Obsure gastro-intestinal bleedings – peculiarities of diagnostics, treatment and prophylaxis

Abstract

Introduction. Acute gastrointestinal bleeding (AGIB) is a life-threatening complication of a number of diseases, which requires differentiated clinical, laboratory, endoscopic and radiological examinations, often surgical interventions, usually urgent hospitalization into surgical departments. In USA, 513 million patients with AGIB are hospitalized annually and the costs of their treatment reach 5 billion dollars. According to the classification of the American Association of Gastroenterologists, AGIB are divided into upper, the source of which is above the ligament of Treitz and the corresponding duodeno-jejunal transition (esophagus, stomach, duodenum), and lower (jejunum and ileum, colon). The most common causes of upper AGIB are esophageal/gastric varices due to portal hypertension, chronic peptic ulcers, benign and malignant tumors; lower – neoplasms, diverticulosis, polyps. The aim of the study. To find out the frequency of obsure AGIB, peculiarities of its diagnosis, treatment and prevention. Materials and methods. The retrospective study covered 89 patients with AGIB (acute gastro-intestinal bleeding), who were treated in 2021–2022. Age range was 44-90 (average – 59.3±6.4). Men prevailed – 55 (61.8%). Complaints of patients caused by AGIB were: dizziness, general weakness (100%), melaena (87.6%), blood vomiting and melaena (50.6%), loss of consciousness (14.6%), unchanged blood in feces (7.9%). The duration of AGIB before hospitalization was within 1–7 days (average – 1.6±0.2). Communication with hospitalized patients revealed a number of previous and concomitant diseases: arterial hypertension (56.2%), coronary heart disease (39.3%), previous myocardial infarction (11.2%), thrombo-ischemic stroke (7.9%), peptic ulcer disease of stomach (38.2%), duodenal ulcer (36%), diverticular disease of the colon (6.7%), chronic pathology of the musculoskeletal system – coxarthrosis, osteochondrosis (14.5%) and others. Hypotension (80/40–106/65 mm Hg) and tachycardia (100-121 bpm) were noticed during the objective examination. Anemia (men – less than 130 g/l, women – less than 120 g/l) was found in all hospitalized patients. Non-steroidal anti-inflammatory drugs – NSAIDs (diclofenac, aspirin etc.) were taken for a long time (at least 1 month) by 54.8% of patients and only by 5.1% – in combination with tablet proton pump inhibitors for the purpose of primary or secondary prevention of myocardial infarction or joint-bone pain. In all cases, esophago-gastro-duodenoscopy (EGDS) was performed. Detection of peptic ulcer of the stomach and/or duodenum with continuous bleeding or unstable hemostasis served as an indication for combined hemostasis (injectional and argonic plasma coagulation). Multiple acute erosions and ulcers of the stomach and duodenum were found in 6.9% of patients. The absence of an obvious source of bleeding during EGDS and blood discharge with feces had determined the need for fibrocolonoscopy (FCS). In 6 patients (6.7%), the presence of obsure bleeding was ascertained, since EGDS and FCS did not reveal sources of hemorrhage. In all patients, it was manifested by the release of slightly changed blood mixed with fecal matter. All patients noted long-term use of NSAIDs due to the reasons above. Two patients died from acute transmural myocardial infarction. Obsure bleeding was found in 6 (6.7%) patients with AGIB. None of the methods of enteroscopy were used due to the lack of appropriate equipment, which is characteristic of most medical institutions in Ukraine. Conservative treatment turned out to be successful in all cases and consisted in stopping the use of NSAIDs and continued hemostatic therapy. Two male patients were prescribed misoprostol 200 mg four times a day for 8 weeks. Side effects were not observed. Conclusions. 1. Bleeding from the digestive tract should be considered obsure if there is no source of its occurrence according to the data of EGDS and FCS. 2. Obsure bleeding was found in 6.7% of those hospitalized with AGIB. 3. Without exception, all patients with obsure bleeding took NSAIDs for 1 month or more. 4. The empirical presoription of the synthetic prostaglandin misoprostol is pathogenetically justified in patients with obsure bleeding.