Internal bleeding. Dysfunctional uterine bleeding in women By clinical course

O44 Placenta previa

O44.0 Placenta previa, specified as without bleeding

O44.1 Placenta previa with bleeding

O45 Premature placental abruption

O45.0 Premature placental abruption with bleeding disorder

O45.8 Other premature placental abruption

O45.9 Premature placental abruption, unspecified

O46 Antepartum haemorrhage, not elsewhere classified

O46.0 Antepartum haemorrhage with coagulation disorder

O46.8 Other prenatal haemorrhage

O46.9 Antepartum haemorrhage, unspecified

O67 Labor and delivery complicated by haemorrhage during labor, not elsewhere classified

O67.0 Bleeding during childbirth with bleeding disorder

O67.8 Other haemorrhage during childbirth

O67.9 Bleeding during childbirth, unspecified

O69.4 Labor and delivery complicated by vascular presentation

O70 Perineal laceration at delivery

O71 Other obstetric injuries

O71.0 Rupture of uterus before labor begins

O71.1 Rupture of uterus during labor

O71.2 Postpartum uterine inversion

O71.3 Obstetric rupture of cervix

O71.4 Obstetric rupture of upper vagina only

O71.7 Obstetric pelvic hematoma

O72 Postpartum haemorrhage

Includes: bleeding after the birth of a fetus or baby

O72.0 Bleeding during third stage of labor

O72.1 Other early puerperal haemorrhage

O72.2 Late or secondary postpartum haemorrhage

O72.3 Postpartum coagulation defect, afibrinogenemia, fibrinolysis

D68.9 Coagulopathy

R57.1 Hypovolemic shock

O75.1 Maternal shock during labor or after labor and delivery

Risk group of pregnant women for bleeding

An important measure in the prevention of bleeding is the formation of risk groups for the occurrence of this pathology during pregnancy, childbirth and the postpartum period. These groups include pregnant women:

ü with diseases of the kidneys, liver, endocrine glands, hematopoiesis, cardiovascular system and impaired fat metabolism.

ü in the history of which there was infertility of any etiology, ovarian hypofunction, signs of general and genital infantilism, menstrual dysfunction, abortion, complicated labor, inflammatory diseases of the female genital organs.

Timely examination, consultation of related specialists and treatment of pregnant women from the listed risk groups should be carried out.

Causes of bleeding during pregnancy

I. Bleeding in the first half of pregnancy:

1. Bleeding not associated with the pathology of the ovum: "false menstruation", pseudo-erosion, polyps and cervical cancer, vaginal trauma, varicose veins of the external genital organs and vagina.

2. Bleeding associated with the pathology of the ovum: incipient miscarriage, interrupted ectopic pregnancy, cystic drift.

II. Bleeding in the second half of pregnancy and childbirth.

1. Placenta previa.

2. Premature detachment of the normally located placenta.

Bleeding can also occur for reasons such as cervical cancer, genital trauma, varicose veins in the vagina, etc., but they are rare.

Placenta previa

Placenta previa is its incorrect attachment in the uterus, when it is located in the region of the lower uterine segment, above the internal pharynx, partially or completely overlapping it and is located below the presenting part of the fetus, that is, on the path of its birth.

Classification:

1) central presentation - the internal pharynx is completely covered by the placenta;

2) lateral presentation - part of the placenta is presented within the internal pharynx. Near the lobules during vaginal examination, rough fetal membranes are determined;

3) marginal - the lower edge of the placenta is located at the edge of the internal pharynx, without going over it. Within the pharynx, only fetal membranes;

4) low attachment - the placenta is implanted in the lower segment, but its edge does not reach the internal pharynx by 60–70 mm.

There are also complete (central) and incomplete presentation (lateral, marginal).

Etiology and pathogenesis of placenta previa

The main reason for presentation is dystrophic changes in the uterine mucosa.

Predisposing factors:

1) inflammatory processes of the uterus, postpartum septic diseases;

2) a large number of childbirth, abortion;

3) deformation of the uterine cavity, developmental anomalies;

4) uterine fibroids;

5) dysfunction of the ovaries and adrenal cortex;

6) infantilism;

7) smoking;

8) low proteolytic activity of the ovum.

Pathogenesis (theory):

1) primary implantation in the isthmus;

2) migration of the placenta from the body of the uterus;

3) origin from placenta capsularis.

Symptomatology and clinical course of placenta previa

The leading symptom of placenta previa is bleeding. It is based on placental abruption from the walls of the uterus due to its location in the lower segment during pregnancy, and then its rapid deployment during childbirth; the villi of the prevailing placenta, due to its insufficient extensibility, lose their connection with the walls of the uterus, the intervillous spaces are opened. Depending on the type of placenta previa, bleeding may occur during pregnancy or during labor. So, with a central (full) presentation, bleeding often begins early - in the second trimester; with lateral and marginal (incomplete) in the third trimester or in childbirth.

The frequency of bleeding increases in the last 2 weeks of pregnancy, when a complex and diverse restructuring takes place in the woman's body, aimed at the development of the birth act. The severity of bleeding with complete placenta previa is usually greater than with partial placenta previa.

The first bleeding often begins spontaneously, without any trauma, it can be moderate or profuse, and is not accompanied by pain. The severity of a woman's condition in most cases is determined by the volume of external blood loss. Sometimes the first bleeding is so intense that it can be fatal, and repeated repeated bleeding, although very dangerous (leading to anemization of the pregnant woman), may be more favorable in outcome.

Fetal hypoxia is also one of the main symptoms of placenta previa. The degree of hypoxia depends on many factors, the leading of which is the area of \u200b\u200bplacental abruption and its rate.

With placenta previa, pregnancy and childbirth are often complicated by oblique and transverse position of the fetus, breech presentation, prematurity, weakness of labor, violation of the course of the postpartum period due to placental ingrowth, hypo- and atonic bleeding in the early postpartum period, amniotic fluid embolism, and thromboembolism ...

Unlike a correctly located placenta, the placenta presenting is located in the area of \u200b\u200bthe internal os, where an infection inevitably spreads ascending, for which blood clots are a very favorable environment. In addition, the body's defenses are significantly weakened by previous bleeding.

The ascent of the infection is facilitated by diagnostic and therapeutic measures carried out vaginally. Therefore, septic complications with placenta previa occur several times more often compared with pregnant women in whom the placenta is located normally.

Diagnosis of placenta previa

1. anamnesis;

2. objective research (examination, obstetric techniques, auscultation, etc.);

3.vaginal examination only to clarify the diagnosis, with a prepared operating room

* with a closed pharynx, a massive, soft spongy tissue is determined through the vaults;

* when the throat is opened by 3 cm or more, the spongy tissue is palpable together with the membranes;

4. examination of the cervix in the mirrors for diff. diagnostics;

5. Ultrasound is the most objective and safe method.

Tactics for identifying presentation over 24 weeks:

ü hospitalization;

ü repeated ultrasound;

ü Prolongation of pregnancy up to 36–37 weeks in the department of pregnancy pathology.

With bloody discharge, a satisfactory condition of a woman:

ü strict bed rest;

ü antispasmodics;

ü tocolytics;

ü infusion-transfusion therapy;

ü prevention of hypoxia, fetal SDR;

ü hemostatic therapy;

ü vit. E, C, B1, B6.

The choice of delivery method depends on:

1.the volume of blood loss;

2. time of bleeding;

3. the state of pregnancy and fetus;

4. the state of the birth canal;

5. term of pregnancy;

6. forms of presentation and position of the fetus.

Vaginal birth is possible with:

1) partial presentation;

2) insignificant blood loss;

3) good labor activity;

4) a well-pressed head;

5) subject to size matching.

Shown:

1) opening the fetal bladder when the cervix is \u200b\u200bdilated\u003e or equal to 4 cm (early amniotonia), if bleeding continues, then a cesarean section;

2) strengthening of the contractile function of the uterus by intravenous administration of uterotonics;

3) antispasmodics;

4) prevention of hypotonic bleeding;

5) manual separation and allocation of the placenta.

The course of pregnancy and childbirth with placenta previa

Treatment of pregnant women with placenta previa with gestational age over 24 weeks is carried out only in obstetric hospitals. Despite the cessation of bloody discharge from the genital tract, pregnant women with placenta previa should under no circumstances be discharged before childbirth. When choosing a method of treatment, one should be guided primarily by the strength of bleeding, the degree of anemia of the patient, its general condition, the type of placenta previa, the duration of pregnancy and the condition of the fetus.

If the bleeding is insignificant and begins with a premature pregnancy, and the patient's condition is satisfactory, then the following is prescribed: strict bed rest, drugs of myolytic and spasmolytic action, which improve the coordinated nature of the contractile activity of the uterus and a smoother gradual stretching of its lower segment; treating anemia; drugs that improve uteroplacental blood flow and metabolic processes.

To improve metabolic processes, it is imperative to use a complex of vitamins, Essentiale, Lipostabil. It is advisable to appoint teonikol, courantil, suppositories with platifillin. According to indications, sedative therapy is used (infusion of motherwort herb, valerian root, seduxen), as well as antihistamines (diphenhydramine, pipolfen, suprastin).

Laxatives are contraindicated in pregnant women with placenta previa. If necessary, a cleansing enema is prescribed.

Indications for a cesarean section during pregnancy are:

and. repeated blood loss, the volume of which exceeds 200 ml;

b. combination of small blood loss with anemia;

at. instantaneous blood loss 250 ml. and more and ongoing bleeding.

In these cases, the operation is performed for health reasons on the part of the mother, regardless of the gestational age and the condition of the fetus.

A planned cesarean section is performed with complete placenta previa at 38 weeks of gestation, without expecting possible bleeding.

An indication for elective caesarean section may also be partial placenta previa in combination with other obstetric or somatic pathology.

During labor, the indication for abdominal delivery is complete placenta previa.

Indications for partial placenta previa for cesarean section during labor:

1) profuse bleeding with small degrees of dilatation of the uterine pharynx;

2) the presence of concomitant obstetric pathology.

To prevent the progression of detachment of a partially presenting placenta, an amniotomy must be performed in preparation for surgery.

Premature detachment of a normally located placenta

Premature detachment of a normally located placenta is its premature separation (before the birth of a child) from the wall of the uterus.

Etiology.

Predisposing factors:

1) late toxicosis;

2) hypertension;

3) pyelonephritis;

4) submucous uterine myoma;

5) polyhydramnios;

6) multiple pregnancy;

7) autoimmune conditions, allergies;

8) blood diseases;

9) diabetes mellitus;

10) overburdening;

11) hypovitaminosis (vit. E).

Mechanical factors are the deciding factor:

1) mental and physical trauma;

2) short umbilical cord;

3) rapid discharge of amniotic fluid with polyhydramnios;

4) late or premature rupture of the fetal bladder;

5) the rapid birth of the first fetus with monochorionic twins.

Premature detachment is preceded by chronic disorders of the uteroplacental circulation:

and. spasm of arterioles and capillaries;

b. vasculopathy, increased permeability;

at. increased blood viscosity with erythrocyte stasis.

Pathogenesis:

1. Detachment begins with hemorrhages in the decidua basalis;

2. destruction of the basal plate of the decidual tissue;

3. the formation of retroplacental hematoma;

4. detachment: compression, destruction of the adjacent placenta;

5. violation of the contractile function of the uterus, diffuse blood soaking of the myometrium, peritoneum, parametrium (Kuveler's uterus).

Classification:

1) partial detachment: progressive, not progressive

By the nature of bleeding:

1) external;

2) internal;

3) mixed.

Clinic, diagnosis of premature detachment is normal

located placenta

1) spotting of a dark color (it does not intensify during a contraction), there may not be any discharge;

2) acute abdominal pain (especially with retroplacental hematoma);

3) clinic of internal bleeding;

4) hypertonicity of the uterus, it is tense, sharply painful, enlarged, sometimes asymmetric;

5) palpation of the fetus is difficult;

6) fetal hypoxia, palpitations are difficult to listen to;

7) with large blood loss (\u003e 1000 ml), signs of hemorrhagic shock and disseminated intravascular coagulation.

Diagnostics: ultrasound; clinical picture; anamnesis; CTG.

Differential diagnosis with placenta previa

With placenta previa

and. no pain syndrome;

b. external bleeding, scarlet blood;

at. the usual shape and consistency of the uterus, painless;

d. the fetus is well palpated;

e. the heartbeat suffers little;

g. the patient's condition corresponds to the volume of external bleeding;

h. contractions increase bleeding;

and. no signs of peritoneal irritation.

Laboratory tests in patients with blood loss:

1) Blood group, Rh factor;

2) Complete blood count, hemoglobin level, hematocrit, erythrocytes;

3) The number of platelets, fibrinogen concentration, prothrombin time (PTI, INR), activated partial thromboplastin time (APTT), fibrin / fibrinogen degradation products (PDP), thromboelastogram (electrocoagulogram), D-dimer, RFMK blood clotting time -White, Sukharev;

4) Acid-base status, blood gases and plasma lactate levels;

5) Biochemical parameters of blood: total protein and albumin, urea, creatinine, bilirubin, AST, ALT, ALP;

6) Plasma electrolytes: sodium, potassium, chlorine, calcium, magnesium;

7) General analysis of urine;

8) With a known congenital pathology of the hemostatic system, determine the level of deficiency of the corresponding coagulation factor (for example, von Willebrand factor).

4. Clinical studies in patients with blood loss:

1) Measurement of blood pressure sist. and diast., mean blood pressure \u003d (blood pressure syst + 2 blood pressure diast) / 3 - if the indicator is less than 70 - BCC deficiency. Measurement of pulse, respiratory rate, temperature, central venous pressure

2) Calculation of shock index, Algover index (ratio of heart rate to systolic blood pressure (N-0.6-0.8)

3) Capillary filling test - a symptom of a "white spot" - the main sign of a decrease in peripheral blood flow (restoration of the pink color of the nail bed for more than 2 seconds indicates a violation of microcirculation)

4) Auscultation of fetal heart sounds, CTG (according to indications)

5) ultrasound, PDM of the feto-placental complex (according to indications)

6) Ultrasound of the abdominal organs (according to indications)

7) Oxygen saturation

In a serious condition of the patient - hemorrhagic shock - all studies are carried out in the operating room and simultaneously with intensive therapy.

The interval "decision making - delivery" with continued antenatal or intrapartum bleeding should not exceed 30 minutes!

Treatment of premature detachment normally located

placenta

The choice of delivery method and medical tactics depends on:

ü severity of bleeding;

ü condition of mother and fetus;

ü term of pregnancy;

ü the state of the birth canal;

ü state of hemostasis.

For mild detachment during pregnancy:

ü careful control;

ü complete clinical examination;

ü antispasmodics;

ü iron preparations;

ü treatment of fetal hypoxia;

ü correction of hemostasis disorders.

With a pronounced clinical picture during pregnancy, urgent delivery by cesarean section.

Bleeding - the outflow of blood from a blood vessel in case of violation of the integrity or permeability of its wall.

Code for the international classification of diseases ICD-10:

• H92.2
• I85.0
• K62.5
• P50.3
• P50.4
• T79.2

Classification. By etiology .. Traumatic - bleeding as a result of mechanical damage to the blood vessel wall .. Non-traumatic - bleeding as a result of pathological changes in blood vessels (arrosion, wall dissection), for example, atherosclerosis, syphilis, malignant neoplasms, purulent inflammation, blood clotting disorders .. Postoperative bleeding occur in patients with blood clotting disorders (prolonged jaundice, echinococcosis of the liver, DIC), with slipping or eruption of the ligature imposed on the vessel. At the place of bleeding .. External - bleeding into the external environment through damaged skin and mucous membranes .. Internal - bleeding into the lumen of a hollow organ or body cavity: ... in the gastrointestinal tract - gastrointestinal bleeding ... into the bladder - hematuria ... into the uterus - hematometer ... into the trachea and bronchi - pulmonary hemorrhage ... hemorrhages and hematomas. By the time of occurrence .. Primary - bleeding that occurs at the time of injury .. Secondary - bleeding that occurs some time after injury and caused by wound suppuration, blood clotting disorders, etc. ... By the source of bleeding .. Arterial bleeding - blood is bright red, pulsates, flows in a stream. Bleeding from large arteries (aorta, carotid, femoral, brachial) can quickly lead to cardiac arrest. Venous bleeding - dark red blood flows out in a slow stream. Bleeding from large veins (femoral, subclavian, jugular) is life-threatening due to significant blood loss and the possible development of air embolism .. Capillary bleeding - the entire surface of the wound bleeds, as a rule, stops on its own. The danger is represented by capillary bleeding in patients with blood clotting disorders (for example, hemophilia) .. Parenchymal bleeding occurs when tissue of parenchymal organs (liver, kidneys, spleen, etc.) is damaged. The walls of the blood vessels of these organs are fixed and do not collapse; therefore, bleeding rarely stops on its own and leads to large blood loss.

Symptoms (signs)

The clinical picture. Common symptoms are pallor of the skin and mucous membranes, dizziness, weakness, yawning, thirst, tachycardia, decreased blood pressure. In case of development of hemorrhagic shock - loss of consciousness, cold sweat. With prolonged bleeding - a decrease in Hb and Ht (blood dilution). External bleeding is easily diagnosed due to the presence of a wound. Often, with injuries, there is simultaneous damage to both arteries and veins, as a result of which bleeding cannot be unambiguously characterized as arterial or venous. Damage to the great vessels is the most dangerous. Internal bleeding .. In case of bleeding into the abdominal cavity - dullness of percussion sound in the sloping places of the abdominal cavity .. With bleeding into the pleural cavity - dullness of percussion sound, displacement of the mediastinum in the opposite direction, weakening of breathing on the affected side, with X-ray examination - hydrothorax. bleeding into the pericardial cavity - expansion of the borders of the heart, weakening of tones .. Even a small internal blood loss in a confined space can be life-threatening due to blood compression of vital organs (brain, heart).

Treatment

TREATMENT

Temporary stopping of bleeding is aimed at preventing massive blood loss and allows you to gain time for the final stop of bleeding .. Applying a pressure bandage is indicated for stopping small external bleeding: venous, capillary, from arteries of small caliber, bleeding from wounds located on the trunk (for example, on the gluteal region ), forearm, lower leg, scalp. A sterile gauze napkin is applied to the wound, an unwound bandage or improvised material is applied on top, and then a tight circular bandage is applied. Finger pressing of the arteries along the length of the bone stops bleeding almost instantly. The disadvantage is the short duration (10-15 minutes) due to fatigue of the hands of the first aid provider, however, during this time, other methods of stopping bleeding can be applied, for example, a tourniquet ... The common carotid artery is pressed against the transverse process C VI ... Subclavian artery - in the supraclavicular fossa to the 1st rib ... Brachial artery - to the humerus at the inner edge of the biceps muscle on the inner surface of the shoulder ... Femoral artery - to the pubic bone in the middle of the distance between the pubis and the superior anterior iliac spine. The pressure is produced with the thumbs of both hands or with a fist ... The popliteal artery is pressed against the posterior surface of the tibia in the popliteal fossa. The application of a tourniquet is indicated for bleeding from the femoral or brachial arteries. Venous bleeding is stopped with a tight bandage and an elevated position of the limb. Instead of a standard hemostatic tourniquet, various improvised means and cloth twists can be used ... The tourniquet is applied proximal to the wound ... The criterion for the adequacy of the tourniquet is to stop bleeding. Ongoing bleeding may indicate incomplete clamping of the artery and bleeding from simultaneously damaged veins ... The tourniquet must be applied through the lining, cannot be applied to the skin ... The maximum period is 2 hours, after which it is necessary to remove the tourniquet by applying finger pressure to the artery immediately above the wound ... After a short time, apply the tourniquet again, more proximally to the previous level. When applying a tourniquet, the time of application should be recorded (the time is recorded directly on the skin or a piece of paper with the time is left under the tourniquet) .. Maximum flexion of the limb in the joint with additional compression of the vessel due to laying the roller (bandage) over the artery leads to the cessation of bleeding. .. The forearm is maximally bent at the elbow joint and fixed with a bandage to the shoulder ... In case of bleeding from wounds of the upper shoulder and subclavian region, the upper limb is brought behind the back with flexion in the elbow joint and fixed with a bandage or both arms are brought back with flexion in the elbows joints and pull to each other with a bandage ... The lower limb is bent at the knee and hip joints and fixed .. Pressing the vessel in the wound with fingers and applying a clamp to the bleeding vessel is used mainly during surgical interventions.

Final stop of bleeding .. Ligation of a vessel in a wound or throughout .. Sewing of soft tissues and bandaging them together with a vessel in them .. Electrocoagulation of a vessel .. Applying a vascular suture or vessel prosthetics .. Tamponade of a wound .. Pressing a tampon to a wound of a parenchymal organ moistened with hot (50-70 ° C) sterile 0.9% p-rum sodium chloride for 3-5 minutes. Exposure to low temperature .. For parenchymal bleeding - treatment with a scattered laser beam, plasma flow .. Chemical method - use agents (1-2 ml of 0.1% solution of epinephrine) or drugs that increase blood clotting (for example, 10 ml of 10% solution of calcium chloride) .. Biological methods ... Tamponade of the wound with a muscle or omentum ... Application thrombin, fibrin sponges, hemostatic sponges ... Transfusion of drugs and blood components.

The elevated position of the limb and the provision of rest.

ICD-10. H92.2 Bleeding from ear. I85.0 Varicose veins of the esophagus with bleeding. K62.5 Bleeding from anus and rectum. P10 Rupture of intracranial tissue and bleeding due to birth injury. P26 Perinatal pulmonary hemorrhage. P38 Omphalitis of newborn with little or no bleeding. P50.3 Bleeding of another identical twin fetus. P50.4 Bleeding of the fetus into the mother's bloodstream. P51 Newborn umbilical cord haemorrhage. R04 Bleeding from the respiratory tract. T79.2 Traumatic secondary or recurrent bleeding

In Russia, the International Classification of Diseases of the 10th revision (ICD-10) has been adopted as a single normative document to take into account the incidence, reasons for the population's visits to medical institutions of all departments, and causes of death.

ICD-10 was introduced into health care practice throughout the Russian Federation in 1999 by order of the Ministry of Health of Russia dated 05/27/97. No. 170

A new revision (ICD-11) is planned by WHO in 2017 2018.

As amended and supplemented by WHO

Processing and translating changes © mkb-10.com

Coding for gastrointestinal bleeding in ICD

The diagnoses of any medical institution are subject to the unified International Statistical Classification of Diseases and Health Problems, officially approved by WHO.

K92.2 - according to ICD 10, the code of gastrointestinal bleeding, unspecified.

These figures are displayed on the title page of the medical history and processed by the statistics authorities. Thus, data on morbidity and mortality due to various nosological units are structured. Also, the ICD includes a division of all pathological diseases into classes. In particular, gastrointestinal bleeding belongs to the XI class - "Diseases of the digestive system (K 00-K 93)" and to the section "Other diseases of the digestive system (K 90-K93)".

Gastrointestinal bleeding

Gastrointestinal bleeding is a serious pathology associated with damage to blood vessels in the cavity of the gastrointestinal tract and the leakage of blood from them. In such cases, blood loss can be significant, sometimes it leads to shock and can pose a serious threat to the patient's life. Intestinal bleeding in ICD 10 has a code the same as gastrointestinal unspecified - K 92.2.

In any case, this condition is extremely dangerous and requires urgent medical attention. Etiological reasons leading to GCC:

• peptic ulcer of the stomach or duodenum in the acute stage;
• gastroesophageal reflux disease (erosion of the walls of blood vessels by aggressive gastric juice);
• chronic or acute hemorrhagic erosive gastritis;
• nonspecific ulcerative colitis, Crohn's disease;
• chronic inflammation of the esophagus;
• long-term use of non-steroidal anti-inflammatory drugs, glucocorticosteroids, acetylsalicylic acid;
• acute stress and the occurrence of ulcers in the gastrointestinal tract under the influence of ischemia and stress neurotransmitters, hormones;
• hypersecretion of gastrin as a result of Zollinger-Ellison syndrome;
• with strong indomitable vomiting, the occurrence of ruptures in the esophagus, which can bleed;
• enterocolitis and colitis of bacterial origin;
• benign and malignant neoplasms in the gastrointestinal tract;
• portal hypertension.

To find the cause of the bleeding that has occurred, you need to deal with the department that is affected. If there is scarlet blood from the oral cavity, then the esophagus is damaged, if it is black, then this is bleeding from the stomach. Blood unchanged from the anus indicates damage to the lower intestines, if mixed with mucus, feces, with clots - from the upper sections. In any case, regardless of the etiology of bleeding, the HCC code is set according to ICD 10 - K92.2.

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Self-medication can be hazardous to your health. At the first sign of disease, consult a doctor.

ICD code 10 gastrointestinal bleeding

Any diagnosis is strictly subject to a single classification of all diseases and pathologies. A similar classification is officially adopted by WHO. Gastrointestinal bleeding code - K92.2. These figures are noted on the title page of the medical history, and are processed by the relevant statistical bodies. This is how the structuring, fixation of information about pathologies and mortality takes place, taking into account various causes, nosological units. The ICD has a division of all diseases according to classes. Bleeding refers to diseases of the digestive system, as well as other pathologies of these organs.

Etiology and features of treatment of the disease according to ICD 10

Gastrointestinal bleeding is considered a serious disease related to damage to the vessels located in the area of \u200b\u200bthe gastrointestinal tract, as well as the subsequent leakage of blood from them. With such diseases, the tenth convocation adopted a special abbreviation, namely - K 92.2. The international classification indicates that with profuse blood loss, shock can develop, which forms a serious danger and threat to life. The stomach and intestines can be affected at the same time, so emergency medical attention will be needed.

The main causes of bleeding are:

• portal hypertension;
• exacerbation of gastric and duodenal ulcers;
• gastritis;
• inflammatory process in the esophagus;
• crohn's disease;
• nonspecific ulcerative colitis;
• bacterial enterocolitis, colitis;
• long-term use of anti-inflammatory nonsteroidal drugs;
• indomitable vomiting, rupture of the esophagus;
• hypersecretion of gastrin;
• neoplasm in the gastrointestinal tract.

Before starting treatment, it is important to identify the causes of such bleeding, to determine the affected gastrointestinal tract. In the case of scarlet blood coming from the mouth, the esophagus is damaged, but if black blood is observed, the stomach. Blood from the anus signals the defeat of the lower sections of the intestine, when there is feces or mucus in it, we are talking about the defeat of the upper sections.

Treatment can be conservative and prompt. The tactics of conservative therapy is based on the nature of the disease itself, in which bleeding acts as a complication. The principle of such treatment is based on the severity of the condition. If the severity is low, then the patient is prescribed calcium supplements and vitamins, Vikasol injections, as well as a gentle diet. With moderate severity, a blood transfusion, endoscopy with mechanical or chemical action on the bleeding focus is prescribed.

In the case of severe severity, a set of resuscitation actions, an urgent operation, are taken. Postoperative recovery takes place in an inpatient unit. To normalize the functioning of hemostasis, the following drugs are taken: Thrombin, Vikasol, Somatostatin, Omeprazole, Aminocaproic acid and Gastrocepin.

Gastrointestinal bleeding is a dangerous condition that threatens human life. In this situation, it is necessary to seek medical help without delay and not to self-medicate.

First emergency measures for gastric bleeding

They should be distinguished from cavity bleeding that occurs in the gastrointestinal tract (as a result of blunt abdominal injuries, penetrating wounds of the abdominal cavity, intestinal ruptures), but accompanied by the outpouring of blood into the abdominal cavity.

Gastrointestinal bleeding in the medical literature can be referred to as gastrointestinal bleeding, gastrointestinal bleeding syndrome, gastrointestinal bleeding.

Not being an independent disease, gastrointestinal bleeding is a very serious complication of acute or chronic diseases of the gastrointestinal tract, most often - in 70% of cases - arising in patients suffering from peptic ulcer of the duodenum and stomach.

Gastrointestinal bleeding syndrome can develop in any part of the gastrointestinal tract:

The prevalence of bleeding of the gastrointestinal tract is such that they are assigned the fifth position in the general structure of gastroenterological pathologies. The first places, respectively, are taken by: acute appendicitis, cholecystitis, pancreatitis and strangulated hernia.

Most often, male patients suffer from them in age. Among patients admitted to surgical departments in connection with emergency conditions, 9% of cases fall on the share of GCC.

Gastrointestinal bleeding symptoms

The clinical picture of GCC depends on the location of the bleeding source and the degree of hemorrhage. Its pathognomonic signs are represented by the presence of:

• Hematemesis - vomiting of fresh blood, indicating that the source of bleeding (varicose veins or arteries) is localized in the upper gastrointestinal tract. Vomiting, which resembles coffee grounds, due to the effect of gastric juice on hemoglobin, leading to the formation of hydrochloric acid hematin, colored brown, indicates a stopped or slowed down bleeding. Profuse gastrointestinal bleeding accompanied by vomiting of a dark red or scarlet color. A resumption of bloody vomiting that occurs after one to two hours is a sign of ongoing bleeding. If vomiting develops after four to five (or more) hours, the bleeding is repeated.
• Bloody stool, most often indicating the localization of hemorrhage in the lower gastrointestinal tract (blood is secreted from the rectum), but there are cases when this symptom occurs with massive bleeding from the upper gastrointestinal tract, provoking an accelerated transit of blood through the intestinal lumen.
• Tarry - black - stool (melena), usually accompanying hemorrhages arising in the upper gastrointestinal tract, although cases of this manifestation are not excluded with small intestinal and colonic bleeding. In these cases, streaks or clots of scarlet blood may appear in the stool, indicating the localization of the source of bleeding in the colon or rectum. The release of 100 to 200 ml of blood (with hemorrhage from the upper gastrointestinal tract) can provoke the appearance of melena, which can persist for several days after blood loss.

In some patients, black stools without the slightest signs of occult blood may result from the intake of activated charcoal and preparations containing bismuth (De-Nol) or iron (Ferrum, Sorbifer Durules), which give the intestinal contents a black color.

Sometimes such an effect is given by the use of certain products: blood sausage, pomegranates, prunes, black chokeberries, blueberries, black currants. In this case, it is necessary to differentiate this trait with melena.

Severe bleeding is accompanied by shock symptoms, manifested by:

• the appearance of tachycardia;
• tachypnea - rapid shallow breathing, not accompanied by a violation of the respiratory rhythm.
• pallor of the skin;
• increased sweating;
• confusion of consciousness;
• a sharp decrease in urine output (oliguria).

General symptoms of GCC can be represented by:

• dizziness;
• fainting;
• feeling unwell;
• causeless weakness and thirst;
• the release of cold sweats;
• changes in consciousness (agitation, confusion, lethargy);
• pallor of the skin and mucous membranes;
• blueness of the lips;
• blue tips of the fingers;
• lowering blood pressure;
• weakness and rapidity of the pulse.

The severity of general symptoms is determined by the volume and rate of blood loss. Scanty low-intensity bleeding observed during the day can manifest itself:

• slight pallor of the skin;
• a slight increase in heart rate (blood pressure, as a rule, remains normal).

The paucity of clinical manifestations is explained by the activation of the protective mechanisms of the human body, which compensate for blood loss. At the same time, the complete absence of general symptoms is not a guarantee of the absence of bleeding of the gastrointestinal tract.

To identify latent chronic hemorrhage that develops in any part of the gastrointestinal tract, a laboratory study of blood (a sign of bleeding is the presence of anemia) and feces (the so-called Gregersen test for occult blood) is necessary. With blood loss exceeding 15 ml per day, the result is positive.

The clinical picture of GCC is always accompanied by the symptoms of the underlying disease that provoked the complication, including the presence of:

• belching;
• difficulty swallowing;
• ascites (accumulation of fluid in the abdominal cavity);
• nausea;
• manifestations of intoxication.

Forms

In the international classification of diseases of the tenth version (ICD-10), unspecified gastrointestinal bleeding is assigned to the XI class, covering diseases of the digestive system (section "Other diseases of the digestive system") under code 92.2.

The main classification is considered to be the GCC, taking into account their localization in a certain part of the digestive tract. If the source of hemorrhage is the upper parts of the gastrointestinal tract (the incidence of such pathologies is from 80 to 90% of cases), bleeding is:

• esophageal (5% of cases);
• gastric (up to 50%);
• duodenal - from the duodenum (30%).

In diseases of the lower gastrointestinal tract (no more than 20% of cases), bleeding can be:

The ligament that supports the duodenum (the so-called Treitz ligament) is a guideline that allows you to differentiate the gastrointestinal tract into the upper and lower sections.

There are many more classifications of gastrointestinal bleeding syndrome.

1. Depending on the etiopathogenetic mechanism of the occurrence of GLCs, they are ulcerative and non-ulcerative.
2. The duration of pathological hemorrhages - hemorrhages - allows you to subdivide them into acute (profuse and small) and chronic. Profuse bleeding, accompanied by vivid clinical symptoms, leads to a serious condition within several hours. Minor bleeding is characterized by the gradual appearance of signs of growing iron deficiency anemia. Chronic hemorrhages are usually accompanied by long-term recurrent anemia.
3. In terms of the severity of clinical symptoms, GCC can be overt and hidden.
4. Depending on the number of episodes, hemorrhages are recurrent or single.

There is another classification that subdivides GCC into degrees depending on the amount of blood loss:

• With mild gastrointestinal bleeding, a patient who is fully conscious and experiencing slight dizziness is in a satisfactory condition; his diuresis (excretion of urine) is normal. The heart rate (HR) is 80 beats per minute, the systolic pressure is at 110 mm Hg. Art. The circulating blood volume deficit (BCC) does not exceed 20%.
• Moderate GCC leads to a decrease in systolic pressure to 100 mm Hg. Art. and an increase in heart rate up to 100 beats / min. Consciousness continues to persist, but the skin becomes pale and covered with cold sweat, and diuresis is characterized by a moderate decrease. The level of BCC deficiency ranges from 20 to 30%.
• The presence of severe GLC is indicated by weak filling and tension of the heart pulse and its frequency, which is more than 100 beats / min. Systolic blood pressure is less than 100 mm Hg. Art. The patient is inhibited, inactive, very pale, he has either anuria (complete cessation of urine production) or oliguria (a sharp decrease in the volume of urine excreted by the kidneys). BCC deficit is equal to or greater than 30%. Gastrointestinal bleeding, accompanied by massive blood loss, is commonly called profuse.

Causes

In medical sources, more than a hundred diseases are described in detail, capable of provoking the occurrence of gastrointestinal bleeding of varying severity, conventionally attributed to one of four groups.

HCC are subdivided into pathologies caused by:

• lesions of the gastrointestinal tract;
• blood diseases;
• damage to the blood vessels;
• the presence of portal hypertension.

Bleeding caused by damage to the gastrointestinal tract occurs when:

Diseases of the circulatory system can provoke gastrointestinal bleeding syndrome:

• leukemia (acute and chronic);
• hemophilia;
• hypoprothrombinemia - a disease characterized by a deficiency of prothrombin (a clotting factor) in the blood;
• vitamin K vitamin deficiency - a condition caused by a violation of blood coagulation processes;
• idiopathic thrombocytopenic purpura;
• hemorrhagic diathesis - hematological syndromes resulting from violations of one of the links of hemostasis: plasma, platelet or vascular.

Bleeding of the gastrointestinal tract due to vascular damage can develop as a result of:

• systemic lupus erythematosus;
• varicose veins of the stomach and esophagus;
• thrombosis of mesenteric (mesenteric) vessels;
• scleroderma (connective tissue pathology, accompanied by fibro-sclerotic changes in internal organs, articular-muscular apparatus, blood vessels and skin);
• avitaminosis C;
• rheumatism (inflammatory infectious-allergic systemic lesions of connective tissues, localized mainly in the vessels and heart muscle);
• randu-Osler disease (a hereditary disease characterized by persistent expansion of small skin vessels, leading to the appearance of vascular networks or asterisks);
• periarteritis nodosa (a disease leading to inflammatory necrotic lesions of the walls of the visceral and peripheral arteries);
• septic endocarditis (infectious inflammation of the inner lining of the heart muscle);
• atherosclerosis (systemic lesions of medium and large arteries).

Gastrointestinal bleeding that develops against the background of portal hypertension may occur in patients suffering from:

• cirrhosis of the liver;
• thrombosis of the hepatic veins;
• chronic hepatitis;
• constrictive pericarditis (fibrous thickening of the pericardial structures and the emergence of gradually contracting granulation tissue, which forms a dense scar that prevents the full filling of the ventricles);
• squeezing the portal vein with scars or tumors.

In addition to the above ailments, gastrointestinal bleeding can result from:

• alcohol intoxication;
• an attack of severe vomiting;
• taking corticosteroid drugs, aspirin, or nonsteroidal anti-inflammatory drugs;
• contact with certain chemicals;
• exposure to severe stress;
• significant physical stress.

The mechanism of the emergence of the HCC follows one of two scenarios. The impetus for its development can be:

• Violations of the integrity of blood vessels resulting from their erosion, rupture of varicose veins or aneurysms, sclerotic changes, fragility or high permeability of capillaries, thrombosis, rupture of walls, embolism.
• Blood coagulation system pathologies.

Diagnostics

At the initial stage of diagnosing gastrointestinal bleeding, the following is performed:

• Careful collection of anamnesis.
• Assessment of the nature of feces and vomit.
• Physical examination of the patient. Very important information for making a preliminary diagnosis can be provided by the color of the skin. So, hematomas, telangiectasias (vascular networks and asterisks) and petechiae (multiple punctate hemorrhages) on the patient's skin can be manifestations of hemorrhagic diathesis, and yellowness of the skin may indicate varicose esophageal veins or pathology of the hepatobiliary system. Palpation of the abdomen - so as not to provoke an increase in the GIQ - should be carried out with extreme caution. During an examination of the rectum, a specialist may find hemorrhoids or fissures in the anal canal that can be sources of blood loss.

A complex of laboratory tests is of great importance in the diagnosis of pathology:

• The data of the general blood test for GCC indicate a sharp decrease in the level of hemoglobin and a decrease in the number of red blood cells.
• In case of bleeding caused by pathologies of the blood coagulation system, the patient takes a blood test for platelets.
• No less important are the coagulogram data (an analysis that reflects the quality and speed of the blood coagulation process). After profuse blood loss, blood clotting increases significantly.
• Liver function tests are performed to determine the level of albumin, bilirubin and a number of enzymes: ACT (aspartate aminotransferase), ALT (alanine aminotransferase) and alkaline phosphatase.
• Bleeding can be detected using the results of a biochemical blood test, characterized by an increase in urea levels against the background of normal creatinine values.
• The analysis of feces for occult blood helps to reveal hidden bleeding, accompanied by a slight loss of blood, which is not able to change their color.

In the diagnosis of GCC, X-ray techniques are widely used:

• X-ray contrast examination of the esophagus, consisting of two stages. At the first of them, the specialist performs a survey fluoroscopy of internal organs. On the second stage, after taking a sour cream-like barium suspension, a number of targeted X-ray images are performed in two projections (oblique and lateral).
• X-ray of the stomach. The same barium suspension is used to contrast the main digestive organ. Sighting and survey radiography is performed at different positions of the patient's body.
• Irrigoscopy - X-ray contrast study of the colon by tight (through an enema) filling it with a suspension of barium sulfate.
• Celiacography is a radiopaque study of the branches of the abdominal part of the aorta. After puncture of the femoral artery, the doctor places a catheter in the lumen of the celiac trunk of the aorta. After the introduction of a radiopaque contrast agent, a series of images is taken - angiograms.

Endoscopic diagnostic methods provide the most accurate information:

• Fibrogastroduodenoscopy (FGDS) is an instrumental technique that allows for a visual examination of the organs of the upper gastrointestinal tract using a controlled probe - a fibroendoscope. In addition to examination, the EGD procedure (performed either on an empty stomach, under local anesthesia, or under general anesthesia) allows you to remove polyps, remove foreign bodies and stop bleeding.
• Esophagoscopy is an endoscopic procedure used to examine the esophageal tube by inserting an optical instrument - an esophagoscope - through the mouth. It is performed for both diagnostic and therapeutic purposes.
• Colonoscopy is a diagnostic technique designed to inspect the lumen of the large intestine using a flexible optical apparatus - a fibrocolonoscope. The introduction of the probe (through the rectum) is combined with the supply of air, which helps to straighten the folds of the large intestine. Colonoscopy allows for a wide range of diagnostic and therapeutic procedures (up to ultrasound scanning and recording the information received on digital media).
• Gastroscopy is an instrumental technique carried out with the help of a fibroesophagogastroscope and allowing to assess the condition of the stomach and esophagus. Due to the high elasticity of esophagogastroscopes, the risk of injury to the organs under study is significantly reduced. Unlike X-ray methods, gastroscopy is able to detect all kinds of superficial pathologies, and thanks to the use of ultrasonic and Doppler sensors, it allows one to assess the state of regional lymph nodes and walls of hollow organs.

In order to confirm the presence of HCC and determine the place of its exact localization, they resort to a number of radioisotope studies:

• static bowel scintigraphy;
• scintigraphy of the gastrointestinal tract with labeled erythrocytes;
• multispiral computed tomography (MSCT) of the abdominal organs;
• dynamic scintigraphy of the esophagus and stomach.

First aid

In the event of acute gastrointestinal bleeding, it is necessary to provide the patient with first aid:

• The first step is to call an ambulance.
• The patient is immediately put to bed so that his legs are raised above body level. Any manifestations of physical activity on his part are completely unacceptable.
• In the room where the patient lies, it is necessary to open a window or window (for fresh air).
• You should not give the patient any medicine, food or water (this will only provoke increased bleeding). He can swallow small pieces of ice.
• In the presence of severe bleeding, the patient is sometimes given ice-cold aminocaproic acid (no more than 50 ml), 2-3 powdered tablets of dicinone (instead of water, the powder is “washed down” with pieces of ice) or one or two teaspoons of a 10% solution of calcium chloride.
• An ice pack should be placed on the patient's abdomen, which should be removed from time to time (every 15 minutes) to avoid frostbite of the skin. After a three-minute pause, the ice is returned to its original place. In the absence of ice, you can use a hot water bottle with ice water.
• There must be someone near the patient until the ambulance arrives.

How to stop bleeding at home with folk remedies?

• With HCC, the patient needs to create a calm environment. Putting him to bed and putting an ice pack on his stomach, you can give him several pieces of ice: swallowing them accelerates the cessation of bleeding.
• To stop the bleeding, sometimes it is enough to drink 250 ml of tea from a shepherd's purse.
• An infusion of sumach, snake knotweed root, raspberry and virgin hazel leaves, wild alum root has good hemostatic properties. Pour a teaspoon of one of the above herbs with boiling water (200 ml is enough), keep the infusion for half an hour. Drink after straining.
• Taking dry yarrow (a couple of teaspoons), pour 200 ml of boiled water into it and infuse for an hour. After filtration, take four times a day (¼ cup) before meals.

Treatment

All therapeutic measures (they can be both conservative and operational) begin only after making sure of the presence of HCC and after finding its source.

The general tactics of conservative treatment is determined by the nature of the underlying disease, the complication of which was gastrointestinal bleeding.

The principles of conservative therapy depend on the severity of his condition. Patients with low severity are prescribed:

• vicasol injections;
• vitamins and calcium supplements;
• a sparing diet involving the use of pureed food that does not injure the tissue of the mucous membranes.

With bleeding of moderate severity:

• sometimes blood transfusions are performed;
• carry out medical endoscopic procedures, during which they carry out mechanical or chemical action on the source of bleeding.

In relation to patients in extremely serious condition:

• carry out a number of resuscitation measures and urgent surgery;
• postoperative rehabilitation is carried out in a hospital setting.

Medicines

To normalize the hemostatic system, use:

Surgery

In the vast majority of cases, surgical therapy is planned and is carried out after a course of conservative treatment.

The exception is cases of life-threatening conditions that require an emergency surgery.

• In case of bleeding, the source of which is varicose veins of the esophagus, they resort to endoscopic stopping by ligating (applying elastic ligating rings) or clipping (installing vascular clips) of bleeding vessels. To perform this minimally invasive manipulation, an operating gastroduodenoscope is used, into the instrumental canal of which special instruments are introduced: a clipper or ligator. Having brought the working end of one of these instruments to the bleeding vessel, a ligation ring or clip is applied to it.
• Depending on the available indications, in some cases, colonoscopy with chipping or electrocoagulation of bleeding vessels is used.
• Some patients (for example, with a bleeding gastric ulcer) require surgical stopping of the GCC. In such cases, an economical gastrectomy or suturing of the bleeding area is performed.
• In case of bleeding caused by ulcerative colitis, an operation of subtotal colon resection is indicated, followed by the imposition of a sigmostomy or ileostomy.

Diet

• A patient with profuse gastrointestinal bleeding is allowed to eat no earlier than one day after stopping it.
• All food should be lukewarm and liquid or semi-liquid in consistency. Mashed soups, liquid cereals, vegetable purees, light yoghurts, jelly, mousses and jellies are suitable for the patient.
• With the normalization of the condition, the patient's diet is diversified by the gradual introduction of boiled vegetables, meat soufflé, steam fish, soft-boiled eggs, baked apples, omelets. There must be frozen butter, cream and milk on the patient's table.
• Patients whose condition has been stabilized (as a rule, this is observed by the end of 5-6 days), it is recommended to take food every two hours, and its daily volume should be no more than 400 ml.

When animal fats are consumed, blood clotting increases significantly, which helps to accelerate the formation of blood clots in patients with peptic ulcer disease.

How to raise hemoglobin?

Frequent blood loss provokes the onset of iron deficiency anemia - a hematological syndrome characterized by a violation of hemoglobin production due to a lack of iron and manifested by anemia and sideropenia (taste perversion, accompanied by an addiction to chalk, raw meat, dough, etc.).

The following products must be on their table:

• All types of liver (pork, beef, poultry).
• Seafood (crustaceans and shellfish) and fish.
• Eggs (quail and chicken).
• Turnip greens, spinach, celery and parsley.
• Nuts (walnuts, peanuts, pistachios, almonds) and plant seeds (sesame, sunflower).
• All types of cabbage (broccoli, cauliflower, Brussels sprouts, Chinese).
• Potatoes.
• Cereals (buckwheat, millet, oats).
• Corn.
• Persimmon.
• Watermelon.
• Wheat bran.
• Bread (rye and coarse).

Patients with low (100 g / l and below) hemoglobin levels must be prescribed medication. The duration of the course is several weeks. The only criterion for its effectiveness is normal laboratory blood counts.

The most popular drugs are:

In order to prevent an overdose, the patient must strictly follow all the doctor's prescriptions and be aware that the use of tea and coffee slows down the absorption of iron preparations into the blood, and the use of juices (thanks to vitamin C) speeds up.

Complications

Gastrointestinal bleeding is fraught with the development of:

• hemorrhagic shock resulting from massive blood loss;
• acute renal failure;
• acute anemia;
• syndrome of multiple organ failure (a dangerous condition characterized by the simultaneous failure of the functioning of several systems of the human body at once).

Self-medication attempts and late hospitalization of the patient can be fatal.

Prevention

There are no specific measures to prevent HCC. To prevent the occurrence of gastrointestinal bleeding, you must:

• Engage in the prevention of diseases, the complication of which they are.
• Regularly visit the gastroenterologist's office (this will reveal the pathology at the earliest stages).
• Timely treat diseases that can provoke the development of gastrointestinal bleeding syndrome. A qualified specialist should deal with the development of treatment tactics and the appointment of medications.
• Elderly patients have an occult blood test every year.

ICD code: K92.2

Gastrointestinal bleeding, unspecified

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Socket bleeding is capillary-parenchymal bleeding that occurs more often after tooth extraction.

ETIOLOGY AND PATHOGENESIS

The cause of bleeding from the hole of the tooth is tissue trauma, rupture of blood vessels (dental artery, arterioles and capillaries of the periodontal and gums) during operations in the maxillofacial region, more often tooth extraction or injury. After a few minutes, blood clotting in the hole occurs and bleeding stops. However, in some patients, there is a violation of the formation of a clot in the hole, which leads to prolonged bleeding. More often this is due to significant damage to the gums, alveoli, oral mucosa, pathological processes in the maxillofacial region (trauma, bacterial inflammation), less often - the presence of concomitant systemic diseases in the patient (hemorrhagic diathesis, acute leukemia, infectious hepatitis, arterial hypertension, sugar diabetes, etc.), taking drugs that affect hemostasis and reduce blood clotting (NSAIDs, antiplatelet agents, anticoagulants, fibrinolytic drugs, oral contraceptives, etc.).

With prolonged bleeding, the patient's condition worsens, weakness, dizziness, pallor of the skin, acrocyanosis, a decrease in blood pressure and a reflex increase in heart rate appear.

If the patient was injected with a local anesthetic drug with epinephrine, which has a vasoconstrictor effect, when its concentration in the tissues decreases, the vessels dilate and the stopped bleeding can resume, i.e. early secondary bleeding may occur. Later, secondary bleeding occurs after a few hours or days.

CLASSIFICATION

■ Primary bleeding - bleeding does not stop on its own after surgery.

■ Secondary bleeding - bleeding that has stopped after surgery develops again after a while.

CLINICAL PICTURE

Usually, hole bleeding is short-term and after 10-20 minutes. stops on its own. However, a number of patients with concomitant somatic pathology may develop long-term hemorrhagic complications immediately after surgery or after a while due to washing out or disintegration of a thrombus.

DIFFERENTIAL DIAGNOSTICS

When determining the indications for hospitalization of a patient at the prehospital stage, differential diagnosis of bleeding from a tooth socket with the following diseases is necessary.

■ Bleeding with concomitant systemic diseases (hemorrhagic diathesis, acute leukemia, infectious hepatitis, arterial hypertension, diabetes mellitus and other diseases) or after taking drugs that affect hemostasis and reduce blood clotting (NSAIDs, antiplatelet agents, anticoagulants, fibrinolytic drugs, oral other drugs), which requires urgent hospitalization and assistance in a specialized hospital.

■ Bleeding caused by trauma to the gums, alveoli, oral mucosa, pathological processes in the maxillofacial region (trauma, inflammation), which can be stopped at home or by a doctor at an outpatient surgical dental appointment.

TIPS TO CALLER

■ Determine blood pressure.

□ If blood pressure is normal, a sterile gauze pad should be placed over the bleeding area.

□ With high blood pressure, it is necessary to take antihypertensive drugs.

CALL ACTIONS

Diagnostics

MANDATORY QUESTIONS

■ What is the general condition of the patient?

■ What caused the bleeding?

■ When did the bleeding occur?

■ Has the patient rinsed their mouth?

■ Has the patient eaten after surgery?

■ What is the patient's BP?

■ How does bleeding usually stop in the event of tissue damage (cuts and other injuries) in the patient?

■ Is there a fever or chills?

■ How did the patient try to stop the bleeding?

■ What comorbidities does the patient have?

■ What drugs does the patient take?

INSPECTION AND PHYSICAL EXAMINATION

■ External examination of the patient.

■ Examination of the oral cavity.

■ Determination of heart rate.

INSTRUMENTAL STUDIES

Measurement of blood pressure.

Treatment

INDICATIONS FOR HOSPITALIZATION

In case of persistent profuse bleeding that cannot be stopped on an outpatient basis, the patient must be admitted to a surgical dentistry hospital. If the patient has a history of blood disease after the provision of dental care, hospitalization in the hematology department is necessary.

■ If bleeding is caused by trauma to the gums, alveoli, oral mucosa, pathological processes in the maxillofacial region (trauma, inflammation), after stopping the bleeding, it is recommended not to take hot food and drink during the day.

■ Ethamsylate, calcium chloride, calcium gluconate, aminocaproic acid, aminomethyl benzoic acid, ascorbic acid, menadione sodium bisulfite, ascorutin * can be prescribed to improve blood clotting. With elevated blood pressure, antihypertensive therapy is necessary.

COMMON ERRORS

■ Insufficiently complete collection of anamnesis.

■ Incorrectly carried out differential diagnostics, leading to errors in the diagnosis and treatment tactics.

■ Prescribing drugs without taking into account the somatic condition and the drug therapy used by the patient.

■ Aminomethylbenzoic acid appoint orally at a dose of 100-200 mg 3-4 times a day, topically in the form of a sponge.

■ Vitamin C shown internally at a dose of 50-100 mg 1-2 times a day, intramuscularly and intravenously, 1-5 ml of 5-10% solution.

■ Ascorbic acid + rutoside (ascorutin *) appoint inside 1 tablet 2-3 times a day.

CLINICAL PHARMACOLOGY OF DRUGS

■ Any bleeding must be identified as a cause. If bleeding is due to local causes, rinse the well with a solution of hydrogen peroxide, dry it with a gauze swab and carry out a tight tamponade with gauze soaked in hemostatic drugs (thrombin, etc.) or turunda with iodoform * or iodinol *.

■ In case of late secondary bleeding, the hole is washed with an antiseptic drug solution, dried and filled with turunda with hemostatic drugs and an antiseptic. The tamponade can slow down healing, so the tampon should not be in the hole for a long time. To increase blood clotting, ethamsylate, calcium chloride, calcium gluconate, aminocaproic acid, amben *, ascorbic acid, menadione sodium bisulfite, ascorutin can be prescribed. With elevated blood pressure, antihypertensive therapy is necessary.

They should be distinguished from cavity bleeding that occurs in the digestive tract (as a result of blunt, penetrating wounds of the abdominal cavity, intestinal ruptures), but accompanied by the outpouring of blood into the abdominal cavity.

Gastrointestinal bleeding in the medical literature can be referred to as gastrointestinal bleeding, gastrointestinal bleeding syndrome, gastrointestinal bleeding.

Not being an independent disease, gastrointestinal bleeding is a very serious complication of acute or chronic diseases of the gastrointestinal tract, most often - in 70% of cases - arising in patients suffering from the duodenum and stomach.

Gastrointestinal bleeding syndrome can develop in any part of the gastrointestinal tract:

• large and small intestine;
• esophageal tube;
• stomach.

The prevalence of bleeding of the gastrointestinal tract is such that they are assigned the fifth position in the general structure of gastroenterological pathologies. The first places, respectively, are taken by: acute appendicitis, cholecystitis, pancreatitis and strangulated hernia.

Most often, male patients aged 45-60 years suffer from them. Among patients admitted to surgical departments in connection with emergency conditions, 9% of cases fall on the share of GCC.

Gastrointestinal bleeding symptoms

The clinical picture of GCC depends on the location of the bleeding source and the degree of hemorrhage. Its pathognomonic signs are represented by the presence of:

• Hematemesis - vomiting of fresh blood, indicating that the source of bleeding (varicose veins or arteries) is localized in the upper gastrointestinal tract. Vomiting, which resembles coffee grounds, due to the effect of gastric juice on hemoglobin, leading to the formation of hydrochloric acid hematin, colored brown, indicates a stopped or slowed down bleeding. Profuse gastrointestinal bleeding accompanied by vomiting of a dark red or scarlet color. A resumption of bloody vomiting that occurs after one to two hours is a sign of ongoing bleeding. If vomiting develops after four to five (or more) hours, the bleeding is repeated.
• Bloody stool, most often indicating the localization of hemorrhage in the lower gastrointestinal tract (blood is secreted from the rectum), but there are cases when this symptom occurs with massive bleeding from the upper gastrointestinal tract, provoking an accelerated transit of blood through the intestinal lumen.
• Tarry - black - stool (melena), usually accompanying hemorrhages arising in the upper gastrointestinal tract, although cases of this manifestation are not excluded with small intestinal and colonic bleeding. In these cases, streaks or clots of scarlet blood may appear in the stool, indicating the localization of the source of bleeding in the colon or rectum. The release of 100 to 200 ml of blood (with hemorrhage from the upper gastrointestinal tract) can provoke the appearance of melena, which can persist for several days after blood loss.

In some patients, black stools without the slightest signs of occult blood may result from the intake of activated charcoal and preparations containing bismuth (De-Nol) or iron (Ferrum, Sorbifer Durules), which give the intestinal contents a black color.

Sometimes such an effect is given by the use of certain products: blood sausage, pomegranates, prunes, black chokeberries, blueberries, black currants. In this case, it is necessary to differentiate this trait with melena.

Severe bleeding is accompanied by shock symptoms, manifested by:

• appearance;
• tachypnea - rapid shallow breathing, not accompanied by a violation of the respiratory rhythm.
• pallor of the skin;
• increased sweating;
• confusion of consciousness;
• a sharp decrease in urine output (oliguria).

General symptoms of GCC can be represented by:

• dizziness;
• fainting;
• feeling unwell;
• causeless weakness and thirst;
• the release of cold sweats;
• changes in consciousness (agitation, confusion, lethargy);
• pallor of the skin and mucous membranes;
• blueness of the lips;
• blue tips of the fingers;
• lowering blood pressure;
• weakness and rapidity of the pulse.

The severity of general symptoms is determined by the volume and rate of blood loss. Scanty low-intensity bleeding observed during the day can manifest itself:

• slight pallor of the skin;
• a slight increase in heart rate (blood pressure, as a rule, remains normal).

The paucity of clinical manifestations is explained by the activation of the protective mechanisms of the human body, which compensate for blood loss. At the same time, the complete absence of general symptoms is not a guarantee of the absence of bleeding of the gastrointestinal tract.

To identify latent chronic hemorrhage that develops in any part of the gastrointestinal tract, a laboratory study of blood (a sign of bleeding is the presence of anemia) and feces (the so-called Gregersen test for occult blood) is necessary. With blood loss exceeding 15 ml per day, the result is positive.

The clinical picture of GCC is always accompanied by the symptoms of the underlying disease that provoked the complication, including the presence of:

• belching;
• difficulty swallowing;
• ascites (accumulation of fluid in the abdominal cavity);
• nausea;
• manifestations of intoxication.

Forms

In the international classification of diseases of the tenth version (ICD-10), unspecified gastrointestinal bleeding is assigned to the XI class, covering diseases of the digestive system (section "Other diseases of the digestive system") under code 92.2.

Gastrointestinal bleeding in a newborn (code P54.3) is classified in class XVI, including certain conditions arising in the perinatal period.

The main classification is considered to be the GCC, taking into account their localization in a certain part of the digestive tract. If the source of hemorrhage is the upper parts of the gastrointestinal tract (the incidence of such pathologies is from 80 to 90% of cases), bleeding is:

• esophageal (5% of cases);
• gastric (up to 50%);
• duodenal - from the duodenum (30%).

In diseases of the lower gastrointestinal tract (no more than 20% of cases), bleeding can be:

• small intestine (1%);
• colonic (10%);
• rectal (rectal).

The ligament that supports the duodenum (the so-called Treitz ligament) is a guideline that allows you to differentiate the gastrointestinal tract into the upper and lower sections.

There are many more classifications of gastrointestinal bleeding syndrome.

1. Depending on the etiopathogenetic mechanism of the occurrence of GLCs, they are ulcerative and non-ulcerative.
2. The duration of pathological hemorrhages - hemorrhages - allows you to subdivide them into acute (profuse and small) and chronic. Profuse bleeding, accompanied by vivid clinical symptoms, leads to a serious condition within several hours. Minor bleeding is characterized by the gradual appearance of signs of growing iron deficiency anemia. Chronic hemorrhages are usually accompanied by long-term recurrent anemia.
3. In terms of the severity of clinical symptoms, GCC can be overt and hidden.
4. Depending on the number of episodes, hemorrhages are recurrent or single.

There is another classification that subdivides GCC into degrees depending on the amount of blood loss:

• With mild gastrointestinal bleeding, a patient who is fully conscious and experiencing slight dizziness is in a satisfactory condition; his diuresis (excretion of urine) is normal. The heart rate (HR) is 80 beats per minute, the systolic pressure is at 110 mm Hg. Art. The circulating blood volume deficit (BCC) does not exceed 20%.
• Moderate GCC leads to a decrease in systolic pressure to 100 mm Hg. Art. and an increase in heart rate up to 100 beats / min. Consciousness continues to persist, but the skin becomes pale and covered with cold sweat, and diuresis is characterized by a moderate decrease. The level of BCC deficiency ranges from 20 to 30%.
• The presence of severe GLC is indicated by weak filling and tension of the heart pulse and its frequency, which is more than 100 beats / min. Systolic blood pressure is less than 100 mm Hg. Art. The patient is inhibited, inactive, very pale, he has either anuria (complete cessation of urine production) or oliguria (a sharp decrease in the volume of urine excreted by the kidneys). BCC deficit is equal to or greater than 30%. Gastrointestinal bleeding, accompanied by massive blood loss, is commonly called profuse.

Causes

In medical sources, more than a hundred diseases are described in detail, capable of provoking the occurrence of gastrointestinal bleeding of varying severity, conventionally attributed to one of four groups.

HCC are subdivided into pathologies caused by:

• lesions of the gastrointestinal tract;
• blood diseases;
• damage to the blood vessels;
• the presence of portal hypertension.

Bleeding caused by damage to the gastrointestinal tract occurs when:

• peptic ulcer of the stomach or duodenum;
• presence, neoplasms in and;
• ulcerative colitis;
• hemorrhoids;
• helminthiasis;
• the presence of anal fissures;
• ingress of foreign bodies;
• injuries.

Diseases of the circulatory system can provoke gastrointestinal bleeding syndrome:

• (acute and chronic);
• hemophilia;
• hypoprothrombinemia - a disease characterized by a deficiency of prothrombin (a clotting factor) in the blood;
• vitamin K vitamin deficiency - a condition caused by a violation of blood coagulation processes;
• idiopathic thrombocytopenic purpura;
• hemorrhagic diathesis - hematological syndromes resulting from violations of one of the links of hemostasis: plasma, platelet or vascular.

Bleeding of the gastrointestinal tract due to vascular damage can develop as a result of:

• systemic lupus erythematosus;
• varicose veins of the stomach and;
• mesenteric (mesenteric) vessels;
• (connective tissue pathology, accompanied by fibrosclerotic changes in internal organs, articular-muscular apparatus, blood vessels and skin);
• avitaminosis C;
• rheumatism (inflammatory infectious-allergic systemic lesions of connective tissues, localized mainly in the vessels and heart muscle);
• randu-Osler disease (a hereditary disease characterized by persistent expansion of small skin vessels, leading to the appearance of vascular networks or asterisks);
• (a disease leading to inflammatory-necrotic damage to the walls of the visceral and peripheral arteries);
• (infectious inflammation of the inner lining of the heart muscle);
• (systemic lesions of medium and large arteries).

Gastrointestinal bleeding that develops against the background of portal hypertension may occur in patients suffering from:

• cirrhosis of the liver;
• chronic hepatitis;
• (fibrous thickening of the pericardial structures and the emergence of gradually contracting granulation tissue, which forms a dense scar that prevents the full filling of the ventricles);
• squeezing the portal vein with scars or tumors.

In addition to the above ailments, gastrointestinal bleeding can result from:

• alcohol intoxication;
• an attack of severe vomiting;
• taking corticosteroid drugs, aspirin, or nonsteroidal anti-inflammatory drugs;
• contact with certain chemicals;
• exposure to severe stress;
• significant physical stress.

The mechanism of the emergence of the HCC follows one of two scenarios. The impetus for its development can be:

• Violations of the integrity of blood vessels resulting from their erosion, rupture of varicose veins or aneurysms, sclerotic changes, fragility or high permeability of capillaries, thrombosis, rupture of walls, embolism.
• Blood coagulation system pathologies.

Diagnostics

At the initial stage of diagnosing gastrointestinal bleeding, the following is performed:

• Careful collection of anamnesis.
• Assessment of the nature of feces and vomit.
• Physical examination of the patient. Very important information for making a preliminary diagnosis can be provided by the color of the skin. So, hematomas, telangiectasias (vascular networks and asterisks) and petechiae (multiple punctate hemorrhages) on the patient's skin can be manifestations of hemorrhagic diathesis, and yellowness of the skin may indicate varicose esophageal veins or pathology of the hepatobiliary system. Palpation of the abdomen - so as not to provoke an increase in the GIQ - should be carried out with extreme caution. During an examination of the rectum, a specialist may find hemorrhoids or fissures in the anal canal that can be sources of blood loss.

A complex of laboratory tests is of great importance in the diagnosis of pathology:

• The data of the general blood test for GCC indicate a sharp decrease in the level of hemoglobin and a decrease in the number of red blood cells.
• In case of bleeding caused by pathologies of the blood coagulation system, the patient takes a blood test for platelets.
• No less important are the coagulogram data (an analysis that reflects the quality and speed of the blood coagulation process). After profuse blood loss, blood clotting increases significantly.
• Liver function tests are performed to determine the level of albumin, bilirubin and a number of enzymes: ACT (aspartate aminotransferase), ALT (alanine aminotransferase) and alkaline phosphatase.
• Bleeding can be detected using the results of a biochemical blood test, characterized by an increase in urea levels against the background of normal creatinine values.
• The analysis of feces for occult blood helps to reveal hidden bleeding, accompanied by a slight loss of blood, which is not able to change their color.

In the diagnosis of GCC, X-ray techniques are widely used:

• X-ray contrast examination of the esophagus, consisting of two stages. At the first of them, the specialist performs a survey fluoroscopy of internal organs. On the second stage, after taking a sour cream-like barium suspension, a number of targeted X-ray images are performed in two projections (oblique and lateral).
• X-ray of the stomach. The same barium suspension is used to contrast the main digestive organ. Sighting and survey radiography is performed at different positions of the patient's body.
• Irrigoscopy - X-ray contrast study of the colon by tight (through an enema) filling it with a suspension of barium sulfate.
• Celiacography is a radiopaque study of the branches of the abdominal part of the aorta. After puncture of the femoral artery, the doctor places a catheter in the lumen of the celiac trunk of the aorta. After the introduction of a radiopaque contrast agent, a series of images is taken - angiograms.

Endoscopic diagnostic methods provide the most accurate information:

• Fibrogastroduodenoscopy (FGDS) is an instrumental technique that allows for a visual examination of the organs of the upper gastrointestinal tract using a controlled probe - a fibroendoscope. In addition to examination, the EGD procedure (performed either on an empty stomach, under local anesthesia, or under general anesthesia) allows you to extract and stop bleeding.
• Esophagoscopy is an endoscopic procedure used to examine the esophageal tube by inserting an optical instrument - an esophagoscope - through the mouth. It is performed for both diagnostic and therapeutic purposes.
• Colonoscopy is a diagnostic technique designed to inspect the lumen of the large intestine using a flexible optical apparatus - a fibrocolonoscope. The introduction of the probe (through the rectum) is combined with the supply of air, which helps to straighten the folds of the large intestine. Colonoscopy allows for a wide range of diagnostic and therapeutic procedures (up to ultrasound scanning and recording the information received on digital media).
• Gastroscopy is an instrumental technique carried out with the help of a fibroesophagogastroscope and allowing to assess the condition of the stomach and esophagus. Due to the high elasticity of esophagogastroscopes, the risk of injury to the organs under study is significantly reduced. Unlike X-ray methods, gastroscopy is able to detect all kinds of superficial pathologies, and thanks to the use of ultrasonic and Doppler sensors, it allows one to assess the state of regional lymph nodes and walls of hollow organs.

In order to confirm the presence of HCC and determine the place of its exact localization, they resort to a number of radioisotope studies:

• static bowel scintigraphy;
• scintigraphy of the gastrointestinal tract with labeled erythrocytes;
• multispiral computed tomography (MSCT) of the abdominal organs;
• dynamic scintigraphy of the esophagus and stomach.

When diagnosing gastrointestinal bleeding, it is imperative to differentiate them from nasopharyngeal and pulmonary bleeding. This requires a number of endoscopic and radiological examinations of the nasopharynx and bronchi.

First aid

In the event of acute gastrointestinal bleeding, it is necessary to provide the patient with first aid:

• The first step is to call an ambulance.
• The patient is immediately put to bed so that his legs are raised above body level. Any manifestations of physical activity on his part are completely unacceptable.
• In the room where the patient lies, it is necessary to open a window or window (for fresh air).
• You should not give the patient any medicine, food or water (this will only provoke increased bleeding). He can swallow small pieces of ice.
• In the presence of severe bleeding, the patient is sometimes given ice-cold aminocaproic acid (no more than 50 ml), 2-3 powdered tablets of dicinone (instead of water, the powder is “washed down” with pieces of ice) or one or two teaspoons of a 10% solution of calcium chloride.
• An ice pack should be placed on the patient's abdomen, which should be removed from time to time (every 15 minutes) to avoid frostbite of the skin. After a three-minute pause, the ice is returned to its original place. In the absence of ice, you can use a hot water bottle with ice water.
• There must be someone near the patient until the ambulance arrives.

How to stop bleeding at home with folk remedies?

• With HCC, the patient needs to create a calm environment. Putting him to bed and putting an ice pack on his stomach, you can give him several pieces of ice: swallowing them accelerates the cessation of bleeding.
• To stop the bleeding, sometimes it is enough to drink 250 ml of tea from a shepherd's purse.
• An infusion of sumach, snake knotweed root, raspberry and virgin hazel leaves, wild alum root has good hemostatic properties. Pour a teaspoon of one of the above herbs with boiling water (200 ml is enough), keep the infusion for half an hour. Drink after straining.
• Taking dry yarrow (a couple of teaspoons), pour 200 ml of boiled water into it and infuse for an hour. After filtration, take four times a day (¼ cup) before meals.

Treatment

All therapeutic measures (they can be both conservative and operational) begin only after making sure of the presence of HCC and after finding its source.

The general tactics of conservative treatment is determined by the nature of the underlying disease, the complication of which was gastrointestinal bleeding.

The principles of conservative therapy depend on the severity of his condition. Patients with low severity are prescribed:

• vicasol injections;
• vitamins and calcium supplements;
• a sparing diet involving the use of pureed food that does not injure the tissue of the mucous membranes.

With bleeding of moderate severity:

• sometimes blood transfusions are performed;
• carry out medical endoscopic procedures, during which they carry out mechanical or chemical action on the source of bleeding.

In relation to patients in extremely serious condition:

• carry out a number of resuscitation measures and urgent surgery;
• postoperative rehabilitation is carried out in a hospital setting.

Medicines

To normalize the hemostatic system, use:

• "Aminocaproic acid."
• "Vikasol".
• Etamsilat.
• Octreotide.
• "Thrombin".
• Omeprazole.
• "Vasopressin".
• "Gastrocepin".
• "Somatostatin".

Surgery

In the vast majority of cases, surgical therapy is planned and is carried out after a course of conservative treatment.

The exception is cases of life-threatening conditions that require an emergency surgery.

• In case of bleeding, the source of which is varicose veins of the esophagus, they resort to endoscopic stopping by ligating (applying elastic ligating rings) or clipping (installing vascular clips) of bleeding vessels. To perform this minimally invasive manipulation, an operating gastroduodenoscope is used, into the instrumental canal of which special instruments are introduced: a clipper or ligator. Having brought the working end of one of these instruments to the bleeding vessel, a ligation ring or clip is applied to it.
• Depending on the available indications, in some cases, colonoscopy with chipping or electrocoagulation of bleeding vessels is used.
• Some patients (for example, with a bleeding gastric ulcer) require surgical stopping of the GCC. In such cases, an economical operation or stitching of the bleeding area is performed.
• In case of bleeding caused by ulcerative colitis, colon surgery followed by sigmoidostomy or ileostomy is indicated.

Diet

• A patient with profuse gastrointestinal bleeding is allowed to eat no earlier than one day after stopping it.
• All food should be lukewarm and liquid or semi-liquid in consistency. Mashed soups, liquid cereals, vegetable purees, light yoghurts, jelly, mousses and jellies are suitable for the patient.
• With the normalization of the condition, the patient's diet is diversified by the gradual introduction of boiled vegetables, meat soufflé, steam fish, soft-boiled eggs, baked apples, omelets. There must be frozen butter, cream and milk on the patient's table.
• Patients whose condition has been stabilized (as a rule, this is observed by the end of 5-6 days), it is recommended to take food every two hours, and its daily volume should be no more than 400 ml.

Reducing hemorrhagic syndrome is facilitated by foods containing a large amount of vitamins P and C (especially a lot of them in rosehip broth, vegetable and fruit juices), as well as vitamin K (contained in butter, sour cream and cream).

When animal fats are consumed, blood clotting increases significantly, which helps to accelerate the formation of blood clots in patients with peptic ulcer disease.

How to raise hemoglobin?

Frequent blood loss provokes the onset of iron deficiency anemia - a hematological syndrome characterized by a violation of hemoglobin production due to a lack of iron and manifested by anemia and sideropenia (taste perversion, accompanied by an addiction to chalk, raw meat, dough, etc.).

The following products must be on their table:

• All types of liver (pork, beef, poultry).
• Seafood (crustaceans and shellfish) and fish.
• Eggs (quail and chicken).
• Turnip greens, spinach, celery and parsley.
• Nuts (walnuts, peanuts, pistachios, almonds) and plant seeds (sesame, sunflower).
• All types of cabbage (broccoli, cauliflower, Brussels sprouts, Chinese).
• Potatoes.
• Cereals (buckwheat, millet, oats).
• Corn.
• Persimmon.
• Watermelon.
• Wheat bran.
• Bread (rye and coarse).

Patients with low (100 g / l and below) hemoglobin levels must be prescribed medication. The duration of the course is several weeks. The only criterion for its effectiveness is normal laboratory blood counts.

The most popular drugs are:

• "Hemohelper".
• Maltofer.
• Sorbifer.
• Ferlatum.
• Aktiferrin.

In order to prevent an overdose, the patient must strictly follow all the doctor's prescriptions and be aware that the use of tea and coffee slows down the absorption of iron preparations into the blood, and the use of juices (thanks to vitamin C) speeds up.

Another feature of treatment with iron preparations is that after assimilation of a portion of iron, intestinal cells will lose their susceptibility to this microelement for the next six hours, so it makes no sense to take these drugs more than twice a day.

Complications

Gastrointestinal bleeding is fraught with the development of:

• hemorrhagic shock resulting from massive blood loss;
• acute renal failure;
• acute anemia;
• syndrome of multiple organ failure (a dangerous condition characterized by the simultaneous failure of the functioning of several systems of the human body at once).

Self-medication attempts and late hospitalization of the patient can be fatal.

Prevention

There are no specific measures for the prevention of HCC. To prevent the occurrence of gastrointestinal bleeding, you must:

• Engage in the prevention of diseases, the complication of which they are.
• Regularly visit the gastroenterologist's office (this will reveal the pathology at the earliest stages).
• Timely treat diseases that can provoke the development of gastrointestinal bleeding syndrome. A qualified specialist should deal with the development of treatment tactics and the appointment of medications.
• Elderly patients have an occult blood test every year.