Gastric ulcer hemorrhage

　　1. Etiology

　　Massive bleeding from gastric ulcers is caused by erosion and destruction of the basal vessels of the ulcer, mostly arterial bleeding. Ulcers with massive bleeding are generally located on the lesser curvature of the stomach or the posterior wall of the duodenum, so the source of bleeding from gastric ulcers is often the branches of the left and right gastric arteries or the vessels within the gastrohepatic ligament, while bleeding from duodenal ulcers (DU) often originates from the superior pancreaticoduodenal artery or the vessels near the gastroduodenal artery.

　　2. Pathogenesis

　　The pathophysiological changes caused by massive bleeding from ulcers are related to the amount and speed of bleeding. Bleeding of 50-80ml often causes tarry stools without other significant symptoms. Massive and rapid blood loss can cause hypovolemic shock, anemia, hypoxia, circulatory failure, and death. Large amounts of blood in the gastrointestinal tract often also cause changes in blood biochemistry, manifested as increased non-protein nitrogen.

　　Bleeding from gastric ulcer can lead to hemorrhagic shock when the bleeding volume is too large or when chronic blood loss is not well controlled. This is a life-threatening situation that requires active blood transfusion and symptomatic treatment. At the same time, bleeding can lead to perforation of the gastric wall, which can cause the contents of the stomach to enter the abdominal cavity, thus causing peritonitis and other conditions.

　　1. Symptoms

　　The main symptoms of massive bleeding from gastric and duodenal ulcers are hematemesis and melena, with most patients only having melena without hematemesis. Hematemesis usually indicates a large amount of bleeding or rapid bleeding, and may be accompanied by weakness, dizziness, or even fainting after hematemesis or melena.

　　2. Signs

　　The severity and amount of bleeding determine the compensatory response of the circulatory system, such as pallor of the skin, fine pulse, normal or slightly elevated blood pressure; if the blood loss is above 800ml, there will be signs of shock, including decreased blood pressure, rapid and thready pulse, rapid breathing, sweating, cold and wet extremities, and abdominal signs are usually only active bowel sounds, half of the patients have increased body temperature.

　　Daily health care:

　　1. Do not overeat or eat irregularly.

　　2. Eat in small, frequent meals.

　　3. Pay attention to a balanced diet.

　　4. Increase the intake of prebiotics.

　　5. Try baby food.

　　6. Drink cabbage juice.

　　7. Avoid刺激性食物刺激性 foods.

　　8. Avoid using milk.

　　9. Avoid high-fat foods.

　　10. Chew slowly to aid digestion.

　　11. Do not take iron supplements.

　　12. Supplement nutrition.

　　1. Blood test

　　Blood tests related to gastric ulcer hemorrhage, including hemoglobin, hematocrit, reticulocyte count, bleeding and coagulation time.

　　2. Fecal occult blood test.

　　3. Fiberoptic gastroscopy examination

　　Fiberoptic gastroscopy is listed as the first choice for upper gastrointestinal hemorrhage examination. Practice has proven that this examination method has an accuracy of over 90% in diagnosing gastric ulcer hemorrhage.

　　The examination should be performed within 6-12 hours after bleeding. If the patient's general condition permits, the earlier the examination, the better. If the examination time exceeds 12 hours, it may be difficult to detect mucosal healing due to the cessation of bleeding, and at the same time, due to blood clots in the stomach, even after rinsing with ice water, it is not easy to remove, which affects the examination results.

　　For patients with massive gastric ulcer hemorrhage who are difficult to diagnose preoperatively and difficult to find lesions during surgery, fiberoptic gastroscopy can be used during surgery, that is, through gastrostomy, first suck out the blood in the stomach, then insert a fiberoptic gastroscopy that has been soaked and disinfected, tighten the gastrostomy site, and examine segment by segment. It is often possible to find lesions that are not easily found in preoperative examinations.

　　4. Selective arterial angiography

　　It has a high accuracy in diagnosing the bleeding site of gastric ulcer hemorrhage, and it can be displayed when the bleeding rate is 0.5-2ml/min. When fiberoptic gastroscopy cannot clearly indicate the bleeding site, angiography can often show the bleeding site and range. If the angiography shows multiple small bleeding points in the distribution area of the left gastric artery, vascular contraction agents can be infused through the left gastric artery for hemostasis. When a large vascular hemorrhage is confirmed, early surgical treatment should be performed.

　　5. Barium meal examination

　　Barium meal examination for acute hemorrhage is often caused by pseudo-phenomena or affects diagnosis due to the presence of blood clots, and at the same time, due to the presence of barium shadow, it affects other examinations.

　　First, dietary therapy for gastric ulcer hemorrhage

　　1. Two spoons of maltose, dissolve in boiling water and take, effective for treating gastric and duodenal ulcers, with the effect of alleviating stomach pain.

　　2. Mix 125 milliliters of milk and 125 milliliters of goat's milk, boil together, take on an empty stomach in the morning.

　　3. Treatment of gastric ulcer disease: mix 150 milliliters of tomato juice and 150 milliliters of potato juice, take together, once in the morning and once in the evening.

　　4. Steamed eggs with notoginseng and lotus root juice: beat one egg, add 30 milliliters of fresh lotus root juice and 3 grams of notoginseng powder, add a little sugar for seasoning, steam and eat. It has the effects of hemostasis, pain relief, and blood stasis dispersal. Suitable for symptoms such as gastric ulcer hemorrhage, duodenal bulb hemorrhage, and pulmonary tuberculosis hemoptysis.

　　5. Wash, peel, and juice 600 grams of fresh potatoes, remove the渣, and simmer the juice over low heat until it becomes thick. Add 1200 milliliters of honey, continue to simmer until even thicker, then cool. Store in a wide-mouth bottle in the refrigerator. Take one tablespoon on an empty stomach in the morning and evening, very reliable in effect.

　　6. Dried lotus leaf, roasted and ground into fine powder, take 1 gram each time, once a day, for several days consecutively.

　　7. Treatment of gastric ulcer hemorrhage: 100 grams of sea cucumber, 100 grams of Bletilla striata, grind into fine powder, take 5 grams each time, take with warm water or dissolve in water, 3-4 times a day.

　　8. Tomato juice 150 milliliters, potato juice 150 milliliters, mixed and taken, once in the morning and once in the evening.

　　9. Malt sugar two spoons, dissolved in boiling water, has the effect of alleviating stomachache.

　　10. Treat various chronic gastric diseases: one stomach, wash clean with salt. 30-60 grams of Shi Xian Tao, placed in a bowl, steamed with water in a pot, seasoned with salt to taste and eaten. Suitable for gastric ulcer, duodenal ulcer, malnutrition, and other conditions.

　　11. 500 grams of jellyfish skin, 500 grams of jujube, 250 grams of brown sugar, boil into paste, take 1 tablespoon each time, twice a day.

　　II. Foods that are good for the body when eating with gastric ulcer bleeding:

　　1. 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.

　　2. 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.

　　III. Foods with auxiliary therapeutic effects for gastric ulcer

　　1. Honey, it really tastes good. It contains glucose, fructose, organic acids, yeast, various vitamins, and trace elements, and can play a protective role on the ulcer surface of the gastric mucosa.

　　2. Lotus root, rich in starch, can promote gastrointestinal motility, accelerate the healing of gastric ulcer, and also has the function of detoxifying alcohol!

　　3. Eggs, the yolks contain a large amount of lecithin and cephalin, which have a strong protective effect on the gastric mucosa. So remember to eat more egg custard!

　　4. Jujube, jujube has the function of invigorating the spleen and stomach. Eating jujube or congee made from jujube and glutinous rice can have a certain preventive and therapeutic effect on gastric ulcer.

　　Four. Foods that should be avoided for gastric ulcer bleeding:

　　1. Limit the intake of fibrous foods. It is advisable to avoid eating fried or deep-fried foods, as well as foods rich in rough fibers such as celery, chives, sprouts, ham, preserved 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.

　　2. Avoid eating foods with strong刺激性, such as broths, raw scallions, raw garlic, concentrated fruit juices, coffee, alcohol, strong tea, and foods that are too sweet, sour, salty, hot, raw, cold, hard, etc. 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 the ulcer surface blood vessels to dilate and bleed; spicy foods can stimulate the ulcer surface, increasing gastric acid secretion; cold and hard foods are difficult to digest and can worsen the condition.

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

　　I. Treatment

　　Most patients with gastric ulcer bleeding can be controlled through non-surgical treatment, only considering surgical treatment for those with continuous bleeding or recurrent bleeding after temporary cessation.

　　1. Non-surgical treatment includes the following aspects:

　　(1)General Treatment: Including bed rest, administration of sedatives, such as barbiturate drugs or morphine preparations, to calm the patient's spirit and reduce fear. Close observation of vital signs changes and examination of hemoglobin and red blood cell count are performed as a basis for further treatment. If the patient's general condition is stable, oral ulcer diet can be given, and oral hemostatic drugs, such as Herba epimedii, Yunnan Baiyao, Panax notoginseng, or other hemostatic drugs, can be taken.

　　(2)Blood Transfusion and Fluid Replacement: For patients with severe conditions, blood transfusion or fluid replacement should be given. Commonly used fluids include:

　　①Balanced Salt Solution: Not only can it replenish water loss but also can replace part of blood transfusion. It should be given priority when there is no possibility of blood transfusion for hemorrhagic shock. For every 1 ml of blood loss, 3 ml of balanced salt solution can be given to replenish, and within the first hour, 10 ml per kilogram of body weight can be infused, and then 5 ml per kilogram of body weight per hour can be reduced thereafter.

　　②Dextran: Including low molecular weight dextran and high molecular weight dextran. The high molecular weight ones (molecular weight above 10×10^3) have an effect on blood coagulation, can cause microcirculatory blockage, and are not easy to be excreted from the body, so they are no longer used in clinical practice. The low molecular weight ones (molecular weight about 4×10^3) are beneficial to improve peripheral circulation, and the middle molecular weight ones (molecular weight about 7×10^3) can increase blood volume. Each gram of middle molecular weight dextran can increase plasma volume by 15 ml. For example, 500 ml of 6% dextran containing 30g of dextran can increase plasma volume by 450 ml, which can maintain the effect for 6 to 12 hours. Large amounts of this solution are easy to cause bleeding and renal dysfunction, so the daily dosage should not exceed 1000 ml.

　　③Blood Transfusion: The most effective method to replenish blood volume, so when there is massive bleeding, especially in the presence of symptoms of hemorrhagic shock, blood transfusion should be given. The amount of blood transfusion should be equivalent to the amount of bleeding, but the estimation of blood loss in clinical practice is difficult to be precise, and the complex pathophysiological changes that occur after bleeding are also very complex. Large amounts of blood transfusion can also cause many complications, so it is not necessarily necessary to transfuse all whole blood. Part or most of it can be replaced with balanced salt solution or plasma substitutes. Generally, after blood transfusion, the blood pressure rises to 13.3 kPa (100 mmHg) or above, and the hematocrit rises to about 40%, it can be considered to have reached an ideal level. If the hematocrit decreases by 10%, about 1000 ml of blood transfusion is needed; if it decreases by 5%, about 300 to 500 ml of blood transfusion is needed. When the blood pressure reaches above 13.3 kPa (100 mmHg) after blood transfusion, blood transfusion should be stopped. If the blood pressure decreases again after stopping blood transfusion, it indicates persistent bleeding, and surgery should be considered.

　　(3)Hemostasis:

　　①Gastric Hypothermia Therapy: A special gastric tube with a rubber balloon is inserted into the stomach (the stomach is cleaned with cold saline before inserting the tube to remove residual blood and blood clots), and then a special circulating pump is used to continuously inject and withdraw ice water and alcohol through the tube end to keep the stomach at a low temperature of 24 to 72 hours, maintaining the temperature in the return tube at 5 to 10℃. This method not only reduces bleeding but also decreases gastric secretion. The effective rate of hemostasis is over 80%, but the equipment is relatively complex, the recurrence rate of bleeding is high, and it is more suitable for patients with continuous bleeding and severe complications that are not suitable for surgery.

　　② Cold physiological saline lavage method: 4℃ cold physiological saline is infused through a gastric tube to cause local vasoconstriction in the stomach, and it can also reduce the local ability to dissolve纤维素, thus achieving the purpose of hemostasis. This method is simple and easy to perform, and can be adopted by general hospitals. In recent years, some people have also used norepinephrine solution to achieve good hemostatic effects by injection through the gastric tube. The method is to first clean the residual blood in the stomach after inserting the gastric tube, then inject 100ml of physiological saline solution containing 8mg of norepinephrine through the gastric tube, clamp the tube for 30 minutes. During the clamping period, the patient can change positions, and then rinse with physiological saline to observe for continuous bleeding. This method can be repeated every minute, and the duration can be appropriately extended according to the bleeding situation. Since norepinephrine is absorbed through the portal vein and inactivated in the liver, it has little effect on the cardiovascular system.

　　③ Endoscopic hemostasis:

　　A, Hypertonic sodium-epinephrine solution (HS-E) local injection: After the bleeding site is determined through endoscopy, a plastic tube is inserted through the biopsy hole, the surface blood clots are cleaned, and the HS-E solution is injected directly around the bleeding vessel in 3 to 4 places, 3ml each time, as long as the injection is sure, it can achieve hemostasis. The mechanism is that hypertonic sodium can extend the local action time of epinephrine and can cause edema of the surrounding tissue, fibrosis of the vascular wall, and thrombosis. Hata Yajikuni et al. (1980) reported on 21 cases of 23 times of upper gastrointestinal hemorrhagic lesions, in which 82% achieved permanent hemostasis, 9% temporary hemostasis, and 9% were ineffective after local injection of hypertonic sodium-epinephrine solution.

　　B, Laser photocongelation therapy: After the bleeding site is determined through endoscopy, laser is used for coagulation and hemostasis. Laser is a very dense and powerful light energy, which, when its beam hits an appropriate absorbing surface, the light energy is converted into heat energy, thereby achieving the purpose of coagulation and hemostasis. The lasers currently used include ruby laser, carbon dioxide laser, argon ion laser, and neodymium-yttrium-aluminum-garnet (Nd∶YAG) laser, among which argon ion laser irradiation is most commonly used. Animal experiments and clinical applications have shown that laser irradiation alone often causes damage to the gastric or duodenal wall, even perforation, so some people advocate using CO2 coaxial jet method for laser irradiation. This can reduce the deep damage of the laser to the gastric wall, and before laser irradiation, CO2 is first jetted locally to produce a certain pressure at the vascular rupture site for hemostasis, followed by laser irradiation, which can quickly achieve coagulation and hemostasis. Laurence (1980) reported on 60 cases of gastric or duodenal hemorrhage patients, in which, after the bleeding site was determined by endoscopy, coagulation therapy was performed using argon ion laser through variable弯曲 quartz fiber. In 36 cases with arterial jet hemorrhage, 25 cases (69%) of hemorrhage were controlled, but 3 cases (8.3%) recurred; in 24 cases of chronic ooze bleeding, 23 cases (95.8%) of hemorrhage were controlled, and 2 cases (8.3%) recurred.

　　C. High-frequency coagulation hemostasis: In addition, there are methods such as high-frequency coagulation hemostasis for ulcer bleeding through endoscopy or using a strong magnetic field to press the iron magnetic admixture containing thrombin on the bleeding lesion to achieve hemostasis. These methods have certain clinical effects, but there are few cases, and further research is needed in the future.

　　D. Intra-arterial drug hemostasis: After selective arterial angiography confirms the bleeding site, drugs that constrict blood vessels can be injected through the catheter. The commonly used drug is posterior pituitary vasopressin (pitressin), injected at a rate of 0.1 to 0.3U per minute, and continuously infused for 20 minutes (using an infusion pump). After another angiography can be performed. If the distal arteries show constriction, blood flow into the capillaries, and the venous phase appears, and there is no leakage of the drug, it indicates that the infusion rate is appropriate, and the catheter can be fixed, and continuously infused with an infusion pump for at least 18 to 24 hours, and gradually reduced before discontinuation. Sometimes, due to significant blood loss, the dose of vasopressin can be increased to 0.4U per minute. The catheter is usually removed after 36 to 72 hours, and before removal, 5% glucose infusion can be used for 12 to 24 hours, and then the catheter can be removed.

　　2. Surgical treatment

　　Patients who cannot stop bleeding after non-surgical treatment should undergo surgical treatment. However, the decision to undergo surgery is extremely difficult in clinical practice, as such patients often have a significant amount of blood loss, poor overall condition, and high surgical risk; conversely, if the bleeding does not stop on its own, delaying the timing of surgery will result in more blood loss, and the overall condition will worsen, increasing the surgical risk even more. The situation is full of contradictions, so how to determine whether bleeding can stop on its own when the patient's overall condition is good is the key to deciding the timing of surgery.

　　(1) Indications for surgery: Emergency early surgery should be considered under the following conditions:

　　① The bleeding is extremely rapid, and a significant amount of blood is lost in a short period of time. After the symptoms appear, the patient quickly enters shock, which is mostly due to bleeding from large arteries, which is not easy to stop on its own.

　　② If the blood pressure, pulse, and overall condition do not improve within 6 to 8 hours after the administration of moderate amounts of blood (600 to 800ml), it is likely that the amount of blood loss is significant, or the bleeding is still continuing and relatively rapid. If the condition improves after blood transfusion and then rapidly worsens when the transfusion is stopped or slowed down, it also proves that the bleeding is still continuing.

　　③ There has been a significant hemorrhage in the recent past. Although the bleeding has stopped after non-surgical treatment, there has been a large amount of bleeding again in a short period of time. The bleeding is not easy to stop on its own, and even if it temporarily stops, the possibility of recurrence is still very high. Moreover, the patient's tolerance for surgery is further reduced when bleeding recurs.

　　④ If there is a massive hemorrhage during the period of medical treatment for ulcer disease, the ulcer is erosive, bleeding is not easy to stop spontaneously, and the efficacy of non-surgical treatment is not satisfactory.

　　⑤ If the age is >60 years and there is atherosclerosis, bleeding is difficult to stop spontaneously.

　　⑥ If there is a long and recurrent ulcer history, and the ulcer was confirmed to be located on the posterior wall of the duodenum and the lesser curvature of the stomach before bleeding, the bleeding is likely to come from a larger artery. The base scar tissue of the ulcer is abundant, and bleeding is also difficult to stop spontaneously.

　　Clinical experience shows that surgery within 48 hours of bleeding has a mortality rate

　　(2) Preoperative Preparation: Preoperative preparation should include sufficient blood supply, blood volume supplementation, maintaining a patent venous access, and correcting acid-base and electrolyte balance.

　　(3) Surgical Methods: The primary purpose of the surgery is to stop bleeding, while also treating the ulcer itself. In China, subtotal gastrectomy including ulcers is still commonly used. If the ulcer is difficult to remove, it should be left in place, and non-absorbable sutures should be used to ligate the bleeding point in the left ulcer. If the ulcer is left in place without ligation, the possibility of recurrent bleeding in the near postoperative period is high. Another purpose of the surgery is to prevent recurrent bleeding.

　　During the operation, the first step is to explore and find the bleeding site. If there is active bleeding, stop the bleeding or ligate the corresponding blood vessels first. Then, according to the situation, decide whether to perform subtotal gastrectomy. If the patient's condition is poor, the stomach cavity can also be opened, the bleeding point sutured and ligated, and the corresponding artery blood supply ligated as soon as possible to end the operation early, and then perform an elective operation after the operation.

　　Some scholars believe that it is feasible to perform ligation止血 after suture ligation for duodenal ulcer bleeding, and Li Shiyong and others have performed the operation on 11 cases. After a follow-up of 11 years, there was no recurrence of bleeding or surgical death. Therefore, some people believe that vagotomy combined with suture ligation or vascular ligation is associated with a lower mortality and rebleeding rate than subtotal gastrectomy. For gastric ulcer bleeding, the primary surgical method is still subtotal gastrectomy, with Billroth I anastomosis.

　　II. Prognosis

　　About 10% to 50% of patients with bleeding ulcers may experience recurrent bleeding within 5 years after medical treatment, with a mortality rate of 2% to 10% for surgery. The mortality rate of massive bleeding from duodenal ulcers is higher than that from gastric ulcers. The mortality rate is closely related to age, with a mortality rate of 10% to 15% for those aged ≥60, and 25% to 30% for those aged ≥80, while the overall mortality rate of patients with peptic ulcer bleeding is only 5% to 8%.