differentiated from acute and

chroniccholecystitis, pancreatitis, gastroduodenitis. Endoscopy is help to
diagnoseduodenalulcer.
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Conservative treatment. In most patients after conservative treatment

anulcerhealsoverin46weeks.Warningofrelapsescanbecarriedoutby
onlysupportingtherapyduringmanyyears.
The best therapy of duodenal ulcer is associated with a helicobacter
infection, there is the use of antagonists of 2 receptors of histamine
(renitidine300mgintheeveningor150mgtwicefordaysfamotidine
40 mg in the evening or 20 mg twice for days nisatidine 300 mg in the
evening or 150 mg twice for days roxatidine 150 mg in the evening) in
combination with sucralfate (venter) for 1 three times for days and
antacid (almagel, maalox or gaviscon 1 dessertspoon in a 1 hour after
food intake).To this complex it is needed to add antibacterial preparations
(Denol1tabl.4timesperadayduring46weeks+oxacyllinefor0,5g4
timesperaday10days+Tryhopol(metronidazole)for0,5g4timesper
aday15days).
Intreatmentofduodenalulcerusedchinoliticsandmiolitics(atropine,
methacin,platyphyllin),andalsomesoprostol(200mg4timesperdays)and
omeprasole(20or40mgondays).
Such treatment of patients with the duodenal ulcer must be 46
weeks.Ifcomplicationsabsentsthereisnonecessityinthespecialdiet.
Because of appearance of new pharmaceutical preparations and
moderntherapeutictreatment,indicationtotheoperativemethodsnarrowed.
Butthenumberofacutecomplicationsofduodenalulcerdoesnotgodown,
especiallybleedingandperforationswhichrequiretheurgentsurgery.
Indicationstotheelectiveoperation:
1. Passing of duodenal ulcer with the frequent relapses which could
nottreatedconservatively.
2.Repeatedulcerousbleeding.
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3.Stenosisofoutcomepartofstomach.
4.Chronicpenetrationulcerswiththepainsyndrome.
5.Suspicionformalignizationulcers.
Methodsofsurgicaltreatment.
At patients with the duodenal ulcer three types of operations are
distinguished:
organsavingoperations
organsparingoperations
resection.
From them the better are: organsaving operations with vagotomy,
excisionofulceranddrainageoperation.
Typesofvagotomy:trunk(TrV)(Pic..3.2.7),selective(SV)(Pic.3.2.8),
selectiveproximal(SPV)(Pic.3.2.9).Selectiveproximalvagotomyisoptimal
intheelectivesurgeryofduodenalulcer.Howeverinurgentsurgeryatrunk,
selective or selective proximal is often used in combination with drainage
operations.
Drainage of the stomach operations are: HeinekeMikulicz
pyloroplasty,Finneypyloroplasty,submucouspyloroplastybyDiverBarden
Shalimov,gastroduodenostomybyJaboulay,gastroenteroanastomosis.
ItisnecessarytomarkthatcleanisolatedSPV,performedinpatients
with duodenal ulcer, often (in 1520 % cases) results in the relapses. The
considerably less number of relapses (810 %) is observed after SPV in
combinationswithdrainageoperations.Especiallydangerousistherelapses
of the ulcers placed in the projection of large duodenal papilla, after
gastroduodenostomybyJaboulay.
The least number of relapses of duodenal ulcer is observed after
organsavingoperations,thatcombineSPVandulcerexcision.
If ulcer localized on the anterior surface of duodenal bulb it can be
performed by the method Jade (Pic. 3.2.13) with subsequent to the
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pyloroplastybyHeinekeMikulich.
Atpatientswithdecompensatestenosisandexpresseddilatationand
by the atony of stomach it is needed to apply the classic resection of
stomachdependingonpossibledampingsyndromebyBillrothIorBillroth
II.
The choice of subtotal resection of stomach needs to be done at
suspicionformalignizationorathistologicalconfirmedmalignizationulcers.
Inaduodenumthisprocesshappensveryrarely.
Pic.Trunkvagotomy(TrV)
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Pic.Selectivevagotomy(SV)
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Pic.Selectiveproximalvagotomy(SPV)
Pic.HeinekeMikuliczpyloroplasty
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Pic.GastroduodenostomybyJaboulay
Pic.Finneypyloroplasty
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BLEEDINGGASTRODUODENALULCERS
Bleeding gastroduodenal ulcers are outpouring of blood in the

gastrointestinal tract cavity as a result of strengthening and distribution of
necrosisprocessintheulcerareatovesselswiththesubsequentmeltingof
theirwalls.
Complicationofpepticorduodenalulcerbybleedingiscriticalsituation
whichthreatenstolifeofpatientandrequiresfromthesurgeonofimmediate
and decisive actions for clarification of reasons of bleeding and choice of
tactic of treatment. The ulcerous bleeding has 60 % of the acute bleeding
fromtheupperpartsofgastrointestinaltract.
Theoriginofthegastrointestinalbleedingatpatientswithagastricor
duodenalulceralmostisalwaysrelatedtoexacerbationofulcerousprocess.
The reason of bleeding is a erosive vessel, that is on the bottom of ulcer.
The expressed inflammatory and sclerotic processes round the damaged
vessel embarrassed its contraction, that diminishes chances on the
spontaneousstopofbleeding.
Gastriculcers,comparewiththeulcersofduodenum,complicatedby
bleeding more frequent. Bleeding at gastric ulcers are more expressed,
profuse,withheavypassing.
Attheduodenalulcerbleedingmorefrequentcomplicatetheulcersof
backwall,whichpenetratesintheheadofpancreas.
Atthemenulceriscomplicatedbybleedingtwicemorefrequent,than
atwomen.Itcoststomarkthat80%patientswhichcarriedbleedingfroman
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ulcer and treated oneself by conservative preparations, are under the

permanentthreatoftherecurrentbleeding.
Pathomorphology
Strengthening of necrosis process are leading factors in the origin of

the ulcerous bleeding in the area of ulcerous crater with distribution of this
process to a vessel and subsequent melting of vascular wall activation of
fibrinolysisintissuesofstomachandduodenumischemiaoftissuesofwall
ofstomach.
Classification
Bleeding gastroduodenal ulcers after the degree of weight of loss of

blood(by..ShalimovandV.F.Saenko,1987)aredivided:
Idegreeiseasyobservedatthelossto20%volumeofcirculatory
blood(atapatientwithweightofbody70kgitisupto1000ml)
II degree middle weight is loss from 20 to 30 % volume of
circulatoryblood(10001500ml)
TheIIIdegreeisheavyisobservedatlossofbloodmorethan30%
volumeofcirculatoryblood(15002500ml).
Clinicalmanagement
At patients with an peptic ulcer disease, bleeding pops up, mainly at

night. Vomiting can be the first sign of it, mostly, at gastric localization of
ulcers. Vomiting masses, as a rule, looks like coffeegrounds. Sometimes
theyareasafreshredbloodoritsgrume.
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The black tarlike emptying are the permanent symptom of the

ulcerousbleeding,withanunpleasantsmell(melena),thatcantakeplace
toafewtimesperdays.
Bloody vomiting and emptying as melena is accompanied by
worseningofthegeneralconditionofpatient.Aacuteweakness,dizziness,
noiseinaheadanddarkeningineyes,sometimeslossofconsciousness.
A collapse with the signs of hemorrhagic shock can also develop. Exactly
withasuchclinicalpicturethesuchpatientsgettothehospital.Itisneeded
to remember, that for diagnostics anamnesis is very important. Find out
often, that at a patient an peptic ulcer was already diagnosed once. It
appears sometimes, that bleeding is repeated or surgery concerning a
perforated ulcer took place in the past. At some patients a gastric or
duodenum ulcer is was not diagnosed before, the however attentively
collectedanamnesisexposed,thatatapatienthadastomachache.Thusit
communication with acceptance of food and seasonality is typical (more
frequent appears in spring and in autumn). Patients tell, that pain in
overhead part of abdomen which disturbed a few days prior to bleeding
suddenlydisappearedafterfirstitsdisplays(theBergmann'ssymptom).
Atpatientswiththeulcerousbleedingtherearethetypicalchangesof
hemodynamicindexes:apulseisfrequent,weakfillingandtension,arterial
pressure is mostly reduced. These indexes need to be observed in a
dynamics,astheycanchangeduringtheshortintervaloftime.
Thereisthepallorofskinandvisiblemucoustunicsataexamination.
A stomach sometimes is moderately exaggerated, but more frequent is
pulled in, soft at palpation. In overhead part it is possible to notice
hyperpigmentalspotstracksfromtheprotractedapplicationofhotwater
bottle. Painful at deep palpation in the area of right hypochondrium
(duodenal ulcer) or in a epigastric area (gastric ulcer) it is possible to
observeatpenetratedulcers.ImportantsymptomofMendelalsopainful
atpercussionintheprojectionofpiloroduodenalarea.
Attheexaminationofpatientswiththegastrointestinalbleedingfinger
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examination of rectum is obligatory. It needs to be performed at the first

examination, because information about the presence of black excrement
(melena) more frequent get according to a patient anamnesis, that can
result in erroneous conclusions. Finger examination of rectum allows to
expose tracks of black excrement or blood. In addition, it is sometimes
possibletoexposethetumourofrectumorhaemorrhoidalknotswhichalso
arethesourceofbleeding.
The deciding value in establishment of diagnosis has the endoscopic
examination.Fibergastroduodenoscopyenablesnotonlytodenyorconfirm
the presence of bleeding but also, that it is especially important, to set its
reason and source. Often embarrassed the examination of stomach and
duodenumpresentinitbloodandcontent.Insuchcasesitisnecessaryto
remove blood or content, by gastric lavage, and to repeat endoscopic
examination.Duringtheexaminationoftenexposedthebleedingwithfresh
bloodfromthebottomofulcerorulcerousdefectwithoneorafewerosive
and thrombosed vessels (stopped bleeding). The bottom of ulcer can be
coveredbythepackageofblood.
Importantinformationaboutsuchpathologyisgivenbyhaematological
indexesalso.Diminishmentofnumberofredcorpusclesandhaemoglobinof
blood, decline of haematocritis is observed in such patients. However
alwaysneededtoremember,thatatfirsttimeafterbleedinghaematological
indexescanchangeinsignificantly.Conductingofglobalanalysisofbloodin
adynamicsineveryafewhoursismoreinforming.
Variantsofclinicalpassingandcomplication
Itisnecessaryalwaystorememberthatcomplicationofpepticulcerby
bleedinghappensconsiderablymorefrequent,thanisdiagnosed.Usually,to
5055%moderatebleeding(microbleeding)havethehiddenpassing.The
massive bleeding meet considerably rarer, however almost always run
acrosswiththebrightlyexpressedclinicalsignswhichoftencarriesdramatic
character. In fact profuse bleeding with the loss 5060 % to the volume of
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circulatorybloodcouldstoptheheartandcausethedeathofpatient.
Theclinicalsignsandpassingofdiseasedependonthedegreeoflost
ofblood(..ShalimovandV.F.Saenko,1987).
ForlostofbloodIdegreetypicalthereisafrequentpulseto90100,
decline of arterial pressure of to 90/60 mm Hg. The excitability of patient
changes by lethargy, however clear consciousness is, breathing some
frequent. After the stop of bleeding and in absent of hemorrhage
compensation the expressed disturbances of circulation of blood does not
observe.
At patients with the II degree of hemorrhage the general condition
needs to be estimated as average. Expressed pallor of skin, sticky sweat,
lethargy. Pulse 120130 per min., weak filling and tension, arterial
pressure 9080/50 mm Hg. At first hours the spasm of vessels
(centralization of circulation of blood) comes after bleeding, that
predetermines normal or increased, arterial pressure. However, as a result
oftheprotractedbleedingcompensatemechanismsofarterialpressureare
exhausted and can acutely go down at any point. Without the proper
compensationofhemorrhagethesuchpatientscansurvive,howeveralmost
always there are considerable disturbances of blood circulation with
disturbanceoffunctionsofliverandkidneys.
The III degree of hemorrhage characterizes heavy clinical passing.
Thereisapulseinsuchpatients130140permin.,andarterialpressure
from60to0mmHg.Consciousnessisalmostalwaysdarkened,acutely
expressedadynamy.Centralveinpressureislow.Oliguriaisobserved,that
canchangebyanuria.Withoutactiveanddirectedcorrectionofhemorrhage
apatientcandie.
But,notalwaysweightofbleedingwhichisconditionedbythedegree
ofhemorrhagecorrespondthegeneralconditionofpatient.Onoccasionthe
considerable loss of blood during the set time is accompanied by the
relatively satisfactory condition of patient. And vice versa, moderate
hemorrhagecanbringtotheconsiderableworseningofgeneralcondition.It
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can depend both on compensate possibilities of organism and from the

presenceofaccompanyingpathology.
It is needed to remember, that the ulcerous bleeding can
accompanying with the perforation of ulcer. During perforation ulcers are
often accompanied by bleeding. Correct diagnostics of these two
complicationshastheimportantvalueintacticalapproachandinthechoice
of method of surgical treatment. In fact simple suturing of perforated and
bleeding ulcer can complicated in postoperative period by the profuse
bleedingandcausethenecessityoftherepeatedoperation.
Diagnosisprogram
2.Fingerexaminationofrectum.
3.Gastroduodenoscopy.
4.Globalanalysisofblood.
5.Coagulogram.
6.7.Biochemicalbloodtest.
7.XRayexaminationofgastrointestinaltract.
8.Electrocardiography.
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Pic.Endoscopystoppedbleeding.
At wide introduction of gastroduodenoscopy of question of differential

diagnosticsofbleedinglosttheactuality.Howevermuchaproblemarisesup
at impossibility to execute this examination through the heavy general
condition of patient or taking into account other reasons. Differential
diagnosticsisconductedwithbleedingofunulcerousorigin,whichariseup
indifferentpartsofdigestivetract.
For bleeding from the varicose extended veins of esophagus during
portalhypertensionatpatientswiththecirrhosisoflivertheacutebeginning
without pain is characteristic, like during exacerbation of ulcerous disease.
These bleeding differ by the special massiveness and considerable
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hemorrhage. Vomiting by fresh blood, expressed tachycardia, falling of

arterialpressureareobserved.Insuchpatientsitispossibletofindthesigns
of cirrhosis of liver and portal hypertension (head of jellyfish,
hypersplenism,ascites,oftenisicterus).
Sliding hernia of the esophagus opening of diaphragm can be
accompaniedbyformationofulcersintheplaceofclenchofthestomachby
the legs of diaphragm and bleeding from them. However for this pathology
are more typical microbleeding, that is hidden. In such patients often the
present protracted anaemia which can achieve the critical values.
Sometimesinthemobservemoreexpressedbleedingwithclassicvomiting
coffeegrounds and melena. During the roentgenologic examination with
barium is possible to expose the signs of sliding hernia of the esophagus
opening:theobtusecardialangle,absenceordiminishmentofgasbubbleof
stomachorringingsymptom.
The cancer tumour of stomach in the destruction stage can be also
complicatedbybleeding.However,suchbleedingaremassive,andchronic
character is carried mostly with gradual growth of anaemia. For this
pathology there are the inherent worsenings of the general condition of
patient,lossofweightofbody,declineofappetiteandwaiverofmeatfood.
At the roentgenologic examination the defect of filling is exposed in a
stomach.
The gastric bleeding can be related to the diseases of the cardio
vascular system (atherosclerosis, hypertensive disease), however such
happens mainly in the older years people. Clearly, that in such patients
during the endoscopic examination the source of bleeding exposing is not
succeeded.
Among other diseases, with which it is necessary to differentiate the
ulcerous bleeding, it is needed to remember the MalloryWeiss syndrome,
benign tumours of stomach and duodenum (more frequent leiomyoma),
hemorrhagic gastritis, acute (stress) erosive defeats of stomach,
arteriovenousfistulaofmucoustunic.
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Often differential diagnostics performed according to the level of

localization of source of bleeding in different parts of gastrointestinal tract.
Fortheupperpartsofdigestivetract(esophagusandstomach)typicalthere
isvomitingbygrumeorcoffeegroundscontentandemptyingbymelena.
Thefartheraboralplacedsourceofbleeding,thebloodyemptyingchanges
the more so. During the bleeding from a thin bowel excrement looks as
melena.Incaseofsuchpathologyofcolon(polypuses,tumours,unspecific
ulcerouscolitis)emptyinghavetheappearanceoffreshredblood,mostlyas
packages.
The conservative therapy indicated to patients with the stopped

bleedingofIdegreeandbleedingoftheIIIIIdegreesatpatientswhichhave
heavyaccompanyingpathology,becauseofoperativerisk.
Conservativetherapymustinclude:
prescription of hemostatic preparations (intravenously the
aminocapronicacid5%200400ml,chlorouscalcium10%10,0ml,
vicasol1%3,0ml)
additiontothevolumeofcirculatoryblood(gelatin,poliglukine,salt
bloodsubstitutes)
preparationsofblood(fibrinogen23,cryoprecipitate)
blood substitutes therapy (red corpuscles mass, washed red
corpuscles,plasmaofblood)
antiulcerous preparations blocker of 2 receptor (ranitidine,
roxatidine,nasatidinefor150mg12timesperdays)
antacid and adsorbents (almagel, phosphalugel, maalox for 12
dessertspoonsthrough1hourafterfoodintake).
Itisexpedienttoapplywashingofstomachbywaterwithiceandthe
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use5%solutionofaminocapronicacidinwardfortoa1soupspooninevery
2030minutes.
The endoscopic methods of stop of bleeding are used also. Among
themmosteffectiveisalaserandelectrocoagulation.
Absolute indications to surgical treatment are: 1) lasting bleeding I
degree2)recurrentbleedingafterhemorrhageIdegree3)bleedingofthe
IIIIIdegrees4)stoppedbleedingwithhemorrhageoftheIIIIIdegreesat
the endoscopically exposed ulcerous defect with a presence on the ulcer
bottom thrombosed vessels or erosive vessels covered by the package of
blood.
The choice of method of surgical treatment always needs to be
decided individually. On today the best tactic which gives advantage to
organsavingandorgansparingmethodsofoperations.Theremovingulcer
as sources of bleeding must be an obligatory condition. The methods of
sewing of bleeding vessels or edging of ulcer and bandaging of vessels
which feed a stomach and duodenum did not justify itself through the real
threatofrelapseofbleedingalreadyinanearlypostoperativeperiod(912
days).
Palliative operations (cutting of ulcer, forming of roundabout
anastomosis)canbejustifiedonlytakingintoaccountthegeneralcondition
of patient and on a necessity as possible quick and least traumatically to
makeoffoperation.
At the bleeding ulcers of duodenum it is better to apply excision of
ulcer or it exteritirization after methods, developed by V.Zajtsev and
Velihotskyy. Operation complemented by one of types of vagotomy, it is
betterbyaselectiveproximalwithpiliroplastic.Theresectionofstomachon
the second or first method of Bilroth can be realized only in the stable
generalconditionofpatient.Duringtheresectionofstomachincaseoflow
bleeding duodenal ulcers it is better to execute mobilization of duodenum
and suturing of its stump on transcholedochus drainage which formed as
transcholedochus duodenotomy (Laqey, 1942). This method warns the
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possible intraoperative damages of choledoch, that are the possible at low

duodenal ulcers. Transcholedochus duodenotomy by performing the
decompression of stump of duodenum, warns insufficiency of its stitches,
thatcanariseupinanearlypostoperativeperiod.
Incaseofbleedinggastriculcers,theresectionmethodsofoperations
are also usable. Only on occasion, when patients has the grave general
condition,itispossibletoassumethewedgecuttingofulcer.
video
MALLORYWEISSSYNDROME
MalloryWeiss syndrome (MWS) is characterised by upper

gastrointestinal bleeding (UGIB) from mucosal lacerations in the upper
gastrointestinal tract (GIT) (usually at the gastrooesophageal junction or
gastric cardia). Mallory and Weiss described the syndrome in 1929 in
patientsretchingandvomitingafteranalcoholicbinge.
MWS may also occur with other events, causing a sudden rise in
intragastric pressure or gastric prolapse into the oesophagus. Sudden
increased pressure within the nondistensible lower oesophagus causes
tearing. It is a feature of about 10% (ranging from 1% to 15%) of upper
gastrointestinalbleedsandcausessignificanthypovolaemiainabout10%of
these.Thereappearstobeatrendtowardslessassociatedbloodlossand
lower mortality. It is often associated with hiatus hernia and is also
associatedwithalcoholismanddialysis.
Epidemiology
Inrecentyears,MWSmayhavebecomemorefrequent.
TheincidenceofUGIBisbetween47and116per100,000population
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(mostlyfromulcers).
MalloryWeiss tears cause approximately 315% of all episodes of
haematemesisinadults.Tearscanoccurinchildrenbutarelesscommon.
Thereisawideagerange.Itismostcommonbetweenage40and50
years.
PatientPlus
UpperGastrointestinalBleeding(includesRockallScore)
Thepredeterminingfactorsoforiginofsyndromeare:protractedwhooping,
attacks of cough, physical overstrain after the surplus food intake, alcohol with
vomiting,
chronic
diseases
of
stomach,
with
the
acute
increase
of intaragastric pressure as a result of discoordinated function of cardial and

pyloric sphincter, especially at older patients with atrophy gastritis.The increase
ofintaragastricpressurecauseschangeofbloodflowinthewallofthestretched
stomach. Spontaneous break of mucous tunic ofcardial part of stomach, is
accompaniedbybleedinginthegastrointestinaltractlumen.Thebreaktakesnot
only mucous tunic but also muscular layer, that weight of bleeding is
predetermined. Most often the breaks are localized on small curvature, on the
backwallofstomachandesophagus.
Classification
(by..Rumjantsev,1979)
1.Bylocalizationofbreak:a)esophagusb)cardioesophagealc)cardial.
2.Bytheamountofbreaks:
a)single
b)plural.
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3.Bythedepthofbreaks:
a)superficial(Idegree),whichpenetratetothesubmucosallayer
b)deep(IIdegree),whichtakemucusandsubmucosallayer
c) complete break (III degree) which is characterized by the break of all
layersoforgan.
4.Bythedegreeofhemorrhage:
a)easy
b)middle
in)heavy.
5.Byclinicalpassing:
1)simpleform
2)deliriousform:a)withthesignsofacutehepaticinsufficiencyb)without
thesignsofacutehepaticinsufficiency.
Causes
Excessivealcoholingestion.
Aspiriningestion.
Hiatusherniaisapredisposingfactor.Duringretchingorvomiting,the
transmuralpressuregradientisgreaterwithinthehiatusherniathantherest
ofthestomach.
Other precipitating factors include retching, vomiting, straining,
hiccuping, coughing, blunt abdominal trauma and cardiopulmonary
resuscitation.
Other gastrointestinal diseases (gastroenteritis, gastric outlet
obstruction,malrotation,volvulus).
Hyperemesisgravidarum.
Hepatitis(causesvomitingin1020%ofpatients).
Biliarydisease(gallstonesandcholecystitis).
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Renal disease vomiting is often associated with diseases affecting

thekidneys(fromurinarytractinfectionstorenalfailure).
Raised intracranial pressure may lead to vomiting (particularly in
children).
Cyclicalvomitingsyndrome.
Othercausesincludedrugs,andseverediabeticketoacidosis.
Iatrogenictearsareuncommon,evenwithahighincidenceofretching
duringendoscopy.Thereportedprevalenceis0.070.49%.Ithasalsobeen
reportedintransoesophagealechocardiography.
No apparent precipitating factor can be identified in about 25% of
patients.
Presentation
History
The classic presentation is of haematemesis following a bout of
retchingorvomiting.However,atearmayoccurafterasinglevomit.
Other symptoms include melaena, lightheadedness, dizziness, or
syncope, and features associated with the initial cause of the vomiting, eg
abdominalpain.
Examination
Therearenospecificphysicalsigns.
An assessment of the degree of blood loss should be made. The
RockallscoringsystemcanbeusedtoassessUGIB.Ascoreoflessthan3
isassociatedwithanexcellentprognosisand8oraboveanextremelypoor
prognosis.MWSisusuallyassociatedwithascoreof3orless.
Differentialdiagnosis
Haematemesis as a symptom has quite a long differential diagnosis.
The following are important to consider (particularly with the retching and
suddenbrightbleedingassociatedwithMWS):
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Boerhaave'ssyndrome(oesophagealrupture).
OthercausesofUGIBseeseparateUppergastrointestinalbleeding
(includesRockallScore)article.
Investigations
Endoscopy is the primary diagnostic investigation. Other relevant
investigationsinclude:
FBC,includinghaematocrittoassesstheseverityoftheinitialbleeding
episodeandtomonitorpatients.
Coagulation studies and platelet counts to detect coagulopathies and
thrombocytopenias (routine platelet count, prothrombin time, and activated
partialthromboplastintime).
Renal function, urea, creatinine, and electrolyte levels (to guide
intravenousfluidtherapy).
Crossmatching/ blood grouping and antibody screen (potential blood
transfusion).
Electrocardiogram and cardiac enzymes (may be indicated if
myocardialischaemiaissuspected).
Management
Initial management is described in the separate article Upper
gastrointestinalbleeding(includesRockallScore).
Initialassessmentandmanagement
Resuscitationisaprioritymaintainairway,providehighflowoxygen,
correctfluidlosses(placetwowideborecannulaeandalsosendbloodsat
thesametime).Initialfluidresuscitationmaybewithcrystalloidsorcolloids
give intravenous blood when 30% of circulating volume is lost. Major
haemorrhageprotocolsshouldbeinplace.
Once the patient is more stable take a history and perform an
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examination (as 'Examination', above) identify severity of blood loss and

treatanycomorbidconditions.
MWS usually follows a benign course but occasionally endoscopic
treatmentisrequiredtostopbleeding.Sclerotherapy,electrocoagulationand
nd:YAG laser treatment can all be used to arrest bleeding. Banding and
clippingtechniqueshavealsobeenused.
Clinicalmanagement
The main symptom of syndrome is bloody vomiting which the dyspeptic

signs preceded: nausea and unbloody vomiting. Sometimes patients complain
for pain in a epigastric area, in the lower part of thorax, which is related to
suddencardialandlowerpartofesophagusdistension.
Weight of bleeding depends on length and depth of breaks and caliber of
the damaged vessels. In one case at first the some dark blood is excreted and
only at the repeated vomiting is a lot of bright red blood. In other case at once
thereisvomitingbyabrightredblood.Sometimesbleedinglookedasthetarlike
emptying. The degree of hemorrhage and its weight is determined after the
generallyacceptedchart.
Takingintoaccountthatasyndromearisesupafteracceptanceofaplenty
of alcohol and food, the clinical forms of passing are distinguished: simple,
delirious,withthesignsofacutehepaticinsufficiency,withoutthesignsofacute
hepaticinsufficiency,thatmattersverymuchforthechoiceofmedicaltactic.
Urgent esophagogastroscopy is the basic method of diagnostics of
syndrome. During it in the cardial part of stomach or esophagus single or plural
fissures are diagnosed by length 0,54,0 cm, by width 0,50,8 cm which pass
longitudinally,bleeding.Theedgesofmucusroundafissuresswelled,elevated,
covered by a fibrin. Often the muscular layer of stomach or esophagus is the
bottomoffissure.
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Diagnosisprogram
1.Anamnesisandphisicalexamination.
2.Esophagogastroscopy.
4.Coagulogram.
5.GroupandRhesusfactorofblood.
Endoscopy
Ideally,endoscopyshouldbeperformedwithin24hours,astearsheal
rapidlyandmaynotbereadilyapparentatendoscopyafter23days.Proton
pump inhibitor (PPI) use is not recommended prior to diagnosis by
endoscopy.
535% of patients require some form of intervention, usually
endoscopic.
Mostpatients(>80%)presentwithasingletear.Thetearisusuallyjust
below the gastrooesophageal junction on the lesser curvature of the
stomach.
Tears are usually associated with other mucosal lesions (83% of
patients). These may contribute to bleeding and/or cause the retching and
vomiting. Endoscopic examination should be thorough because such co
existinglesionsarecommon.
Several endoscopic modalities are effective for treating a bleeding
MalloryWeiss tear. Injection therapy is often regarded as the firstline
therapy.
Fasting is restricted to haemodynamically unstable patients and to
thosewhorequirerepeatendoscopy.
Patients can resume oral intake following endoscopy (starting with a
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liquid diet and advancing as tolerated to a normal diet) within 48 hours

(unlessnauseaorvomitingisaproblem).
Postinitialendoscopy
Calculatethefull(postendoscopic)RockallScore,asdescribedinthe
Upper gastrointestinal bleeding (includes Rockall Score) separate article
score <3 is associated with low risk of rebleeding or death and can be
consideredforearlydischarge,whereasascore>3indicatespatientsneed
furthercloseobservationasaninpatient.
Careful monitoring is needed after endoscopy for UGIB (pulse, blood
pressure, urine output). It is imperative to identify rebleeding or continuing
bleeding.
Patients with clinical risk factors for rebleeding (for example, portal
hypertension, coagulopathy) comprise about 10% of cases. These and
those with certain endoscopic findings (nonbleeding visible vessel,
pigmentedprotuberance,oradherentclot)shouldbeobservedfor48hours.
Ifpatientsarestable46hoursafterendoscopytheyshouldbeputon
alightdiet,asthereisnobenefitincontinuedfasting.
Ifrebleedingoccurs,itusuallytakesplacewithin48hours.Shockat
initial manifestation and active bleeding at endoscopy are independent risk
factorspredictingrecurrentbleedinginpatientswithMWS.[3]
Conservative treatment of the MalloryWeiss syndrome is indicated at the

small rupture of mucus stomach, to the stop of bleeding, absence of bleeding.
Treatment of patients is begun with active conservative therapy, which includes
blood
transfusion,
infusion
of
hemostatic,
application
of
antacid, Meulengracht's diet. At the rupture of the III degrees

indicated endoscopy by amonopolar electrocoagulation of the fissure and
covering of aerosol filmforming preparation Lifusol.The conservative method of
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stopofbleedinginsuchpatientsisespeciallyperspective,becausemostofthem
hasthedeliriousstateoracutehepaticinsufficiency.
Operative treatment is indicated at the deep large ruptures of mucus and
muscular layers, cardial part of stomach, which are complicated by bleeding. In
suchcasesconductgastrotomyandsuturingofrapturesbyinterruptedsutureor
8shapedstitch,applyingnonabsorbablefilaments.Sewingsofrupturesofmucus
stomach often supplement with vagotomy with pyloroplasty.At deep, especially
plural ruptures which are accompanied by the edema of tissues, sewing of
rupturesissupplementwithbandagingofleftgastricartery.
Complications
Theserelateto:
Symptoms:
Vomiting (hypokalaemia and other metabolic disturbance, aspiration
pneumonia,perforationandmediastinitis).
Severityofbleeding:
Hypovolaemicshock,anddeath(veryrarewithgoodcare).
Myocardialischaemiaorinfarction.
Comorbidities:
Myocardial ischaemia (precipitating, for example, myocardial
infarction).
Hepatitis(precipitating,forexample,liverfailure).
Renaldisease(precipitating,forexample,renalfailure).
Diabetes(worseningcontrolanddiabeticcoma).
Treatmentorinvestigation:
Endoscopy (mediastinitis, aspiration pneumonia, perforation or
aggravationofbleeding).
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Angiotherapy (organ ischaemia and infarction, aggravation of

bleeding).
Prognosis
The prognosis is generally excellent. Most patients usually stop
bleeding spontaneously and the tears heal rapidly, usually within 4872
hours.
However, bleeding is variable and can range from a few specks or
streaks of blood mixed with mucus to large amounts of fresh blood. Shock
occursinadultsinasmanyas20%butismuchlesscommoninchildren.
Associated diseases may have a significant effect on prognosis for
example,cirrhosiscarriesaverypoorprognosis.
Prevention
Recurrence is rare but it makes sense to counsel patients about
precipitating factors (for example, binge drinking, alcohol consumption,
excessive straining and lifting, violent coughing) that may lead to a
recurrenceandaregenerallyhazardoustohealth.Riskfactorsforrecurrent
bleedinginclude:
Initialpresentationofshock.
Livercirrhosis.
Decreasedhaemoglobinandplateletcount.
Needforbloodtransfusion.
Intensivecaremanagement.
Activebleedingnotedatthetimeofendoscopy.
CANCEROFSTOMACH
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The cancer of stomach is a malignant formation, that develops from

epithelium tissue of mucus stomach. Among the tumours of organs of
digestion this pathology takes first place and is the most frequent, by the
reason of death from malignant formations in many countries of world.
Frequencyofitatthelast30yearsconsiderablydiminishedinthecountries
of Western Europe and North America, but yet remains high in Japan,
China,countriesofEastEuropeandSouthAmerica.
Etiology of cancer of stomach is unknown. It is known that, as other
diseases of gastrointestinal tract, a cancer damages a stomach.According
tostatisticalinformation,itmeetsapproximatelyin40%ofalllocalizationsof
cancer.
Thefactorsofexternalenvironmenthasthesubstantialinfluencingon
frequency of this pathology. Above all things, feed, smoke food, salting,
freezing of products and their contamination of aflatoxin. Consider that a
foodfactorcanbe:a)byacarcinogenb)bythesolventofcarcinogensc)
togrowintoacarcinogenintheprocessofdigestiond)tobeinstrumentalin
actionofcarcinogense)notenoughtoneutralizecarcinogens.
In the USA and countries of Western Europe frequency of cancer of
stomach in 2 times more large in the lower socioeconomic groups of
population.Someprofessionalgroupsalsocanit(miners,farmers,worksof
rubber,
woodworking
and
asbestine
industry).
High
correlation
communication is set between frequency of cancer of stomach and use of

alcohol and smoking. The value of genetic factors (heredity, blood type) is
notledto.
The cancer of stomach arises up mainly in age 60 years and above,
morefrequentmenareill.
Precancer. The precancer diseases of stomach are: a) chronic
metaplastic disregenerator gastritis conditioned by helicobacter pylori b)
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villouspolypusesofstomachandchroniculcersc)nutritionalanemiadueto
vitamin B12 deficiency (pernicious) d) resected stomach concerning an
ulcer.
The presence of precancer changes of mucous tunic of stomach has
substantial influence for frequency of stomach cancer. In those countries,
where morbidity on the cancer of stomach is higher, considerably more
frequent chronic gastritises are diagnosed. Lately in etiology of chronic
gastritisestaketheimportantvaluehelicbacterpylori.InJapan,wherethe
cancerofstomachisin40%casesisthereasonofdeath,chronicgastritis
appearsin80%casesofresectedstomach,concerningacancer.
Connection between polypuses, chronic gastric ulcers and possible it
malignization comes into question in literature during many decades. Most
authors consider that polypuses could be malignant differently. There are
three histological types of polypuses: hyperplastic, villous and hamartoma.
Therearehyperplasticpolypuses,butitnotmalignant.
Hamartoma is accumulation of cells of normal mucous tunic of
stomach.Theyneverbecomesmalignant.
Villous polypuses are potentially malignant in 40 % cases, but it
happenin10timesless,thanhyperplastic.Thepossibilityofmalignizationof
chronic gastric ulcers is not proved. The American scientists support a
hypothesis, that the cancer of stomach can be ulcerous often, but
malignizationofulcerstakesplacerarely(nomorethan3%).Fromdataof
theJapanesescientists,on5070ththerewashighercorrelationconnection
betweenchronicgastriculcersandcancerofstomach.Thefrequentdecline
ofthiscorrelationislatelynoticed(70%on5070thand10%on80th).
Frequency of cancer of stomach at patients with pernicious anaemia
hesitates within the 510 %, that in 20 times higher, compare with control
population. In patients with a resected stomach after peptic ulcers is
multipliedtheriskoforiginofstomachcancerin23times(durationoflatent
periodhesitatesfrom15to40years).Thereasonofsuchdependenceisnot
foundout,butthereisaversion,thatthisislinkedwithagastricepithelium
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metaplasiabyanintestinaltype.
Pathomorphology
Fromallmalignantformationsofthestomachin95%adenocarcinoma
is observed. Epidermoid cancer, adenoacanthoma and carcinoid tumours
donotexceed1%.Frequencyofleiomyosarcomahesitateswithinthelimits
of13%.Lymphomaofgastrointestinaltractislocalizedinastomach.
The prognosis of localization depends on the degree of invasion,
histologicalvariantsoftumour.
The macroscopic forms of cancer of stomach in different times were
described variously. More than 60 years ago the German pathologist
Bermanndescribed5macroscopicformsofcancerofstomach:1)polypoid
or mushroomlike 2) saucershaped or with ulcerous and expressly salient
edges 3) with ulcerous and infiltration of walls of stomach 4) diffuse
infiltrate5)unclassified.
American pathopsychologs is selected 4 forms. The tumours of
stomachwithulcerousarethemostfrequentmacroscopicformofcancerof
stomach and arise up on soil of chronic ulcer. The signs suspicious on
malignization are: the sizes of ulcer more than 2 cm in a diameter,
appearanceoftheheightenededges.
The polypoid tumours of stomach observed only in 10 %. These
tumourscanachieveconsiderablesizeswithoutaninvasionandmetastasis.
Scirrhouscarcinomaisthethirdmacroscopictype.Thiscategoryoftumours
also does not exceed 10 %. The scirrhous carcinoma is the signs of
infiltration by anaplastic cancer cells, diffusely developed connecting tissue
which results in the bulge and rigidity of wall of stomach. So called small
cancers belong to the fourth macroscopic type. It meet comparative rarely
(no more than 5 %) and is characterized by superficial accumulation of
cancer cells which substitute for normal mucus in such kind: a) superficial
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flatlayerwhichdoesnotriseabovethelevelofmucusb)salient(bursting)
formationc)erosions.
Mainly(morethan50%)tumoursariseupinaantralpartorindistal
(lower)thirdofstomach,rarer(to15%)inabodyandincardia(to25%).
However, lately more often observed cardioesophageal cancers and
diminishment of frequency of tumours of distal parts of stomach. In 2 %
cases meet the multicentric focuses of growth, but from data of some
authors, this percent could be multiplied in 10 times after carefully
histologicalinspectionoftheresectedstomaches.Thisassertionisbasedon
thetheoryofthetumourfield(D.I.Holovin,1992).Especiallythistypically
for patients which has pernicious anaemia or chronic metaplastic
disregenerativegastritis.
Metastasis is carried out by lymphogenic, hematogenic and
implantationwaysmostly.Three(fromdataofsomeauthors,four)poolsof
lymphogenicmetastasisareselected:leftgastric(knotsonpassingofsmall
curvature of stomach in a gastrosubgastric ligament and pericardial)
splenic (mainly, suprainfrapancreatic knots) hepatic (knots in a hepato
duodenal ligament, right gastric omentum that lower pyloric groups, right
gastricandsuprapyloricgroups,pancreatoduodenalgroup).
However, the such way of lymphogenic metastasis is conditional and
incomplete, as at presence of block lymph flow passes retrograde
metastasis,socalledjumpingmetastaseswhichpredeterminetheoriginof
remotelymphogenicmetastasesinleftsupraclavicularlymphnodes(Virhov
metastasis) appear, in Lymph nodes of left axillar and inguinal areas,
metastasesinaumbilicus.
Direct distribution: small and large omentum, esophagus and
duodenumliveranddiaphragmpancreas,spleen,bileducts.
Frontwallofstomach:colonbowelandmesocolonorgansandtissues
ofretroperitonealspace.
Lymphogenicmetastasis:regionallymphnodes,remotelymphnodes,
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leftsupraclavicularlymphnode(Virhov),lymphnodeofaxillararea(Irish)in
aumbilicus(sistersJoseph).
Hematogenicmetastasis:liver,lungs,bones,cerebrum.
Peritoneal metastasis: peritoneum, ovarium (the Krukenberg
metastasis),Duglasspace(theShniclermetastasis).
Classification(bysystemofNM)
primarytumour.
0isaprimarytumourisnotdetermined.
notenoughdataforestimationofprimarytumour.
isisinvasivecarcinoma:intraepithelialtumourwithouttheinvasionof
ownshellmucus(Carcinomainsitu).
1isatumourinfiltratethewallofstomachtothesubmucouslayer.
2isatumourdamagesmucus,submucousandmuscularlayers.
3isatumourgerminatesinaserousshell.
4isatumourpassestotheneighbouringstructures.
Nareregionallymphaticnodes.
Nnotenoughinformationforthedamageassessmentoflymphatic
nodes.
Nmetastasesinregionallymphnodesarenotpresent.
N1aredamagedperigastrallymphnodesinthedistancenomorethan
3cmfromaprimarytumouralongsmallorlargecurvatureofstomach.
N2aredamagedperigastrallymphnodesinthedistancemorethan3
cmfromaprimarytumour,whichcanberemotedduringoperation,including
lymph nodes placed along left gastric, splenic, abdominal and general
hepaticarteries.
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isremotemetastases.
notenoughinformationforestimationofremotemetastases.
remotemetastasesarenotpresent.
1ispresenceofremotemetastases.
Groupmentbystages
Stage0NoMo.
StageI12NoMo.
StageIIT23NoMo.
StageIIIT14N12Mo.
StageIVanyT,anyNM1.
Exceptforclinicalclassification(NMorTNM),forthemostdetailed
study pathological classification (postsurgical, posthistological) which is
signedN.
Ghistopathologicaldifferentiation:
G1isthewelldifferentiatedtumour
G2isthemoderatelydifferentiatedtumour
G34itisbadlyorundifferentiatedtumour.
Clinicalmanagement
All authors which are engaged in the study of problem of cancer of

stomach underline absence or vagueness, no specificity of symptoms,
especiallyontheearlystagesofdisease.Thedisplaysofcancerofstomach
are very various and depend on localization of tumour, character of its
growth, morphological structure, distribution on contiguous organs and
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tissues.Atlocalizationoftumourinacardialpartpatientcomplainsfirstly,as
arule,forappearanceofdysphagy.
At careful, purposeful collection of anamnesis it is not succeeded to
exposesomeother,mostearlysymptoms,whichprecedestodysphagyand
forces a patient to appeal to the doctor. The unpleasant feeling behind a
breastboneandfeelingofunpassingofhardfoodonaesophagusappearat
the beginning of disease.After some time (as a rule, it is enough quickly,
duringafewweeks,sometimesevendays)ahardfooddoesnotpass(itis
to wash down by water or other liquid). This period can be during 13
months. Patients address a doctor exactly in this period. Other symptoms
appeartothistime:regurgitation,painbehindabreastbone,lossofmassof
body, sometimes even exhaustion, the grey colouring of person, a skin is
dry,quicklygrowsgeneralweakness.Sometimespatientsaddressadoctor,
when already with large effort a spoonmeat passes only or complete
stenosiscame.
At localization of tumour in the antral part of stomach the first
complaints,asarule,areuptoappearanceoffeelingofweightinepigastric
region after the reception of food (even in a twobit), feeling of saturation
(after the reception of glass of water), belch (at first it is simple by air, and
then with a smell). Feeling of weight grows for a day, patients forced to
cause vomiting. In the morning there can be vomiting by mucus with the
admixtures of coffeegrounds (so called cancer water). Patients loses
weight(massofbodyislost),aweakness,anaemiagrows.
Tumours localized in the body of stomach show up either a pain
syndrome or syndrome of so called small signs (.I. Savitskyy, 1947),
which is characterized by appearance of amotivational general weakness,
declineofcapacity,rapidfatigueability,depression(bythelossofinterestto
the environment), proof decline of appetite, gastric discomfort, making
progressweightlost.
Thecarriedchronicdiseasesofstomach,forwhichtypicalseasonality,
can influence on the clinical sign of cancer of stomach. At appearance of
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gastriccomplaintsoutofseasonorinabsentofeffectfromthegottherapy
concerningtheexacerbationofgastritis,ulcersmustguardapatientand
doctor(symptomofprecipiceofgastricanamnesis).
In case of occurring of gastric symptoms first in persons in age 50
yearsandolderitisforemostnecessarytoeliminatethecancerofstomach.
In parts of patients cancer of stomach shows up only the metastatic
damage of other organs or complications. More than twenty so called
atypical forms, which are characterized by causeless anaemia, ascites,
icterus, fever, edemata, hormonal disturbances, changes of carbohydrate
exchange,intestinalsymptoms,aredistinguished.
During the examination of patients with the cancer of stomach the
pallor of skin covers (at anaemia) is observed, in neglected case is frog
stomach(signofascites).
During palpation determined painful in a epigastric area, sometimes
possibletopalpatethetumour.
During auscultation of patients with pylorostenosis it is possible to
definenoiseofsplash.
Laboratory
information:
hypochromic
anaemia,
neutrophilic
leukocytosis, megascopic ESR during examination of gastric secretion:

hypoandanacidityandachlorhydria.
Gastroduodenoscopy enables to diagnose a tumour even smaller 5
mmandconductanaimingbiopsywithhistologicalexaminationofthetaken
material.
Roentgenoscopyandroentgenographyexaminationofstomach.Basic
signs: defect of filling, local absence of peristalsis, malignant relief of
mucoustunic(Pic.3.2.18).
Ultrasonicexamination:presenceofmetastasesinaliver,pancreas.
Computer tomography allows to estimate the basic parameters of
tumour,germinationinneighbouringorgansandpresenceofmetastases.
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It is expedient to apply laparoscopy, mainly, for the decision of

question about operable of tumour (diagnostics of metastatic defeat of
organsofabdominalcavity).
Diagnosisprogram
1.Anamnesisandphysicalmethodsofexamination.
2.Roentgenologicexaminationofstomach.
3. Endoscopic examination with a biopsy (if necessary from a few
placesandevenrepeatedly),cytologicandhistologicalexamination.
4.Sonography,computertomography.
5.Laboratory,radioisotopemethodsofexamination.
6.Laparoscopy.
7.Diagnostic(therapeutic)laparotomy.
At an early cancer complaints depend on the previous gastric

diseases.Therefore,onthebasisofclinicalinformation,suspectingatumour
ispossibleonlyonoccasion,wheninpatientsnexttoclearpainsymptoms
anappetitegoesdown,appearanaemia,generalweakness.Inpracticean
earlycancerisrecognizedatpurposefulscreening,andalsointheprocess
ofendoscopicorroentgenologicexaminationofgastricpatients.
A differential diagnosis is conducted with an peptic ulcer, gastritis,
polyposis,othergastricandungastricdiseases.Foracancerthereistypical
firmness of symptoms, instead of their seasonality (typical syndrome of
precipiceofgastricanamnesis)ortendencytotheirgradualprogress.
The row of diseases, with which the cancer of stomach is to
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differentiatetothedoctor,dependsfromcharacterofcomplaintsofpatients.
Fivebasicclinicalsyndromesareselected:
1)pain
2)gastricdiscomfort
3)anaemic
4)dysphagic
5)disturbanceofevacuationfromastomach.
Atpatients,atwhatcancerofstomachshowsupapainsyndromeand
syndromeofgastricdiscomfort,adifferentialdiagnosisisconductedwiththe
pepticulcer,gastritis,cancerofbodyofpancreas.
Itisorientedonfeaturesdynamicsofdevelopmentofpainsyndrome,
ingravescentofthegeneralcondition,changeofcharacterofcomplaints.
Aquestionaboutcharacterofanaemia,sourceandnatureofbleeding
decidesatananaemicsyndrome.Intheprocessofexaminationattentionis
paidtothestateofbottomofstomach,wherebleedingmalignantformations
canbe.
Atadysphagicsyndromeadifferentialdiagnosisisconductedwiththe
cicatrical narrowing, achalasia of esophagus. For malignant formations
testify short anamnesis, gradual progress of symptoms, signs of gastric
discomfort,generalweakness,weightlost.
Atdisturbanceofevacuationfromastomachduringstenosisofpyloric
part, absence of ulcerous anamnesis, declining years of patients, relatively
quick(weeks,months)growthofstenosistestifyfortumor.
Tacticandchoiceofmethodofsurgicaltreatment
The presence of cancer of stomach is a indications for surgical

treatment.However,countingonsuccessispossibleonlyatpresenceofthe
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limited tumours (within the limits of the 0II stages). At the III stage of
diseaseimplementationofthewidespreadcombinedoperationsinaradical
volumeispossible,howevermostpatientsdieduring12years.Adistalor
proximalsubtotalresection(Pic.3.2.19)andtotalgastrectomy(Pic.3.2.20)
is performed with removing of large and small omentumes and regional
areas of metastasis with obligatory histological examination of stomach on
thelinesofresections.
During the combined operations organs which are pulled in to the
pathologicalprocessareremoved.
In case of IV stage of disease and satisfactory state of patient
palliativeoperationswhichimprovequalityoflifeofpatientareperformed.
In case of presence of complications (mainly stenosis) and grave
commonconditionofpatientperformsymptomaticoperativetreatments.
Symptomatic is operations which will liquidate one of symptoms of
cancer of stomach. In this group of operations include: 1) roundabout
gastrojejunoanastomosis (Pic. 3.2.21) and jejunostoma (in case of the
stenosistumoursofstomachoutput)2)gastrostoma(Pic.3.2.22)incaseof
thecancerofcardialpartofstomachwithdisturbanceofpatency3)edging
of bleeding vessels in case of complication of cancer by bleeding 4)
tamponadebyomentumduringtheperforationoftumour.
The value of radial therapy and chemotherapy, as independent
methods of treatment of cancer of stomach, is limited. Radial therapy is
indicated for patients with cardial cancer as preoperative course or as
palliative treatment. Adjuvant mono or polychemotherapy (mainly by 5
phtoruracil)isconductedinapostoperativeperiodascombinedtherapyand
incaseofdisseminationofthetumours.
Prognosis.Theindexesoffiveyearsurvivalofpatientswiththecancer
of stomach hesitate within the limits of 530 %, but, from data of most
authors,theydonotexceed10%.
Hemorrhagicerosivegastritis
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Hemorrhagic erosive gastritis is diffuse bleeding from mucous tunic

stomach as a result of single or plural superficial defects (erosions) of mucous
tunic.Thegastrointestinalbleedingduringerosivegastritismeetinaclinicin13
17 % cases of acute hemorrhage in a gastrointestinal tract and take first place
among bleeding of unulcerous etiology. The disease is met both at men and at
women,butmorefrequentobserveindecliningyears.
Thespasmoflargevesselsinthedeeplayersofgastricwall,whichresults
indisturbanceoflocalmicrocirculation,hypoxiaandincreasesofpermeabilityof
vascular wall, matters in etiology and pathogenesis of hemorrhage erosive
gastritis.Thelocalreactioncausesstrengtheningofreversediffusionofhydrogen
ions,liberationofpepsin,histamine.Suchprocessoftenisconsequenceoflocal
damagingfactoractionofmedicinalortoxicfactorsforthevesselsofmucus.
Damaging factor could be the matters which violate a blood flow in mucus
stomach(aspirin,reserpine,hormonesofadrenalglandscortex).Thelargevalue
informationoferosionsishadbytheanatomicfeaturesofbloodflowofstomach
in a cardial part on small curvature. In connection with absence
ofsubmucosalvascularplexus,eventualvesselsonsmallcurvaturearedisposed
in relation to mucus tangentially. It results in shelling of epithelium, origin of
erosions. Veins damaged at first, that predetermines a hemorrhage and then
bleeding.Intheoriginofacutehemorrhagegastritismatteralsoacutedamageof
mucus stomach by mechanical, chemical (burns) and other factors,
accompanyingdiseases(uremiaandotherslikethat).
Clinicalmanagement
For hemorrhage erosive gastritis there are typical two clinical syndromes:
ulcerous and hemorrhagic. The ulcerous syndrome is the most frequent sign of
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hemorrhage gastritis. Typical ulcerous pain is observed in such patients. A

hemorrhagic syndrome shows up by the repeated gastric bleeding and
moderately increasing anaemia. Bleeding are capillary and are not such
catastrophic,asatgastriculcers.
The clinical picture of hemorrhage gastritis is characterized by dull pain
in a epigastric area, which appears at faults in a food, reception of
alcohol.Patientsdisturbsvomitinglikecoffeegrounds,melena,whichariseup
among a complete health, symptoms of hemorrhage (dizziness, general
weakness, acceleration of pulse, decline of arterial pressure). The decline of
amount
of
red
corpuscles
test,
haemoglobin,
is
observed
haemathokritis,
in
leukocytosis.
the
blood
During
the roentgenologic examination observed the thickened winding folds of mucus

stomach with the small depots of barium.At endoscopic diagnostics of bleeding
thepresenceofsingleorpluralerosionsonmucusupto57mmindiameterare
noticed,symptomofmorningdew(weepsallmucusstomach).
Diagnosisprogram
1.Anamnesisandphisicalexamination.
2.XRayexaminationofstomach.
3.Endoscopy.
5.Coagulograma.
6.Groupandrhesusbelongingofblood.
Treatmentofhemorrhageerosivegastritis,mainly,isconservative.Washing
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of stomach an effective by cold water or by 5 % solution of aminocapronic acid

with subsequent irrigation of mucous tunic by filmforming preparations through
endoscope and introduction of hemostatic. It is important the neutralization of
hydrochloric acid in a stomach (antacid, additional introduction of atropine of
sulfate, aspiration of gastric content), setting of preparations which stimulate
reparative processes in a mucous tunic (methyluracyl, sayotek, seabuckthorn
oil), antihelicobacter preparation (denol). If under the endoscopy control effect
from conservative treatment is absent and it is the obvious threat of life of the
patients,operativetreatmentisindicated.
Surgicaltreatmentmustbeminimum.Sewingandedgingofbleedingareas,
selectivevagotomywithpyloroplastyinmostcasesiseffective.Onlyatbleeding
from arising acute erosions after submucosal telangiectasia, indicated resection
ofstomach.Itisneededtoremember,thattheadditionalfocusofbleedingcanbe
in fundal and cardial part of stomach. Without their edging and
localhemostasis operation can not be radical. At the considerable damage of
stomach by an erosive process, for a patient indicated resection of stomach
orgastrectomy.
Tacticsatbleedingfromthevaricoseveinsofesophagus
(Fig.7.)
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Fig.7.Varicealhemorrhage
Treatmentofpatientsatbleedingfromthevaricoseveinsofesophagusneeds
tobebegunwiththetamponadeinternalsurfaceofesophagusandcardialpartof
stomach by the special doubleballoon SengstakenBlakemore tube (Fig.8
Fig.9.). Some other conservative measures directed on the stop of bleeding
withouttheuseofthisprobeareconsideredineffectiveandtacticallywrong.
Fig.8.SengstakenBlakemoretube
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Fig.9.MethodofapplicationoftheSengstakenBlakemoretube
The SengstakenBlakemore tube has three ducts, two of which are

connected with rubber bulbs, one with the cavity of stomach. Before
applicationofprobebyintroductionofairthevolumeofbulbsismeasured.Probe
throughanoseandinadistal(gastric)bulbisinserted,thenecessaryamountof
airisforced(about150,0ml).Afterthisbydrawingoutofitaround(distal)gastric
bulb is pinned outside against cardia. Farther prolonged esophagus bulb is
inflatedtoappearanceatthepatientsfeelingofarching(volumeabout120,0ml)
anditisobturated.Thentotheproximalendofprobethroughtheblock,theload
is suspended weighing about 1 kg It warns reverse advancement of probe in
stomach and by this provides stability of compression of the varicose extended
veins. The control after hemostasis is carried out through the third, connected
with stomach, duct of probe. By such method it can be succeeded to attain
to hemostasis in 8090 % cases. The probe in such position is held 23
days.After this decompression of repeated bleeding can come almost in half of
patients.Thereforedeletingtheprobeisnotneeded.Takingthisintoaccount,itis
expedient to carry out decompression of bulbs in the light intervals of days and
inflatebulbsatnight,whenthecontrolafterthepossiblebleedingiscomplicated.
Conservativetreatmentisreasonable:1)attheeasydegreeoflossofblood
and I degree of hepatic insufficiency (basic biochemical indexes either are not
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changedorwithinsignificantdeviationsfromanormascitesandencephalopathy
areabsent)2)attheIIIdegreeofhepaticinsufficiency,progressiveascitesand
encephalopathy,regardlessofdegreeoflossofblood.
Conservativetherapyofbleedingfromthevaricoseveinsofesophagusmust
engulfthewholevolumeofmedicalmeasures,asatsimilarpathologyofulcerous
genesis(hemostatictherapy,antacid,2blockerhistaminereceptors).
For
the
decline
of
portal
pressure
pituitrin
is
entered.
Theendoscopicmethodsofstopofbleedingareappliedalso(impositionofclips
on veins, sclerosis therapy 76 % ethyl alcohol, Varicocide, 66 % solution of
glucose,endovascularocclusionofveins,lasercoagulationofveins).Itisneeded
tocountsettingofpreparationsforstimulationofregenerationofliver(esenciale,
lif52andotherslikethat),applicationofdisintoxicationtherapy.
Surgicaltreatmentisconsideredapplicableatbleedingofmiddleandheavy
degreeswiththeIandtheIIdegreesofhepaticinsufficiency(generalbilirubinnot
more large 50 mcmol/L, general albumen not more small 60 g/
,prothrombinindexnotmorelow60%,presenttransientascites)inthecases
whenthevaluableconservativetreatmentdirectedonthestopofbleedingisnot
effectiveduring2448hours.
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Pic. The anatomic relationships in the upper abdomen. The stomach is

Pic. 1 lig. hepatogastricum 2 lien 3 gaster 4 lig. gastro

Pic. 1 lien 2 aa. et vv. gastricae breves 3 a. et v. gastrica

Pic. Anatomically, the stomach is divided into several segments.

syndrome of gastrointestinal bleedings, which can be acute, arising

to a retraction, which posesses a rather essential role in mechanisms of a

results in series of cases in disappearance of these attributes. The

made in Russia by prof. S.P. Fedorov in 1903. Now concerning acute

Such stages of disease are distinguished: erosion, acute and chronic

For today the most known classification of gastric ulcers by Johnson

patients with cardial and subcardial ulcers. It is necessary to bind to

Chronic gastritis, as well as at an gastric ulcer, characterized by the

Conservative treatment of gastric ulcer always must be complex,

stomach with ulcer removing with selective proximal vagotomy. In case of

The duodenal ulcer is the chronic recurrent disease which

There are some etiologic factors of the duodenal ulcer: Helicobacter

Morphogenesis of duodenal ulcer fundamentally does not differ from

Pain in the epigastric region is the most expressed symptom of

pancreas and hepatoduodenal ligament. Usually such patients has good

During endoscopy examination it is possible to define localization,

The duodenal ulcer must be differentiated from acute and

Conservative treatment. In most patients after conservative treatment

Bleeding gastroduodenal ulcers are outpouring of blood in the

ulcer and treated oneself by conservative preparations, are under the

Strengthening of necrosis process are leading factors in the origin of

Bleeding gastroduodenal ulcers after the degree of weight of loss of

At patients with an peptic ulcer disease, bleeding pops up, mainly at

The black tarlike emptying are the permanent symptom of the

examination of rectum is obligatory. It needs to be performed at the first

can depend both on compensate possibilities of organism and from the

At wide introduction of gastroduodenoscopy of question of differential

hemorrhage. Vomiting by fresh blood, expressed tachycardia, falling of

Often differential diagnostics performed according to the level of

The conservative therapy indicated to patients with the stopped

possible intraoperative damages of choledoch, that are the possible at low

MalloryWeiss syndrome (MWS) is characterised by upper

of intaragastric pressure as a result of discoordinated function of cardial and

Renal disease vomiting is often associated with diseases affecting

examination (as 'Examination', above) identify severity of blood loss and

The main symptom of syndrome is bloody vomiting which the dyspeptic

liquid diet and advancing as tolerated to a normal diet) within 48 hours

Conservative treatment of the MalloryWeiss syndrome is indicated at the

antacid, Meulengracht's diet. At the rupture of the III degrees

Angiotherapy (organ ischaemia and infarction, aggravation of

The cancer of stomach is a malignant formation, that develops from

communication is set between frequency of cancer of stomach and use of

All authors which are engaged in the study of problem of cancer of

leukocytosis, megascopic ESR during examination of gastric secretion:

It is expedient to apply laparoscopy, mainly, for the decision of

At an early cancer complaints depend on the previous gastric

The presence of cancer of stomach is a indications for surgical

Hemorrhagic erosive gastritis is diffuse bleeding from mucous tunic

hemorrhage gastritis. Typical ulcerous pain is observed in such patients. A

the roentgenologic examination observed the thickened winding folds of mucus

of stomach an effective by cold water or by 5 % solution of aminocapronic acid

The SengstakenBlakemore tube has three ducts, two of which are

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