Dutka and Grynchuk: Determination of the Risk of Recurrent Gastroduodenal Ulcer Bleeding



Problem statement and analysis of the recent research

The problem of gastric and duodenal ulcer complicated by acute bleeding remains relevant today. Despite significant advances in conservative treatment of peptic ulcer, the incidence of acute bleeding from gastric ulcers of has increased recently [1, 2]. Acute gastrointestinal bleeding (AGB) complicate a number of other diseases as well; its incidence is 50-150 cases per 100,000 population annually [3]. Despite the advances in endoscopic haemostasis, the incidence of recurrent ulcer bleeding remains to be high [4, 5], which necessitates further search for its prognosis and methods of treatment.

The objective of the research was to analyse risk factors for recurrent gastroduodenal ulcer bleeding.

Materials and methods of the research

The study included 203 patients with gastroduodenal ulcer bleeding. There were 13 (66.5%) males and 68 (33.3%) females. The average age was 56.6±17 years. All the patients were examined and received conservative treatment according to treatment protocols [3].

Results of the research and their discussion

In most cases ulcerative defects were localized in the duodenum - 127 (62.3%) patients. Gastric ulcer was diagnosed in 68 (33.3%) patients. Gastrodoudenal ulcer occurred in 9 (4.4%) patients. Regardless of the ulcer location its incidence was higher in men rather than in women. The absence of ulcer in anamnesis was detected in most cases (n = 109 (53.4%). There were 10 (4.9%) patients suffering from ulcer for 1 year, 21 (10.3%) patients suffering from ulcer for 1-2 years, 16 (7.8%) people suffering from peptic ulcer for 5-10 years, and 39 (19.2%) patients suffering from ulcer for more than 10 years. After primary esophagogastroduodenoscopy (EGD) patients underwent at least one EGD within the next 3 days in order to control haemostasis and treatment effectiveness. In addition, in 31 (15.2%) cases more than one control EGD was performed. If necessary, endoscopic haemostasis was performed during control EGD.

We made some injections around ulcer using sodium chloride solution and adrenaline in the ratio of 1:10 or preparations of tranexamic acid (tranexam, hemaxam) in the same proportion. The injections were made at the periphery of ulcer. The rate of occurrences depending on ulcer location and other factors was 2-5%. In case of the failure to achieve adequate haemostasis endoscopically surgery was performed.

The recurrence of bleeding was observed in 24 (11.8%) cases. Most cases of recurrent bleeding (n=11 (45.8%) occurred within 2-3 days after the admission. 9 (37.5%) patients developed the recurrence of bleeding later. The lowest number of recurrent bleeding occurred within the first day - 4 (16.7%) cases. The incidence of recurrent bleeding was higher in men rather than in women - 17 (70.8%). Recurrent bleeding was observed in 9 (64.29%) patients with blood type O; 4 (28.57%) patients with blood type A; 1 (7.14%) patient with blood type B; 1 (7.14%) patient with blood type AB. The majority of recurrences (n=15 (62.5%) occurred in patients without ulcer in anamnesis. There was found no clear connection between ulcer location and the rate of recurrent bleeding.

The aforementioned data show that the major scales of predicting risk of bleeding need to be improved. In particular, the most common Forrest classification [6] is static without considering the consequences of endoscopic treatment, local features, and mechanisms of bleeding occurrence. The Glasgow-Blatchford bleeding score [7] is based only on clinical and laboratory manifestations ignoring endoscopic stigmata of bleeding. The Rockall scale [8] is based on a combination of clinical and endoscopic criteria. It allows estimating the possibility of the recurrence during the initial endoscopic examination, making it more acceptable. However, the given scale does not take into account all the possible factors contributing to the recurrence.

It should be noted that the most common ways of estimating the risk of recurrent bleeding are mainly based on clinical observations ignoring the activity of haemostasis mechanisms, regeneration processes etc. It does not allow estimating their potential possibilities as wells as to identify the possible failure.

Conclusions

  1. The scales of predicting recurrent bleeding that are known today do not consider a number of important clinical and pathogenetic factors as a basis of recurrence.

  2. The improvement of the results of treating bleeding ulcers is possible only on the basis of the complex of factors determining the effectiveness of regeneration.

Prospects for further research

The prospects for further research include the study of the pathogenetic basis of recurrent bleeding.

References

1 

LYa Kovalchuk, EM Shepetko, VO Shaprinskiy, et al. Innovatsiini tekhnolohii khirurhichnoho likuvannia hostrykh shlunkovo-kyshkovykh krovotech. Kyiv: Phoenix; 2014. 421 p.

2 

N Muguruma, S Kitamura, T Kimura, H Miyamoto, T Takayama. Endoscopic management of nonvariceal upper gastrointestinal bleeding: state of the art. Clin Endosc. 2015;48(2):96-101. doi:10.5946/ce.2015.48.2.96

3 

YaS Bereznitskiy, VV Boiko, MP Brusnicina, et al. Standarty orhanizatsii ta profesiino orientovani protokoly nadannia medychnoi dopomohy khvorym z nevidkladnoiu khirurhichnoiu patolohiieiu orhaniv zhyvota. Kyiv: Zdorovia Ukrainy; 2010. 470 p.

4 

EM Shepetko, VV Efremov. Suchasna taktyka i bezposeredni rezultaty likuvannia hostrykh vyrazkovykh shlunkovo-kyshkovykh krovotech. Khirurhiia Ukrainy. 2013;4:29-36.

5 

D Maggio, AN Barkun, M Martel, S Elouali, IM Gralnek. Predictors of early rebleeding after endoscopic therapy in patients with nonvariceal upper gastrointestinal bleeding secondary to high-risk lesions. Can J Gastroenterol. 2013;27(8):454-458. doi:10.1155/2013/128760

6 

JA Forrest, ND Finlayson, DJ Shearman. Endoscopy in gastrointestinal bleeding. Lancet. 1974;2(7877):394-397. doi:10.1016/S0140-6736(74)91770-X

7 

O Blatchford, WR Murray, M Blatchford. A risk score to predict need for treatment for upper gastrointestinal haemorrhage. Lancet. 2000;356(9238):1318-1321. doi:10.1016/S0140-6736(00)02816-6

8 

TA Rockall, RFA Logan, HB Devlin, TC Northfield. Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 1996;38(3):316-321. doi:10.1136/gut.38.3.316



Copyright (c) 2017 I. I. Dutka, F. V. Grynchuk

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