Etiology and clinical features
Intestinal bleeding is most often a severe complication of underlying pathologies. In surgical practice, special attention is paid to patients receiving long-term glucocorticoid (GC) therapy. Ulcerative lesions of the stomach and duodenum associated with GCs are insidious: they can manifest with nonspecific abdominal pain and dyspeptic symptoms. However, the disease is frequently asymptomatic, immediately manifesting as life-threatening complications—massive bleeding or ulcer perforation.
Another important cause is infectious processes, in particular typhoid and paratyphoid diseases (typhoid fever, paratyphoid A, salmonellosis). The diagnosis is usually established based on the typical clinical picture of the infection, but a sharp change in the patient's condition indicates the development of a specific complication: intestinal bleeding.
Classic clinical markers of acute blood loss include:
- Sudden hypotension and severe dizziness.
- A paradoxical hemodynamic reaction (characteristic of typhoid and paratyphoid infections): increasing tachycardia accompanied by a drop in body temperature.
Instrumental and laboratory diagnostics
The gold standard for visualizing the upper gastrointestinal tract is esophagogastroduodenoscopy (EGD). The procedure is completely safe for the fetus at any stage of pregnancy.
EGD is indicated in the following situations:
- Diagnostically unclear cases.
- Suspicion of complications (gastrointestinal bleeding, antral stenosis, gastric cancer).
- Suspicion of a perforated ulcer (PU) with an ambiguous clinical and instrumental picture (absence of classic symptoms of peritonitis and radiological signs of pneumoperitoneum).
- Need to identify other complications of peptic ulcer disease (pyloroduodenal zone stenosis).
When examining patients with ulcers associated with GCs, endoscopy is supplemented by a biopsy and a test for Helicobacter pylori.
If massive blood loss is absent, but there is a risk of microdiapedesis, occult (hidden) bleeding is diagnosed. This includes a fecal occult blood test and a complete blood count (CBC).
Emergency diagnostic algorithm
When clinical markers of bleeding are detected, diagnostic measures are performed urgently and include a number of mandatory steps:
- Blood tests: urgent determination of blood parameters — hemoglobin (Hb) level, erythrocyte count, and hematocrit.
- Immunohematology: determination of blood group and Rh factor (blood sampling must be performed strictly on the day of the patient's admission to the hospital).
- Physical examination: visual inspection of the patient's feces. If absent, a digital rectal examination must be performed to detect traces of blood.
- Anamnesis: clarification of the results of previously performed bacteriological and serological studies (critically important when an infectious origin of bleeding is suspected).
Management tactics and regimen
Treatment of a patient with signs of bleeding begins with immediate conservative measures aimed at stabilizing hemodynamics and stopping blood loss.
The patient is subject to continuous dynamic monitoring of their condition. A strict bed rest regimen is prescribed, and the patient must be provided with complete physical and psycho-emotional rest.
Mandatory regimen measures:
- NPO (nil per os) — complete exclusion of food intake by mouth.
- Cold application to the abdomen — to induce local vascular spasm.
Once the fact of bleeding is definitively confirmed, specific hemostatic therapy is urgently indicated for the patient.
The "Three Ns" rule (in Russian: Holod, Golod, Gemostaz / Cold, NPO, Hemostasis) for suspected bleeding: NPO, Hypothermia (cold on the abdomen), Hemostasis. And a mandatory condition is a strict Horizontal (bed rest) position.
Class and exam questions
Can EGD be performed in pregnant women with suspected bleeding?
Yes, esophagogastroduodenoscopy is considered a safe procedure for the fetus and is performed at any stage of pregnancy according to indications.
How to detect occult bleeding if there are no obvious symptoms?
To rule out occult bleeding, a fecal occult blood test and a complete blood count (CBC) are used.
What should a surgeon do if the patient has no stool to evaluate feces?
In this case, the gold standard is the immediate performance of a digital rectal examination to detect traces of blood.
What vital sign dynamics are characteristic of bleeding in typhoid fever?
A specific clinical marker is the paradoxical reaction: the patient develops increasing tachycardia against the background of falling body temperature and hypotension.
What else to study on this topic
- Clinical manifestations of gastric and duodenal ulcers during GC therapy.
- Differential diagnosis of ulcer perforation: absence of symptoms of peritonitis and pneumoperitoneum.
- Specifics of typhoid and paratyphoid diseases (typhoid fever, paratyphoid A, salmonellosis) and their complications.
- Methodology for performing biopsy and testing for H. pylori during endoscopy.
- Interpretation of emergency blood parameters: hemoglobin, erythrocytes, hematocrit.
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