Gastric and duodenal ulcer hemorrhage

　　Gastric and duodenal ulcer hemorrhage is the result of erosion and rupture of the ulcer base vessels, mostly medium artery hemorrhage. Ulcers with massive hemorrhage are generally located on the lesser curvature of the stomach or the posterior wall of the duodenum. Hemorrhage from gastric ulcer on the lesser curvature often originates from the right and left gastric arteries, while hemorrhage from duodenal ulcer mostly originates from the superior pancreaticoduodenal artery or the gastroduodenal artery and its branches. The lateral wall rupture of the vessel is more difficult to stop bleeding spontaneously than the end bleeding. Sometimes, due to the decrease in blood volume and the decrease in blood pressure after massive hemorrhage, blood clots form at the site of vessel rupture, and bleeding can stop spontaneously. However, about 30% of cases may experience a second massive hemorrhage.

　　Patients with gastric and duodenal ulcer hemorrhage may have compensatory phenomena in the circulatory system in the short term, with bleeding greater than 400ml. The compensatory response of the circulatory system includes increased cardiac output, altered blood flow distribution, pulmonary vasoconstriction, and capillary proliferation.

　　Patients with gastric and duodenal ulcer hemorrhage with bleeding volume greater than 800ml can develop shock. Shock is a clinical syndrome caused by acute insufficient tissue perfusion. The common feature of shock is insufficient effective circulating volume, and although the blood perfusion of tissues and cells is compensated, it is still severely restricted. This leads to poor blood perfusion of systemic tissues and organs, causing a series of pathophysiological changes such as tissue hypoxia, microcirculatory stasis, organ dysfunction, and abnormal cell metabolic function.

　　Most patients with gastric and duodenal ulcer bleeding have a history of gastric and duodenal ulcer disease. Sudden onset of cutting-like continuous severe upper abdominal pain, unable to move due to abdominal pain. At the same time, it may be accompanied by nausea, vomiting, and muscle tension in the abdominal muscles, which may present as rigid rigidity, with obvious tenderness and rebound pain. Early in the disease, the body temperature does not rise. Due to the strong chemical stimulation of the gastric and duodenal fluids after perforation, the patient may experience symptoms such as pale complexion, cold sweat, cold extremities, rapid pulse, and blood pressure drop. In the later stage, due to infection caused by the entry of intestinal bacteria into the abdominal cavity, the patient may experience symptoms such as high fever, intestinal paralysis, abdominal distension, etc. Due to the entry of gastrointestinal gases into the abdominal cavity, X-ray examination shows free gas under the diaphragm.

　　One, Symptoms

　　1, Most patients have a history of ulcer disease and the symptoms of ulcer disease have intensified recently;

　　2, Upper abdominal cutting pain, gradually spreading to the whole abdomen, sometimes radiating to the shoulder and back;

　　3, Accompanied by nausea and vomiting.

　　Two, Signs

　　1, General abdominal tenderness, muscle tension, especially in the upper right abdomen;

　　2, The liver dullness border is reduced or disappears;

　　3, Bowel sounds are weakened or disappear.

　　Gastric and duodenal ulcer bleeding is caused by the erosion and rupture of the blood vessels at the base of the ulcer, most of which are arterial bleeding. About 20%-30% of patients with ulcer disease may experience varying degrees of bleeding. To prevent gastric and duodenal ulcer bleeding, the following points should be done:

　　1, Live a regular life

      Pay attention to combining work and rest, maintaining a pleasant mood, avoiding overwork or mental stress; pay attention to keeping warm during the change of seasons; quit smoking and drinking; eat less or no刺激性 food.

　　2, Try not to use or use drugs that irritate the gastric mucosa with caution

      For example, hypertensive patients should try to avoid using antihypertensive drugs such as Erythromycin; if necessary to take hormones or non-steroidal anti-inflammatory drugs such as indomethacin for joint inflammation or other diseases, it is recommended to take gastric mucosal protectants or drugs to inhibit gastric acid secretion (H2 receptor blockers, proton pump inhibitors, etc.) at the same time. It belongs to H2 receptor blockers and is a commonly used acid suppressant. It can moderately inhibit gastric acid secretion and has relatively few side effects.

　　3, Early detection and early treatment

      Once a patient develops symptoms such as upper abdominal pain, bloating, nausea, and dyspepsia, they should go to the hospital for treatment and necessary examinations in a timely manner. Once digestive ulcers are found, they should follow the doctor's advice for regular treatment and regular follow-up until the ulcers are completely healed.

　　Gastric and duodenal ulcer bleeding is one of the common causes of upper gastrointestinal bleeding. The bleeding is due to the erosion or rupture of blood vessels by ulcers, and the following examinations need to be done:

　　One, there is abdominal tenderness and muscle tension, especially in the upper right abdomen. The liver dullness border is reduced or disappears, and the bowel sounds are weakened or disappear.

　　Two, X-ray films and abdominal透视 show free gas under the diaphragm, and yellow turbid fluid is aspirated from the abdominal puncture.

　　Three, blood routine examination

　　1. White blood cell count: white blood cell count is usually (15-20) × 10^9/L, with a predominance of neutrophils.

　　2. Hemoglobin and red blood cells: often elevated due to dehydration and blood concentration.

　　Four, serum amylase can be moderately elevated, but the ratio of serum amylase creatinine clearance (CAM/CCr) is within the normal range.

　　Diet therapy is an important link in the prevention and treatment of ulcer disease. Patients with gastric and duodenal ulcer hemorrhage should pay attention to strengthening nutrition and restricting rough foods in their diet. Choose easily digestible foods rich in calories, protein, and vitamins, such as congee, thin noodles, milk, soft rice, soy milk, eggs, lean meat, tofu, and soy products; foods rich in vitamins A, B, and C, such as fresh vegetables and fruits. These foods can enhance the body's resistance, help repair damaged tissues, and promote ulcer healing. Patients with heartburn should use less milk.

　　Most patients with ulcer disease massive hemorrhage can stop bleeding after general treatment, such as blood transfusion and fluid replacement, cold saline lavage of the stomach, injection of adrenaline under endoscopy, laser coagulation, or selective arterial injection of vasoconstrictors. Bleeding can stop. However, about 5-10% of patients continue to bleed. If the following conditions are present, surgical treatment should be considered.

　　1. Acute massive hemorrhage with shock symptoms, which is often due to bleeding from larger blood vessels and is difficult to stop on their own.

　　2. If the condition does not improve after 600 to 1000 milliliters of blood are infused within 6 to 8 hours, or if the condition temporarily improves but worsens again after stopping blood transfusion,

　　3. Individuals who have recently experienced a similar massive hemorrhage.

　　4. Patients experiencing massive hemorrhage while in inpatient internal medicine treatment, indicating a large erosive ulcer, and it is difficult to stop bleeding without surgical treatment.

　　5. Individuals over 50 years old or with arteriosclerosis, it is estimated that bleeding is difficult to stop on their own.

　　6. Massive hemorrhage with perforation or pyloric obstruction.

　　Patients who require surgical treatment should actively transfuse blood to combat shock and it is best to strive to perform the operation within 24 hours of bleeding, as this has a better effect. If the operation is delayed until the condition is extremely dangerous, the mortality rate is higher. Elderly patients should strive for early surgical treatment.