Ulcer hemorrhage

　　Both gastric ulcer and duodenal ulcer can cause hemorrhage, especially large ulcers and deep ulcers are prone to erode the blood vessels at the base of the ulcer, leading to hemorrhage. Pyloric ulcer and post-duodenal ampulla ulcer are more likely to cause hemorrhage, and it is often difficult to stop the bleeding after hemorrhage.

　　The following are the complications of ulcer hemorrhage:

　　Section 1: Acute massive hemorrhage, when exceeding 1000ml, may cause symptoms such as palpitations, dizziness, cold sweat, fainting, wet and cold skin, increased heart rate, and rapid pulse, indicating hemorrhagic peripheral circulatory failure. It may also lead to restlessness, delirium, and a heart rate often exceeding 120 times/min. The blood pressure will significantly decrease, and shock may occur.

　　Section 2: Fever patients may have low fever, the body temperature usually does not exceed 38.5℃.

　　The clinical manifestations of hemorrhage from ulcer disease depend on the amount and speed of blood loss, whether the bleeding is still ongoing, the age of the patient, whether there is anemia and dehydration, and their mental state. Generally, healthy adults with blood loss not exceeding 500 ml may have no symptoms, and blood volume can be restored from tissue fluid within 36 hours, but there is a phenomenon of blood dilution with low protein content. Red blood cells and hemoglobin need to recover within 2 weeks. The reserve capacity of the normal spleen is very small and cannot play a significant role.

　　Blood loss of more than 1000 ml can cause palpitations, nausea, and weakness. Over 1500 ml can lead to hypotension, dizziness, fainting, and shock, depending on the speed of bleeding. If 2000 ml is lost within 15 minutes, it is inevitable to develop profound shock and death. Half of the circulatory volume lost within 10 hours can result in a 10% mortality rate in untreated patients. If the same amount of blood is lost within 24 hours or more, death rarely occurs.

　　Large blood loss reduces blood volume, decreases the return blood volume, and therefore the cardiac output also decreases. Through the action of sympathetic adrenaline, it causes reflexive vasoconstriction; mainly the vasoconstriction of small arteries and veins, thereby reducing blood flow to the skin, skeletal muscles, and viscera. This can increase cardiac output by 25% to meet the blood supply of vital central organs. Vasoconstriction is conducive to venous return, which is actually the transfer of blood from the venous pool to the arterial part of the circulation to increase tissue perfusion. It is the manifestation of compensatory function before shock occurs. Especially when bleeding is slow, the compensatory effect is more prominent. Therefore, in chronic bleeding, blood pressure is not a good indicator for estimating blood loss, especially in young people; diastolic pressure is more valuable in reflecting the reduction of blood volume, but it is an exception in hypertensive patients, whose diastolic pressure is easier to maintain than that of normal blood pressure individuals. When blood volume decreases, an increased heart rate often appears before the decrease in arterial pressure. Therefore, the change in pulse rate may provide more meaningful clues to blood loss. However, the pulse is affected by mental state and rapid fluid infusion. Central venous pressure is a reliable indicator of return blood volume. The amount of urine excreted per unit time can reflect the tissue perfusion situation, but the possibility of high output syndrome in the presence of kidney disease and renal failure should be excluded.

　　Hypovolemic shock is the main manifestation of massive hemorrhage, characterized by a rapid pulse, systolic blood pressure below 10.7 kPa (80 mmHg), cold and moist skin of the limbs, pale, shallow and rapid breathing, thirst, nausea, anxiety, and restlessness. Insufficient tissue perfusion can lead to decreased urine output and cellular hypoxia; anaerobic metabolism produces a large amount of pyruvate and lactic acid. In the case of metabolic acidosis, the tension of the vessels gradually disappears, and the body's response to adrenaline and norepinephrine also gradually diminishes. Finally, the vessels dilate, and the patient may die due to circulatory failure.

　　Patients with a history of ulcer should be treated actively, systematically, and normatively to prevent complications of ulcer disease—massive hemorrhage from ulcer disease. Pay attention to adequate rest, do not overwork, and combine activity with rest, which is conducive to the recovery of the body; exercise can enhance physical strength and resistance to disease, and combining both can help recover better.

　　Clinical examination items for ulcer disease bleeding:

　　1. Blood picture

　　The count of blood leukocytes and neutrophils is often slightly increased, and the hemoglobin and red blood cell count decrease (which may not be obvious in the early stage).

　　2. Blood urea nitrogen

　　After bleeding, due to the increase of intestinal urea nitrogen, intestinal azotemia may occur. If the patient's renal function is normal, the degree of increase in blood urea nitrogen can reflect the amount of bleeding.

　　3. X-ray gastrointestinal barium meal造影

　　It has an accuracy of 70% to 90% for the diagnosis of ulcer disease, but it is not advisable to perform it 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 is stable, and it is not advisable to press during the examination. Barium in the gastrointestinal tract may interfere with the observation of the results of angiography, so it should be considered in advance. At present, it is no longer the first choice for the diagnosis of acute upper gastrointestinal bleeding, and emergency endoscopy is chosen.

　　4. Gastroscopy

　　The positive rate can reach 80% to 95%, which is superior to X-ray gastrointestinal barium meal in the diagnosis of upper gastrointestinal bleeding. Endoscopy can not only see the nature of the lesion but also see reliable signs of active or recent bleeding, that is, fresh bleeding or oozing, the lesion area showing a black-brown base or with clots, according to the experience summary of 248 emergency endoscopic examinations in 8 large hospitals in Beijing, it is believed that it does not increase the risk of massive bleeding. If necessary, hemostasis treatment can be performed under endoscopy. As long as the patient's blood pressure is stable and close to normal, after eliminating the patient's concerns and tension, the examination can be performed next to the bed or on the operating table. The examination process should be light and rapid, avoiding rough insertion of the endoscope. The examination should be performed within 24 to 48 hours after bleeding, otherwise, some superficial mucosal lesions such as erosion, superficial ulcers, and mucosal tears may lose diagnostic signs due to partial or complete repair. There is no need to wash the stomach before the examination. If the observation is affected by accumulated blood, the stomach can be washed with ice water through a gastric tube before the examination. The observation should be comprehensive, and not be satisfied with the discovery of a single lesion. It is necessary to examine the esophagus, stomach, and duodenum carefully before making a diagnosis. If necessary, a biopsy can be taken, but one must be vigilant of the varices at the bottom of the stomach, which sometimes present as gray nodular protuberances, but are soft and elastic to the touch. Easy biopsy may pose a risk of severe bleeding.

　　5. Selective abdominal aortic angiography

　　It also helps in the localization diagnosis of acute upper gastrointestinal hemorrhage. The positive rate is not high for chronic small amount of bleeding, and some hospitals use it as the primary diagnostic step, and if it fails, then barium meal or other examinations are performed.

　　6. Swallowing Thread Test

　　The method of swallowing thread test is simple, generally using ordinary white thread. After swallowing one end for 30 minutes, the bleeding location is determined by the distance of the stain from the incisor. Pittman introduces the fluorescence strip test, which is used to diagnose upper gastrointestinal bleeding; after swallowing the end of the strip, fluorescein is injected intravenously, and then the strip is pulled out and observed under ultraviolet light for the part of fluorescein stained with blood, and the length from the incisor is calculated to determine the bleeding location.

　　7, Other tests

　　If Miller-Abbott (M-A) double-lumen tubes are used, after insertion into the gastrointestinal tract, they are continuously aspirated. When fresh blood is aspirated from this tube, it is fixed with adhesive tape and an X-ray film is taken to observe the position of the tip, determining that this is the location of bleeding, which is effective for locating slow bleeding. There is also the use of chromium-labeled red blood cells, which are injected intravenously and then aspirated through the M-A tube. Each sample aspirated is measured for radioactivity, and the sample with the strongest radioactivity is determined to contain the most 51Cr, thereby locating the bleeding site. This test has little diagnostic value for small intestinal bleeding and is therefore rarely used.

　　8, Radioisotope scanning

　　Commonly used 99mTc-labeled red blood cells are injected intravenously and then exude and accumulate in the gastrointestinal tract. The radioactive signal in the gastrointestinal tract is scanned to indicate the location of gastrointestinal bleeding, but it is sometimes difficult to accurately locate.

　　Foods suitable for gastric ulcer bleeding patients:

　　One, strengthen nutrition by choosing easily digestible foods that contain sufficient calories, protein, and vitamins. Examples include congee, thin noodles, milk, soft rice, soy milk, eggs, lean meat, tofu, and soy products.

　　Two, eat more foods rich in vitamin 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.

　　Introduce several foods that have an auxiliary therapeutic effect on gastric ulcers:

　　One, honey, it really tastes good. It contains glucose, fructose, organic acids, yeast, various vitamins, and trace elements, among other nutritional components, which can protect the ulcer surface of the gastric mucosa.

　　Two, lotus root, rich in starch, can promote gastrointestinal motility, accelerate the healing of gastric ulcers, and also has the function of detoxifying alcohol.

　　Three, eggs, egg yolks contain a large amount of lecithin and cephalin, which have a strong protective effect on the gastric mucosa.

　　Four, jujube, jujube has the function of benefiting the spleen and stomach. Eating jujube or porridge made from jujube and glutinous rice can have a certain preventive and therapeutic effect on gastric ulcers.

　　Foods to avoid in gastric ulcer bleeding:

　　Limit the intake of fibrous foods. It is advisable to avoid eating fried or oil-fried foods as well as foods rich in rough fibers such as celery, chives, sprouts, ham, cured pork, dried fish, and various coarse grains. These foods are not only rough and difficult to digest but can also cause excessive secretion of gastric juice, increasing the burden on the stomach. However, easily digestible foods such as mashed vegetables can be consumed after processing.

　　Avoid eating foods that are too stimulating. Foods that stimulate gastric acid secretion should be avoided, such as broths, scallions, garlic, concentrated fruit juices, coffee, alcohol, strong tea, and foods that are too sweet, sour, salty, hot, raw, cold, or hard. Sweet foods can increase gastric acid secretion, stimulate the ulcer surface, and worsen the condition; hot foods can stimulate the ulcer surface, causing pain and even causing bleeding due to the expansion of blood vessels on the ulcer surface; spicy foods can stimulate the ulcer surface, increasing gastric acid secretion; cold and hard foods are difficult to digest and can worsen the condition.

　　In addition, ulcer patients should quit smoking. Nicotine in tobacco can change the acidity of gastric juice, disturb the normal activity of the pylorus, and induce or exacerbate ulcer disease.

　　Provide a detailed introduction to the treatment of ulcer bleeding:

　　First, medical treatment

　　Patients with peptic ulcer disease who have vomiting or bloody stools should be hospitalized for treatment. The patient should lie flat, elevate the lower limbs, keep warm, breathe oxygen, and measure the pulse, blood pressure, and respiration every 10 to 30 minutes. Sedatives may be administered if necessary to keep the patient calm.

　　1. Replenish blood volume:In cases of massive hemorrhage, immediate fluid resuscitation should be initiated during transportation or after admission. If hypovolemic shock has already occurred, it is best to transfuse whole blood. During the process of blood typing and cross-matching, balanced fluid or glucose saline can be infused first, and the initial infusion rate should be fast. Once the blood pressure begins to rise, the infusion rate and type of fluid should be determined based on the central venous pressure and hourly urine output. Measuring hemoglobin and hematocrit has a direct guiding significance for whether to transfuse whole blood. If there is a difficulty in obtaining identical blood types, 'O' type red blood cells can be infused into normal saline, with good efficacy. Plasma can expand blood volume but cannot carry oxygen and is easily diffused into the extravascular space, making it less ideal than whole blood. 5% human serum albumin and various plasma substitutes have a good effect on maintaining osmotic pressure. Crystalloids are only limited to satisfying daily water needs and should not be excessive to avoid tissue edema. They can only have a temporary effect on replenishing blood volume. Rapid blood transfusion can cause acute pulmonary edema and should be noted. Generally, the hematocrit can be raised to 40%, at which point there is no need for further blood transfusion. The blood in the blood bank should be prewarmed to a temperature close to body temperature before infusion. Otherwise, infusing a large amount of cold blood can be dangerous, leading to sudden cardiac arrest. Statistics show that the incidence of cardiac arrest in hemorrhagic patients after the transfusion of prewarmed blood decreased from 58.3% to 6.8%. Central venous pressure can reflect blood volume and right heart function. When the central venous pressure is below 0.5 kPa (5 cmH2O), rapid fluid resuscitation can be performed, and careful fluid administration is required when the pressure reaches 1 kPa (10 cmH2O). A pressure above 1.5 kPa (15 cmH2O) indicates an excessive volume of fluid infusion. Urine output can reflect cardiac output and tissue perfusion. If the urine output is 35 to 50 ml per hour, it indicates that the fluid intake has basically met the needs. It is only necessary to maintain it and strictly record the intake and output.

　　2. Maintain the function of the circulatory system:The stimulation of hemorrhage can cause vasoconstriction through the action of sympathetic adrenaline. Therefore, there is still controversy about whether to use vasoconstrictive drugs after the onset of shock. Generally, it is believed that vasoconstrictive drugs are not helpful for hemorrhagic shock, but many still advocate for their use to avoid prolonged hypotension in cases where blood volume is not supplemented in a timely manner. If the heart rate does not exceed 140 times/min, 1 to 5 mg of isoproterenol can be added to 500 ml of normal saline or other solutions for intravenous infusion to enhance myocardial contractility, reduce venous pressure and peripheral resistance, and have a slight vasodilating effect. When the volume of infusion is large, digitalis should be used to support cardiac function to prevent congestive heart failure, with lanatoside C (Digoxin) or strophanthin K commonly used. Lanatoside C (Digoxin) is administered intravenously at a dose of 0.1 to 0.2 mg each time, with a daily dose not exceeding 1 mg.

　　3. Correction of acidosis:If respiratory acidosis occurs, the breathing should be deepened, and sufficient ventilation should be provided to expel the accumulated carbon dioxide. If necessary, a respirator can be used to assist breathing, or even tracheal intubation can be performed to control breathing. If the carbon dioxide binding power is low, there is metabolic acidosis, appropriate sodium bicarbonate solution should be administered intravenously according to the calculation. To avoid excessive sodium ions causing tissue edema, tris(hydroxymethyl)methane (THAM) can be administered intravenously, which can correct both metabolic acidosis and respiratory acidosis.

　　4. Hemostatic measures:

　　①Local drug hemostasis: 4～8mg of norepinephrine is added to 100ml of normal saline, taken orally or injected through the stomach tube to cause temporary vasoconstriction in the stomach and achieve hemostasis. It can be repeated every 10～15min. Monsell's solution (Monsellssolution) is a basic ferric sulfate solution [Fe4(OH)2·(SO4)5] prepared by heating the coarse powder of ferrous sulfate after treatment with sulfuric acid and nitric acid. The pure liquid is brown-red and a powerful astringent. Generally, it is diluted in normal saline to make a 5% solution for application in the case of ulcer bleeding. Monsell's solution cannot be taken orally and must be injected through the stomach tube. 30～50ml is used each time, repeated every 1～2h, and can be used 2～3 times. Nausea, vomiting, and spasmodic abdominal pain may occur occasionally after medication, which can be relieved by antispasmodic drugs.

　　Icing water lavage was once popular, with 250ml of ice water or ice saline solution injected into the stomach tube each time, then gently and slowly aspirated out, the total amount can reach up to 10L of ice water. Generally, it is washed for 20～30min until the aspirated water becomes clear. Some people also suggest dripping 1mmol/ml sodium bicarbonate solution through the stomach tube at a speed of 1000mmol/d, which has the effect of neutralizing gastric acid. Some also advocate adding norepinephrine to the ice water.

　　②Whole-body drug hemostasis: H2 receptor blockers can reduce the basal gastric acid secretion, which is helpful for hemostasis and healing of ulcers. Although there are still different opinions about its efficacy, it is still applied in clinical practice as an auxiliary hemostatic therapy. Cimetidine (cimetidine) 0.4～0.6g is diluted in 500ml of 10% glucose solution and administered intravenously twice a day. Ranitidine 0.1g is dissolved in 500ml of glucose solution and administered intravenously every 12 hours. Its efficacy can last for 10～12h. The efficacy of famotidine can last up to 24h, so generally 20mg (100ml) is administered intravenously once a day.

　　Somatostatin is a 14-amino acid peptide. Research has found that intravenous infusion can reduce intraperitoneal blood flow and is used for bleeding due to peptic ulcer disease and esophageal varices破裂 caused by liver cirrhosis. After diluting somatostatin 250μg, it is infused intravenously slowly, and then 250μg is injected every hour, and bleeding can stop after 8-12h of treatment.

　　③ Endoscopic hemostasis: With the advancement of endoscopic examination and treatment technology, endoscopic hemostasis for ulcer bleeding has achieved good results.

　　A. Local compression for hemostasis, for smaller areas with clear bleeding, direct compression of the bleeding site with a biopsy forceps during endoscopic examination can have a temporary hemostatic effect. However, it is more difficult for massive bleeding.

　　B. Local drug spraying for hemostasis, through the endoscopic biopsy channel, a plastic tube is inserted to directly spray drugs on the bleeding site. Commonly used drugs include 1% adrenaline solution, 5% Mension solution, etc.

　　C. Local drug injection for hemostasis and thermal hemostasis.

　　5. Diet:Under conditions of shock or fullness and nausea in the stomach, it is undoubtedly necessary to refrain from eating. There is controversy over the dietary issues of patients with non-massive bleeding, but most tend to favor eating. The rationale is that food can neutralize gastric acid, easily maintain water and electrolyte balance, ensure nutrition, and promote peristalsis, which can help the accumulation of blood in the stomach to move downward with food, thereby reducing nausea and vomiting. Opinions on what kind of diet to eat are also inconsistent, with some advocating for liquid food or plain milk, and others advocating for normal food. There is a concern that liquid food may wash away blood clots, so it is suggested to eat semi-liquid, nutritious, and easily digestible food, or soft food that has been pre-digested, which is the opinion of most people, believing that the risk of causing bleeding with this kind of food is very small.

　　Secondly, surgical treatment

　　About 20% to 25% of cases with varying degrees of bleeding due to peptic ulcer disease require surgical treatment. The efficacy is relatively satisfactory and easy to succeed, so the indications for surgery are generally broad, the problem lies in the timing of surgery. Often, patients who are transferred to surgery late, with a longer bleeding time and hemoglobin levels of only 2-3g, are encountered. According to routine practice, surgery should be delayed until bleeding stops and hemoglobin levels increase to 6-8g. If bleeding does not stop, an emergency operation may be forced, which of course carries a high risk. The indications for surgery are summarized as follows:

　　1. Massive bleeding that does not stop.

　　2. Although the amount of bleeding is not large, conservative treatment has been ineffective for a long time.

　　3. A history of recurrent bleeding.

　　4. Long history of ulcer, with a past history of complications such as perforation or pyloric obstruction symptoms.

　　5. Individuals over the age of 50.

　　In the case of emergency massive hemorrhage, it is often not allowed to complete perfect preoperative preparation before surgery, but it is necessary to understand the overall condition of the patient. Blood typing, fluid infusion, and blood tests should be completed before entering the operating room. Procedures such as gastric lavage with a gastric tube, measuring central venous pressure, and inserting a urinary catheter can be done after entering the operating room if not done in time. For the purpose of replenishing blood volume, correcting electrolyte disorders and acidosis, these can be done simultaneously with surgery. The blood transfused after complete hemostasis is effective for increasing hemoglobin. Of course, if the situation is not urgent, it is more appropriate to complete all these before entering the operating room.

　　Chronic cicatricial ulcers, gastric ulcers, or large ulcers are suitable for subtotal gastrectomy. The operation should try to remove the ulcer, but the cicatricial ulcer of the duodenum is sometimes difficult to remove, and forced resection may damage important structures such as the common bile duct. At this time, subtotal gastrectomy can be performed after proper hemostasis. However, it must be emphasized that the ulcer surface after suture hemostasis must be isolated from the gastrointestinal cavity and cannot be left in the gastrointestinal cavity; otherwise, fatal rebleeding may occur 7 to 8 days after the hemostasis suture falls off. For this purpose, the Nissen method can be used. The bleeding cicatricial ulcer is often located on the posterior and medial wall of the duodenal ampulla, while the anterior and lateral wall of the duodenum opposite the ulcer is normal. The posterior and medial wall of the duodenum near the ulcer can be cut off close to the marginal edge of the ulcer, and the anterior and lateral wall opposite the ulcer can be left longer. The anterior and lateral wall edges are sutured to the distal edge of the ulcer to form the first layer of suture. Then, the seromuscular layer of the anterior and lateral wall is sutured to the base of the ulcer as the second layer. The mucosa on both sides of the ulcer may interfere with the second layer suture and can be appropriately removed. Finally, the seromuscular layer of the anterior and lateral wall of the duodenum is sutured together with the proximal edge (incision edge) of the ulcer or the serosal membrane of the pancreas to form the third layer suture. Thus, the base of the ulcer after suture hemostasis is isolated from the gastrointestinal cavity.

　　For those with a short medical history, small and soft ulcers, superficial and easy to suture, especially young people, selective vagotomy is suitable. For those with pyloric obstruction or those who have had the pylorus incised for hemostasis, pyloroplasty should be performed simultaneously. For subtotal gastrectomy or vagotomy after the ulcer is left alone or after ligation and hemostasis, if the ulcer surface after ligation and hemostasis cannot be isolated from the gastrointestinal cavity, to prevent rebleeding, the corresponding artery can be ligated. If the ulcer near the pylorus, ligate the gastroduodenal artery; for high gastric ulcer on the lesser curvature, ligate the left gastric artery. So-called blind subtotal gastrectomy is very unreliable in hemostasis; it is necessary to find the bleeding focus and remove it, or achieve complete hemostasis, which can be considered a successful operation.