Massive ulcer hemorrhage

　　Gastric ulcer hemorrhage is the result of erosion of the ulcer base and rupture of the blood vessels, with lateral wall rupture being more difficult to stop bleeding than the end of the rupture. Sometimes, due to a decrease in blood volume and blood pressure after massive hemorrhage, blood clots may form at the site of vessel rupture, causing bleeding to stop spontaneously, but about 30% of cases may experience a second massive hemorrhage. Most patients have a history of ulcer disease before bleeding, and about 10-15% of patients with massive ulcer hemorrhage have no symptoms of ulcer disease before bleeding.

　　If not treated promptly, acute massive bleeding with shock can lead to death in severe cases. Massive bleeding can be complicated with perforation or pyloric obstruction. When acute massive bleeding exceeds 1000ml, symptoms of hemorrhagic peripheral circulatory failure may occur, such as palpitations, dizziness, cold sweat, fainting, wet and cold skin, rapid heartbeat, and thin pulse. In some cases, there may be restlessness and delirium, with heart rate often exceeding 120 beats/min, and significant blood pressure drop, which may lead to shock. Fever patients may have low fever, with body temperature usually not exceeding 38.5℃.

　　The following are the specific clinical manifestations of massive bleeding in peptic ulcers:

　　One, Black tarry stools and vomiting blood:Most of the cases occur suddenly, and bleeding is often not accompanied by abdominal pain. Most patients first feel nausea, dizziness, and discomfort in the upper abdomen, followed by vomiting blood or black tarry stools, or both may occur simultaneously.

　　Two, Shock:When the blood loss is 400 milliliters, compensation phase of shock, pale complexion, thirst, rapid and strong pulse, normal or slightly high blood pressure may occur. When the blood loss is 800 milliliters, obvious shock symptoms may appear: cold sweat, thin and rapid pulse, shallow breathing, blood pressure drop.

　　Three, Anemia:A significant decrease in hemoglobin, red blood cell count, and red blood cell hematocrit occurs with massive bleeding.

　　The main prevention of massive bleeding in peptic ulcers is the active treatment of peptic ulcers.

　　Firstly, maintain a good mental state, establish good living habits, give up bad habits, and secondly, do a good job of dietary regulation, eat meals on time and in proper amounts, eat nutritious and easily digestible food, avoid eating刺激性 and acidic food, and avoid using drugs that are harmful to the stomach.

　　Furthermore, it is essential to adhere to regular treatment to effectively control recurrence.

　　At the same time, it is necessary to actively treat gastritis and duodenitis, and in addition, drug prevention should be carried out, taking vitamins A, C, E regularly to promote the repair of epithelial cells and connective tissues, and to increase the body's resistance to diseases.

　　In clinical practice, the following methods can be used to examine massive bleeding in peptic ulcers:

　　One, Barium Meal Examination:It has an accuracy of 70% to 90% for diagnosing peptic ulcers. However, it is not advisable to perform this procedure when the patient is in shock, cannot stand, or has a large amount of blood clot in the stomach. It is generally recommended to perform this examination 48 hours after the condition stabilizes, and it is not advisable to press during the examination. Barium in the gastrointestinal tract hinders the observation of the results of arterial angiography, so it should be considered in advance. At present, it is no longer the first choice for diagnosing acute upper gastrointestinal bleeding, and emergency gastroscopy is chosen instead.

　　Two, Selective Arterial Angiography:It also helps in locating the diagnosis of massive bleeding, but the positive rate for chronic small amount of bleeding is not high. Some hospitals use this as the primary diagnostic step and perform barium meal or other examinations if it fails.

　　Three, Radionuclide Scanning:The commonly used 99mTc-labeled red blood cells are injected intravenously and overflow and accumulate in the gastrointestinal tract at the bleeding site. Scanning detects radioactive signals in the gastrointestinal tract, indicating the location of gastrointestinal bleeding. However, it is sometimes difficult to pinpoint the exact location.

　　Fourth, endoscopic examination.

　　For patients with massive bleeding from ulcer disease, it is recommended to consume low-fiber or non-fiber foods, with the temperature of the food slightly cool, preferable when the arm and lips feel cool when touched. Easy-to-digest, high-protein foods should be chosen. Optimal proteins such as eggs, milk, meats, and poultry should account for more than half of the daily protein intake. Plant-based proteins, such as defatted soybean protein powder, are also recommended for better effects.

　　Most patients with massive bleeding from ulcer disease respond to general treatment such as blood transfusion, fluid replacement, cold saline lavage of the stomach, injection of adrenaline under endoscopy, laser coagulation, or selective arterial injection of vasoconstrictors. Bleeding can be stopped. However, about 5-10% of patients continue to bleed.

　　If the following conditions are present, surgical treatment should be considered:

　　First, acute massive bleeding accompanied by shock symptoms, often caused by bleeding from larger blood vessels, which is difficult to stop on its own.

　　Second, 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.

　　Third, patients who have had a similar massive bleeding incident recently.

　　Fourth, patients with massive bleeding while undergoing inpatient treatment in internal medicine, indicating that the ulcer has侵蚀性大, it is difficult to stop bleeding without surgery.

　　Fifth, patients over 50 years old or with arteriosclerosis, it is estimated that bleeding is difficult to stop on its own.

　　Sixth, massive bleeding with perforation or pyloric obstruction.

　　Patients who require surgical treatment should actively receive blood transfusions, antishock treatment, and it is best to perform surgery within 24 hours of bleeding for better results. If surgery is delayed until the condition is extremely critical, the mortality rate is higher. Elderly patients should strive for early surgical treatment.

　　Surgical Treatment:In China, a common surgical method is a subtotal gastrectomy including ulcer, which not only removes the ulcer and stops bleeding, but also treats the ulcer disease, and is an ideal surgical method. If it is difficult to remove the ulcer, it should be left in place, but the bleeding artery at the bottom of the ulcer or its main trunk should be ligated. If the patient's condition is critical and a subtotal gastrectomy is not allowed, a simple puncture and ligation hemostasis method can be adopted. In recent years, some people have performed vagotomy and drainage after treating duodenal ulcer bleeding with puncture and ligation.