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MINISTRY OF HEALTH THE REPUBLIC OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
SYNDROME GASTROINTESTINAL BLEEDING
Toolkit is designed for students with VI-VII of the course of medical schools.
TASHKENT - 2011
Abstract:
The guide highlights the theoretical and practical problems of the gastro-intestinal
bleeding.Described surgical aspects of anatomy, clinical physiology,
pathophysiology and common pharmacology theory. Toolkit is designed for
students with VI-VII of the course of medical schools.
Compiled by Professor Teshaev OR, Kurbanov ShR
Reviewers:
Director Research Center
emergency medical services,
Professor AM Khadjibaev
Professor, Department of optional and
Hospital Surgery, z.d.n
Republic of Uzbekistan A. Asrorov
UDC 616.33/.34-005.1-008.6
Considered at a meeting of the Scientific Council and recommended for
publication in print «___»__________ 2011.
Reviewed and approved at a meeting of educational-methodical commission
TMA.«___»__________ 2011.
© Teshaev OR, Kurbanov ShR 2011
Anesthetic management of emergency endoscopic BME shatelstv varies widely. A
significant part of these studies may perform ¬ investigations under local anesthesia
using throat ksilokainom in apoptosis of narcotic analgesics (1 ml of 2% solution
promedola) and holinolitikov (1 ml 0.1% atropine solution). In the turbulent behavior of
the patient, impeding adequate inspection or performing hemostasis should be wider, as
perfectly natural and common benefit, use intravenous sedation (Relanium 2.0), as well
as intravenous, and in unstable patients - endotracheal anesthesia. In the case of active
peristalsis antrum and / or duodenal ulcer justified intravenous drugs (Buscopan,
papaverine,
metatsin,
benzogeksony)
for
their
relaxation.
Early endoscopy blood clots and remnants of the wash water, povozmozhnosti
completely removed from the lumen and mucus from the stand ¬ membrane through a
biopsy channel of the instrument. Greatly facilitates this task using the operating
endoscope with a 6-mm working channel and a powerful vacuum suction. If the blood
clots and can not be removed completely, removing the source of bleeding in the
available for inspection and easy to manipulate the position achieved by changing the
position of the patient to en ¬ doskopicheskom table, destruction and displacement of
the bunches tools (polipektomicheskaya loop, Dormia basket) used sighting laundering
¬ sources of bleeding by an intense jet fluid through a separate channel of the
endoscope
(preferred)
or
via
a
catheter.
In carrying out urgent endoscopy in patients with gastroduodenal hemorrhage should
osmatri ¬ vat all available this type of research departments of the gastrointestinal tract
ki ¬ muscular, no matter how many sources of bleeding found in the esophagus or
proximal stomach. In order to avoid diagnostic errors, particularly a close study should
be conducted in anemizirovannyh patients and patients with distinctly ¬ howl clinic
massive bleeding, but the "minimum" endoscopic ¬ cal manifestations ("mismatch and
clinical findings.") In doubtful cases, ¬ Tel'nykh if the institution have the technical
capabilities necessary to analyze the video ¬ go study in consultation with more
experienced professionals, or repeat it. Currently, the leading method for diagnosing
gastric bleeding is an urgent esophagogastroduodenoscopy. Do not be afraid of using
this method, even under the most severe condition of the patient. In cases of severe
hypovolemia or hemorrhagic shock study can be made against the background of
intensive care at the same time or prior blood transfusions or PLASMA SUBSTITUTES
solutions. In this case, even a massive blood loss is not a contraindication for
esophagogastroduodenoscopy, of course, subject to a high kvalifikaii researcher. With
unmistakable clarity, diagnosis and critically ill patients is acceptable to do without
FEGDS. Modern fiberoptic endoscopy can produce a detailed examination of the
esophagus, stomach and duodenum 12. Diagnostic accuracy can reach 95-98%. The
study is carried out in endoscopic or directly in the operating room, as well as in the
preoperative, dressing, intensive care. Previously provided all the conditions for
intensive transfusion therapy: the central vein catheterization, the definition of the group
and the Rh blood supplies, stabilization of hemodynamic drug stops bleeding. To
improve the inspection of abdominal organs stomach previously can be washed and
drained a thick probe. The effectiveness of endoscopy significantly superior to that of
other methods. First of all, the ability to accurately identify the source of bleeding and its
location, and then determine the nature of bleeding. At the same time identifies patients:
•
the
continuing
hemorrhage
(profuse,
moderate,
weak);
• no active bleeding, but the real threat of its recurrence (deep defects in areas with
abundant blood supply, thrombosed vessels, blood clots, which cover the defects of the
mucous
membrane);
•
with
the
bleeding
stops
without
the
threat
of
its
recurrence.
The practical significance of these results is the exclusive endoscopy. This information
is
usually
crucial
for
the
choice
Endoscopic classification bleeding on Forrest 1974
of
treatment
strategy.
X-rays of the upper digestive tract, as a method for emergency diagnosis of
gastrointestinal bleeding, faded into the background. Basically it is used to stop bleeding
after a diagnosis method further morphological changes and the motor-evacuation
function of the gastrointestinal tract. Meanwhile, in the presence of ¬ conditions for
endoscopy and the great practical skill radiological method allows to obtain ¬ positive
findings in 80% of cases, especially when such diseases ¬ vaniyah as bleeding ulcers,
tumors, varicose veins.
Angiographic diagnostic method for bleeding from the gastrointestinal tract is still fairly
limited use and is used in special ¬ ized institutions with the necessary equipment ¬ it. A
well-developed technique of catheterization of vessels on the Seldinger technique made
it possible to conduct a selective or superselective even visualize the celiac trunk,
superior mesenteric artery and its branches, as well as venous trunks. Limitations of the
method applied to the conditions ¬ pits emergency surgery is not only due to its
technical slozhnos ¬ whole, but rather small and informative: good contra ¬ tirovanie
ekstravazatov of the source of bleeding is possible only if the arterial bleeding
sufficiently high intensity.
Indications for selective angiography may occur in cases of recurrent bleeding ¬ vtornyh
when the source of hemorrhage is not installed by endoscopic and radiological methods
of investigation of ¬. Of course, diagnostic angiography is performed as the first stage of
endovascular therapeutic intervention aimed at selective ¬ tively infusion of
vasoconstrictor agents, embolization of blood flow ¬ thicket artery or vein, or - the
imposition of portosystemic anastomosis transyugulyarnogo intrapechenochnogo in
portal hypertension.
The accumulated experience of the angiographic diagnosis of bleeding
ezofagogastroduodenalnyh suggests that it can be ¬ Jet great help in identifying the
rare diseases that cause bleeding, as tears aneurysms, vascular-enteric fistula,
hematobilia syndrome, portal hypertension, etc.
The differential diagnosis in some cases carried out with bleeding from the upper
respiratory tract, nose, throat and lungs when ingested by patients with blood can
simulate bleeding from the digestive tract. Carefully collected history and examination of
the patient can binge ¬ dozrit pulmonary hemorrhage, which is characterized by bright
red frothy blood usually released when coughing or spitting individual. X-ray
examination conducted usually solves the diagnostic problem. You should also
remember that the black color of feces may occur after taking certain medications
(drugs ¬ you iron Vikalin, carbol, etc.). In doubtful cases, the assistance of an eye ¬
laboratory study shows fecal blood. The very fact эзофагогастродуоденального
bleeding in most cases installed without too much difficulty. However, some patients
with long latency (latent) period of diagnosis is often delayed bleeding. In the absence
of vomiting and bloody meleny Acute hemodynamic disturbances, fainting, loss of
consciousness may be seen as manifestations of acute cardiovascular disease,
myocardial infarction. Establishing the true cause of any instructions or a history
facilitated the appearance of a characteristic smell meleny or postponed until the
appearance of overt signs of bleeding.
It is difficult to overestimate the importance of history to determine the cause of
bleeding, localization of its source and amount of blood loss.
The first step is to figure out the start time and, consequently, the duration of
bleeding. In many cases, patients indicate that even just an hour, when it came
deterioration of health. What follows is to obtain information indirectly determine the
quantitative characterization of blood loss: the nature of vomiting - crimson blood, blood
clots, stomach contents as a "coffee grounds", a single or repeated vomiting, especially
the chair - decorated in black, single-or multiple-melena, altered blood . The volume of
blood loss and is characterized by common symptoms - weakness, dizziness,
palpitations, cold sweats, loss of consciousness. Patients can talk about the suffering of
diseases complicating эзофагогастродуоденальными bleeding. Thus, bleeding may
occur against the backdrop of worsening the long-standing and repeatedly confirmed by
special studies of gastric ulcer and 12 duodenal ulcer. Or the patient may describe
symptoms of peptic ulcer, with pain associated with eating, heartburn, typical seasonal
exacerbations. Sometimes the patient says nothing ostensibly motivated by epigastric
pain, which, however, cropped intake of soda. In some cases there may be only
heartburn. In favor of peptic ulcer disease in the absence of symptoms can speak and
sign the already mentioned Bergman - the emergence of pain in the epigastrium,
previous bleeding and disappearing after its commencement. On the possibility of
Zollinger-Ellison syndrome can be thought of in the instructions for inefficiency
conducted before surgical treatment of peptic ulcer, when the newly emerged pain and
heartburn associated with the formation of peptic ulcers.
Gastric bleeding nonulcer nature can also identify anamnestic indications of a definite
cause of bleeding. The so-called vague gastric complaints of dull pain in the
abdomen. The feeling of the meat combined with weight loss, general weakness,
fatigue syndrome (small features) suggest a malignant tumor as the cause of gastric
bleeding. The probability of cancer is particularly high in elderly patients with short (1-2
months) history of disease that occurred against the background of previous health.
Heartburn and chest pain may be preceded by bleeding in erosive esophagitis, ulcer on
the basis of gastro-oesophageal reflux disease of any etiology. In such cases, careful
questioning the patient it is often possible to establish that heartburn and pain worse or
appear in a horizontal position during exercise, torso. It should be remembered,
however. That gastro-oesophageal reflux may be in patients with peptic ulcer disease,
often accompanied by increased intragastric pressure and gastric cardia
insufficiency. The difficulty in determining the true source of bleeding with this
combination can be overcome by special studies.
Patients who abuse alcohol, you should specify the sequence of onset of
symptoms. The use of alcohol, followed by repeated vomiting, stomach contents first,
and then the blood indicates a potential breaks in the mucosa of the cardia (MalloryWeiss syndrome). Perennial alcohol abuse and sudden repeated vomiting blood and
melena usually occur in portal hypertension and esophageal varicose veins on the basis
of liver cirrhosis. Portal hypertension and esophageal bleeding are very likely not only in
patients suffering from alcoholism, but also suffered in the past, hepatitis and other liver
diseases, as well as so-called umbilical sepsis, leading to splenic vein thrombosis. The
use of various surrogates of alcohol can lead to severe intoxication with the formation of
one or multiple bleeding ulcers at any level of the digestive tract.
When an obscure diagnosis can be useful information gleaned from family
history. Hereditary and familial are diseases such as peptic ulcer disease, cancer,
digestivny polyposis syndrome (Peytts-Jeghers), hemophilia.
In difficult to diagnose cases of history should be carefully specified, taking into account
a variety of important factors that may indicate the cause of bleeding in each case.
Atherosclerosis and hypertension accompanied by fragility of blood vessels or the
formation of acute ulcers. Acute heart attack and stroke lead to severe hemodynamic
instability, circulatory and acute ulcers of the gastrointestinal tract. The question about
the reason for bleeding can be easily resolved at the mention of prolonged use of
ulcerogenic drugs (salicylates, steroids, anticoagulants). Frequent nosebleeds in the
past suggests the possibility of disease or Randy Verlgofa-Osler. Important information
may be prolonged bleeding at injection site, small injuries.Bruises, evidence of
irregularities in the coagulation of blood.
In general, it should be noted that medical history can be very eloquent and valuable for
the diagnosis and uncertain or even uninformative. Despite the importance of their
relative importance. For example, when a very bright anamnestic indications for peptic
ulcer bleeding may be the cause of erosive esophagitis, gastritis or acute gastric ulcers,
and in the absence of any history of gastric bleeding is a source of chronic gastric ulcer
and 12 duodenal ulcer.
Objective study of a patient with ezofagogastroduodenalnym bleeding. In the external
examination is determined by pallor of the mucous membranes and skin. Ominously
heavy bleeding is a cold sweat drops and yawning, mydriasis. In liver disease and portal
hypertension may be determined subikterichnost sclera, skin and mucous membranes,
increased subcutaneous veins of the abdominal wall, increasing the abdomen
(ascites). Brown spots (lentigo) around the mouth and lips can occur in digestivnom
polyposis. Intradermal and subcutaneous hemorrhage, petechial rash, multiple
telangiectasias indicate blood vessel disease or a violation of the blood coagulation
system.
For percussion the abdomen ascites may be detected as a result of portal
hypertension. On palpation of the abdomen can be felt enlarged liver (cirrhosis), spleen
(portal hypertension, a disease Verlgofa, leukemia). In the case of gastric cancer is
sometimes possible to test the tumor in the epigastrium or distant metastases.
During the inspection defined objective, although the approximate volume of blood loss
criteria.Blood pressure below 100 mm Hg. of Art. and increased heart rate over 100
beats per minute in patients with normal pressure above corresponds to a loss of about
30% of blood volume. If the patient's condition allows, can be carried out orthostatic
test: when transferring a patient from a prone position to a sitting position to quicken the
pulse of 20 beats per minute or arterial blood pressure drops by more than 10 mm
Hg. of Art., which corresponds to the expected blood loss of 15 ml / g weight of the
patient. Special diagnostic methods.
Diagnostic methods used must meet the special requirements of emergency surgery:
ease of implementation, high information content, security for life.
7. Treatment and tactics in gastroduodenal bleeding GPs
Treatment of acute gastrointestinal bleeding still remains a challenge. Ideally, it involves
not only the achievement of hemostasis, but also the elimination of the disease, which
led to bleeding.However, the implementation of this principle in full is not always
possible, and in these cases, the main goal is to stop bleeding, to save the patient's life.
7.1. The primary level of care
Treatment of gastrointestinal bleeding should be started at the prehospital stage, while
simultaneously carrying out a series of organizational measures for emergency
hospitalization of the patient in a hospital. The patient was transported on a stretcher. In
severe hemorrhage and collapse lift foot of the stretcher. The state is facilitated by
inhalation of oxygen through a mask or nasal probes. The first medical care is to ban
eating and drinking in the premises of the bladder with ice or cold water on his
stomach. Simultaneously, the patient must make an introduction of the following drugs:
Scheme in / injection
• Sol. NaCl 0,9% - 400,0 ml
• Sol. Acidi aminocapronici 5% - 100,0 ml
• P-p reopoliglyukina 400.0 ml
• Omeprazole 80 mg / in. In the absence of omeprazole used famotidine 40 mg / in.
Scheme / m injection
• Sol. Etamsylati (Dicynoni) 12,5% - 2,0 ml / m
- With signs of ongoing bleeding and the absence of volume overload to repeat in 2-3
hours.
7.2. The secondary level of care
At the secondary level of care the general principles of treatment of patients with acute
bleeding from upper gastrointestinal involve immediate hospitalization of the patient in
surgery, the most rapid recovery of bcc with intravenous catheter production and
subsequent massive infusion therapy, holding therapy, hemostatic, the use of fresh
frozen plasma and platelet in the presence of bleeding disorders. Roughly 30% of
patients at the time of inspection have stopped bleeding, but to any bleeding from the
upper gastrointestinal tract should be taken seriously, because the risk of their
recurrence in the hospital is great, and mortality due to relapse rather vysokatip A.
Patients with mild bleeding can be placed in the regular ward. They are under the age of
65 years with stable performance of functions of vital organs, with no signs of chronic
liver disease or other serious concomitant diseases, in the absence of income from the
stomach of fresh blood (after washing and removal of old blood and clots), t . is a small
risk of patients to whom you should not use emergency diagnostic and treatment policy
adopted for patients with more severe symptoms of gastrointestinal bleeding.
With a sharp drop of blood pressure produces transfusion plazmozameschayuschie
solutions.Introduction of vasoconstrictive agents is not shown. Patients with moderate
and severe bleeding from the upper gastrointestinal tract should be placed in the
intensive care unit.Examination and treatment of such patients should work together to
engage physicians and surgeons.
7.2.1. General principles of conservative treatment of patients with bleeding from the
upper gastrointestinal tract:
1. Emergency admission to hospital;
2. Recovery BCC;
2. Hemostatic therapy;
4. Blood transfusion;
5. Correction of coagulopathy.
The first event
Airway management: position of the patient on his side
Intravenous access: to restore the initial BCC used a needle of large caliber (14G16G). If peripheral venous access is difficult, you may want catheterization jugular,
subclavian or femoral vein. CVP monitoring allows time to detect recurrence of bleeding
and has a special significance in older patients and patients with massive blood
loss. The fall in CVP at 5 cm H st.within less than 2 hours, indicating a relapse of
bleeding.
Restoring the bcc Infusion therapy should start with eliminating circulating fluid volume
deficit due to colloidal srednemolekulyarnyh solutions, which improve the rheological
properties of blood. Rheological environment (reopoligljukin, 5% albumin solution,
polivisolin, etc.), improving central hemodynamics, and create conditions for the
normalization of microcirculation. In combination with the salt solution is achieved and
glyukozirovannymi opportunity to influence the transcapillary exchange and migrate into
the tissue of active components of the colloidal matter.If there are no signs of
hypoperfusion of the internal organs, performed a slow infusion of saline (NaCl 0,9%) to
maintain intravenous access and fluid volume. Tachycardia, hypotension and postural
blood pressure drop indicate a low intravascular volume.In this case, enter
intravenously 500 ml - 1 L colloid solution for one hour, followed by slow infusion to
continue to receive blood products. Stabilization of blood pressure is more important
than ensuring the balance of sodium (Table 4).
Table 4. Types of colloids
Colloids
Crystalloids
gemodez
Isotonic sodium chloride solution
reopiliglyukin
Ringer's solution
polyglukin
Atsesol
Glucose 5%
Disol
Makrodens (Sweden)
Trisol
Dextran (Poland)
Laktasol
Plazmodeks (Hungary)
Hemodeks (Bulgaria)
Neokompensan (Austria)
You should also monitor urine output and catheterized bladder with signs of
hypoperfusion. It is desirable to achieve a urine output greater than 30 ml / h. Timely
restoration of BCC increases urine output.
Blood transfusion should be carried out in patients with a clinical picture of hemorrhagic
shock, tachycardia, and systolic blood pressure below 90 mm Hg. of Art. (Horizontally),
as well as a fall in hemoglobin levels below 100 g / liter. Blood transfusion is also shown
at the ongoing bleeding, if hematocrit decreased to <30%. In addition, blood transfusion
gives a good therapeutic effect with continued bleeding and is a preventative measure
to prevent its recurrence. If you have a picture of shock is added 4 more doses of the
blood (1 dose = 250 ml) and the resumption of bleeding after the initial stop 2 more
doses (Table 5).
At low levels of fibrinogen, cryoprecipitate may be required. After the transfusion of
several units of citrate-containing blood may decrease serum calcium levels. Therefore,
after the transfusion of blood every 3-4 doses necessary to introduce 10 ml (4.5 mEq) of
calcium gluconate solution.If necessary, enter and magnesium phosphates (their level is
low in people who abuse alcohol).
If you have a compatible blood should be infused at a rate of 1 dose / h, if the rate of
bleeding is small - preferably eritromassa. A few milliliters of serum should be left for the
retrospective assessment of biocompatibility.
Table 5. Conditions and content of the infusion-transfusion therapy.
To beware of volume overload (her symptoms are increased CVP, swelling of the
jugular veins, pulmonary edema, peripheral edema). Too rapid transfusion may cause
pulmonary edema even before it is restored all the lost blood volume.
Some hope for haemostatic effect associated with the use of different types of regional
hypothermia. In particular, the use of permanent gastric lavage with cold water or chilled
effects of ethanol, placed in a rubber balloon. Local hypothermia is most effective in
hemorrhagic erosive gastritis. In general medical practice it is frequently achieved by
use of small pieces of ice, combined with the reception of hemostatic agents local
effects (drink every 15-20 min of 1% solution of aminocaproic acid in an amount of 100150 ml of thrombin or dissolved in a glass of cold water). However, a nasogastric tube
delivers the strain on the patient himself may cause re-bleeding, gastro-oesophageal
reflux and aspiration of gastric contents.
7.2.2. The scheme of conservative treatment (first phase)
Scheme in / injection
• Sol. NaCl 0,9% - 400,0 ml
• Sol. Acidi aminocapronici 5% - 100,0 ml
• FFP odnogrupnaya - 300 ml
• Sol. Glucosi 10% - 400,0 ml + Insulini 10 ED + Sol. Acidi ascorbinici 5% - 3,0 ml
• Sol. KCl 4% - 100,0 ml
• P-p reopoliglyukina 400.0 ml
• Sol. Chlasoli (Ringeri etc.) - 400,0 ml
• Omeprazole 80 mg and then 20 mg 2 times a day / in. In the absence of famotidine
(kvamatel) 20 mg. 2 times a day / in.
Scheme / m injection
Sol. Etamsylati (Dicynoni) 12,5% - 2,0 ml; / m to 4 times a day
- With signs of ongoing bleeding and the absence of volume overload repeated after 45 hours.
7.2.3. The scheme of conservative treatment (second stage)
After stopping the bleeding
Scheme / m injection (haemostatic therapy):
• Sol. Etamsylati (Dicynoni) 12,5% - 2,0 ml; / m to 4 times a day
The scheme of treatment per os:
• Omeprazole 20 mg 2 times a day.
• clarithromycin (klatsid) 250 mg. 2 times a day. In the absence of amoxicillin, 500 mg. 2
times a day at the end of a meal
• metronidazole (trihopol) 500 mg. 2 times a day at the end of a meal
• Sol. Acidi aminocapronici 5% and 1 tablespoon 6-8 times a day
It is established that the optimal dose is 80 mg bolus of omeprazole in the future - 8 mg
/ h for the first three days of treatment. In 4 randomized, placebo-controlled studies in
927 patients with acute GDK was obtained reliable statistical and clinical effect of PPIs
(omeprazole) for the occurrence of repeated GDK, as well as reducing the number of
patients requiring emergency surgery. Meta-analysis of 11 randomized controlled trials
showed that the effectiveness of PPIs in the treatment of ulcer bleeding significantly
greater than that in H2-histamine receptor blockers.
7.3. To prevent bleeding from the upper gastrointestinal
We recommend two types of therapy:
1. Continuous (for months), maintenance therapy with omeprazole 20 mg or famotidine
(kvamatel) to 20 mg at night.
2. Preventive therapy "on demand", which provides the appearance of symptoms
characteristic of acute illness receiving omeprazole full daily dose of 20 mg. morning
and evening for 3 days and then 20 mg. at night.
7.4. The use of somatostatin in bleeding.
Based on a meta-analysis of 14 randomized controlled studies showed that application
of somatostatin did not improve the results of treatment of bleeding compared with other
medical or endoscopic therapy.
7.5. Endoscopic treatment for bleeding.
A meta-analysis showed that the detection at endoscopy evidence of active peptic ulcer
bleeding (jet or with a slow release of the blood) is an indication for the use of
endoscopic methods of hemostasis, which effectively reduces the risk of rebleeding,
mortality rates, frequency of emergency surgery. Most often use different methods of
thermo-activated endoscopic hemostasis based on the fact that the effect of high
temperature leads to coagulation of proteins tissue compression of vascular lumen and
a decrease in blood flow.These methods include laser therapy, multipolar
electrocoagulation, thermocoagulation. In order to apply hemostatic and injecting into
the region of ulcers of various sclerosing and vasoconstrictive agents (epinephrine
solution, polidokanola, ethanol, etc.). Method of choice for endoscopic treatment of
bleeding ulcer are currently considered electrocoagulation, thermocoagulation, injection
sclerotherapy, and combined use of thermocoagulation and injection sclerotherapy
7.6. Surgical
interventions
in
acute
ulcer
bleeding.
1) The immediate surgical interventions to be patient with continued bleeding, not
amenable to medical and endoscopic hemostasis, and patients with early recurrent
bleeding (all of these patients go directly to the operating room, where he performed all
the subsequent remedial measures, including endoscopic hemostasis).
In this category of patients divided into three groups:
Group I - patients young and middle age, having a long history of ulcerative, failure of
medical therapy, with no serious co-morbidities on the background of relatively
stable hemodynamics. In such cases, radical surgery is performed: for gastric ulcer gastric resection for duodenal ulcer - usually vagotomy with excision of the ulcer.
gastroduodenal anastamoz. The seam on
the rear lip
gastroduodenal anastamoz. The seam on the front lip
resection of the stomach by Billroth 1. The final
form
Group II (patients with extremely unstable hemodynamics, severe concomitant diseases,
presence of competing expressed disease) surgery is performed internally for the sole purpose -to
stop the ongoing surgical bleeding or relapsed. Minimum volume of transactions - gastro orgastroduodenotomiya and suturing a bleeding vessel in the ulcer.
excision of ulcer and vagatomy
First and second group of patients with emergency surgical intervention is shown:
1). In the first 4-5 hours of admission to the ongoing bleeding, and his unsuccessful
attempt to medical and endoscopic hemostasis;
2). In the first 2-5 hours of admission, when a) there was a massive blood loss plus
unstable hemostasis, and b) massive loss of blood plus endoscopic hemostasis
achieved by temporary arterial bleeding. 5:00 These used to transfuse blood and fill the
BCC. Otherwise, re-bleeding, layering on the former already massive blood loss,
leading to disruption of the achieved stabilization of unstable operation and has the
character of the operation "despair."
3). At relapse bleeding in the hospital - regardless of the time the beginning of previous
bleeding. Repeat esophagogastroduodenoscopy to endoscopic hemostasis in case of
failure to take the patient from an emergency operation, as well as in the most severe
category of patients, when in principle agreed with inoperable.
In the III group consists of patients (in which the risk exceeds the risk of general
anesthesia operation) with the following concomitant diseases:
1. Circulatory failure of III degree.
2. Acute transmural myocardial infarction.
3. Acute cerebral blood flow.
4. Hypertensive heart disease III century. with blood circulation II-III degree.
5. Pulmonary heart disease with circulatory failure II-III century.
6. Decompensated cirrhosis, hepatocellular failure, severe.
7. Kidney damage with the development of chronic renal failure III degree.
8. Diabetes in the stage of clinical and metabolic decompensation with ketoacidosis,
diabetic coma.
All patients in Group III clinical profuse bleeding and a failed attempt to medical and
endoscopic hemostasis - showing emergency surgery for health reasons. The volume of
surgery is minimal.
suturing ulcer
pyloroplasty on Jaboulay's
An exception may be when the patient is in a terminal state at the clinic capillary
bleeding. In this case, one hour from the arrival of the patient in a hospital, you need to
create a council to decide on the tactics of further treatment. The purpose of a
consultation to decide the validity of repeated attempts to stop capillary bleeding by
non-operational (this council can do to allow for a period of not more than 3 hours). And
they use 3:00 for the correction of vital body functions (it can be called in later and
preoperative preparation). And if during this time the bleeding stopped, the operation is
performed despair.
2) urgent surgical intervention are subject to the following patients. In this category, two
groups of patients:
Group 1 - patients aged less than 70 years of age and without severe competitive
conditions.
Group 2 - patients older than 70 years with severe or competitive conditions. This group
is an urgent surgical treatment is not indicated.
Urgent surgical treatment is indicated for group I patients and performed within 6-36
hours of admission at:
a. Signs of high risk of rebleeding despite endoscopic hemostasis achieved temporary.
b. In the clinically unstable hemostasis, which is expressed in the absence of signs of
normalization of hematological parameters, despite the transfusion of more than 1 liter
of packed red blood cells within 12 hours.
c. If you have a patient with a rare blood group staying severe bleeding.
3) Delayed surgical procedures are performed in 12-14 days after the receipt of an
appropriate investigation and prepare the patient for surgery. Urgent surgical treatment
called routine is impossible, as after emergency hospitalization, transferred blood loss
reached a prosperous condition of the patient is very fragile. This situation requires the
surgeon's error-free surgery, when all faults and defects unpardonable. Reserve a
patient is too small to compensate for the likely complications. In elective surgery, such
situations are rare.
The indications for delayed surgical treatment is to find patients with indications for
planned surgical treatment of peptic ulcer disease.
Indications for routine surgical treatment for stomach ulcers:
a. Penetration of ulcers in the adjacent organs without forming internal fistulas.
b. Recurrence of ulcer after its closure.
c. Bleeding history.
d. Failure of medical therapy for 3 months after the detection of ulcers.
e. A combination of gastric and duodenal ulcers (type 2 by Johnson).
f. Pyloric ulcer of the channel (3 type in Johnson).
Indications for surgical treatment planning in duodenal ulcer patients:
a. Penetration of ulcers in the adjacent organs without forming internal fistulas.
b. Recurrence of ulcer after its closure.
c. Bleeding history.
d. Chronic postbulbarnaya ulcer.
e. Long history of ulcerative and failure of medical therapy for 2 years (from time to time
in the hospital).
f. Peptic ulcer with a continuous type of acid production, acid neutralizing function
decompensated antrum, as well as compensation for the latter, but a negative reaction
to atropine
Treatment of acute bleeding from the proximal gastrointestinal tract is a complex task,
as the tactical and the technical (operation) against. A wide variety of clinical variants,
severity of comorbid conditions make it difficult for a common treatment strategy for all
types of bleeding.You can select only certain general provisions.
Basic principles of treatment. All patients with continuing or even stop the bleeding and
suspected it must urgently hospitalized.
Prehospital on site and en route to carry out urgent measures are shown. Assigned to
strict bed rest, cold in the epigastric region, hunger. The patient is transported on a
stretcher. In severe hemorrhage and collapse rises foot of the stretcher is a transfusion
of colloids, crystalloids, plazmozameschayuschie solutions in an ambulance. All patients
were sent to the surgical department of a hospital, and if necessary the emergency
room or intensive care. By treating these patients in addition to surgeons connected
anesthesiologists-resuscitators, endoscopists, internists.
In the very short term laboratory tests are performed, cannulation of the main veins,
blood type and Rh factor, estimated degree of blood loss, endoscopy is carried
out. According to clinical data and research results established the cause of bleeding is
determined by the medical tactics, the choice of treatment (conservative or
operative). In a survey conducted hemostatic therapy and replenishing blood loss,
taking into account both the severity of blood loss and bleeding time.
Conservative treatment is indicated, particularly in acute ulcers and systemic
diseases.Methods to stop bleeding include local physical effects: cooling. Coagulation
and mechanical pressing of vessels, as well as the use of drugs that enhance the
procoagulant potential of the patient's blood, as well as improving microcirculation,
blood rheology, warning DIC.
Cooling is achieved mainly in two ways:
• by applying ice pack on the epigastric region;
• by gastric lavage with ice water through a tube, while the stomach is washed by the
blood and clots, increased contractile force of his muscles, decreases the concentration
of hydrochloric acid and pepsin activity, decreased volume of blood flow in the
submucosal layer, reducing the lumen of blood vessels.
Special devices for local hypothermia stomach are not widely used. Coagulation of the
source of bleeding is carried out by means of fiberoptic endoscopy. The basic method is
still elekrokoagulyatsiya, but in recent years developed a method of laser
photocoagulation.
Most authors consider the coagulation via endoscope as an effective method of
temporary hemostasis of ulcer and nonulcer etiology. Hemostatic effect can be
achieved in 90% of cases.Temporary cessation of bleeding is usually used to stabilize
the patient, or to prepare for an emergency operation, or to conduct a full medical
treatment. However, in the event of renewed bleeding coagulation repeated attempts
are not only futile, but also risky.
Drug treatment is an essential and indispensable component of the hemostatic
therapy. All patients with massive bleeding is a violation of the hemostatic system. And
because in a situation of excessive bleeding physician often faces the need to
strengthen the capacity of the blood coagulation, mindful of possible adverse
consequences of hypercoagulability can be used:
• 1% solution of calcium chloride;
• epsilon-aminocaproic acid (an inhibitor of fibrinolysis) in a 5% solution per os or
through a tube;
• inhibitors of proteolytic enzymes such as contrycal, transilola, gordox and others;
• vikasol that promotes the synthesis of prothrombin complex factors;
• etamzilat (Dicynone) affecting vascular platelet hemostasis;
• platelets can be used only with proven or thrombocytopenia trombotsitopatii.
It must be remembered that hemostatic therapy, in most cases, is contraindicated in the
presence of a patient clinics of DIC. To his relief and prevention polkazana antiplatelet
therapy in combination with protease inhibitors and fresh frozen plasma. In recent
years, successfully used H2 blockers and proton pump inhibitors
In the acute gastroduodenal bleeding should be allocated two main periods: I - acute
hemorrhage, II - posthemorrhagic.
I period - conventionally the first day, when there was a profound change of
homeostasis and the organism is able to mobilize their defenses and reserve capacity.
II period - posthemorrhagic depending on the depth of pathophysiological changes is
divided into 4 phases.
The first phase, lasting up to 2-3 days after the bleeding stopped, relatively favorable for
the operational benefits, and consists of hypovolemic gidremicheskogo periods. Infusion
of blood and gemokomponentov patients in this phase, in combination with antiplatelet
prevents the development of further violations gemoregulyatsii in the body. In this
phase, possible to perform radical surgery with a high probability of postoperative
complications in the absence of technically correctly performed the operation.
The second phase occurs 3-4 days after bleeding, and is accompanied by the growth of
morphofunctional changes of tissues against posthemorrhagic hypoxia. Due to the
violation trophic tissue repair processes and operations, the implementation of this
phase, often accompanied by postoperative complications.
The most unfavorable for surgery is the third phase, corresponding to 6-21 days of
posthemorrhagic period. In this phase, there is oppression in macroorganism
hematopoiesis and further development of morphofunctional disorders of tissues. The
result is that developing the expressed infringements of reparative
processes. Operations performed in this phase, most often complicated by failure of
seams and anastomosis.
The 4th phase of posthemorrhagic period begins at 21-24 days and is characterized by
a reduction gemopoza, and trophic tissue repair processes. Operations in this phase
are accompanied by minimal morbidity.
During the period of acute hemorrhage in the tactical and practical terms, it is important
to the division on the basis of endoscopic gastroduodenal bleeding into 3 groups: I continued 2 - to stay with unstable hemostasis, 3 - stop the bleeding with a stable
hemostasis.
With continued gastroduodenal bleeding tactics surgeon now clearly developed - with
gastric ulcer - gastric resection, with duodenal - ulcers vagotomy with excision of PP,
AJ. Under extremely heavy patients is possible to perform palliative surgery - excision of
the ulcer to hemostasis and suturing a bleeding vessel in the ulcer.
When bleeding stops need a rational approach to the definition of emergency surgery,
based on the results of endoscopic studies: in a loose thrombus in the lesion, ie, with
unstable hemostasis, regardless of the size of ulcer shows how to perform emergency
surgery after preoperative short-term.
When bleeding stops with stable hemostasis should take into account the size of ulcer
crater and the type of ulcer - acute and chronic ulcers of small size recurrent bleeding
during the intensive pathogenetic and symptomatic therapy is unlikely and these
patients showed delayed surgical treatment in order, 3-4 weeks after the
hemorrhage, ie 4 phase posthemorrhagic period. If there is a chronic ulcer with a
diameter of 1 cm or more, the likelihood of re-bleeding is high, and patients shows an
operation on an urgent basis after full preoperative preparation in the first 2-3 days after
bleeding, ie, in phase I posthemorrhagic period.
Appendix № 1.
Teacher proposes to disassemble management of patients with gastrointestinal
bleeding.
The teacher divides the group into three subgroups calculation 1,2,3, 1,2,3, etc. All of a
room is 1 subgroup and transplanted into the left half of the audience, all 2.2-subgroup
on the right. All 3 room in the middle of the audience.
By lot drawn out task:
1. "First aid to the hospitalization of patients with gastrointestinal bleeding"
2. "First aid in hospital"
3. "First aid in hospital '
Then given time to prepare for writing answers on worksheets. Then one of the
members of each group in turn read the answer. At this time, the rival group, together
with the teacher is the expert.
Coaching - 3 min. Divide the group - 2 minutes preparation time - 10 minutes, the
performance of groups of 10 minutes (30 minutes). Properly respond to a group is
encouraged and is declared the winner.
1. First aid to the hospitalization of patients with gastrointestinal bleeding
Prehospital on site and en route to carry out urgent measures are shown. Assigned to
strict bed rest, cold in the epigastric region, hunger. The patient is transported on a
stretcher. In severe hemorrhage and collapse rises foot of the stretcher is
plazmozameschayuschie transfusion solutions in an ambulance. All patients were sent
to the surgical department of a hospital, and if necessary the emergency room or
intensive care.
2. First aid at admission
By treating these patients in addition to surgeons connected anesthesiologistsresuscitators, endoscopists, internists.
In the very short term laboratory tests are performed, cannulation of the main veins,
blood type and Rh factor, estimated degree of blood loss, endoscopy is carried
out. According to clinical data and research results established the cause of bleeding is
determined by the medical tactics, the choice of treatment (conservative or
operative). In a survey conducted hemostatic therapy and replenishing blood loss,
taking into account both the severity of blood loss and bleeding time.
Appendix № 2
Interactive game "question" the ball
Write questions on the subject na small pieces of paper and stick on the ball with stucco
ribbon so that it is possible to read the questions fully and removed after a response.
Throws the ball to one of the students. The student received the ball tears off one of the
questions and answers the question written on a piece of paper. If the answer is correct
the game continues and the student answered the question throws the ball to another
student. Thus the game continues until you have answers to all questions.
8. The analytical part of
situational problem
1. situational problem
In a patient with peptic ulcer disease 12 - n. intestine after a week of acute
illness manifestedexcruciating pain, smack in the back, heartburn, nocturnal pain (which
is why he was unable to sleep). The last two days the pain disappeared, was heartburn,
but the patient notes the generalweakness, dizziness.
1.How complication occurred?
2. What research should I do?
3. Where should the patient be treated?
4. Where should the patient be treated?
5. Types of operations:
2. situational problem
The patient was 65 years, long suffering from gastric ulcer, noted that the last 2 days of
pain in, itbecame less intense, and at the same time there was increasing weakness,
and dizziness. This morning, after rising from bed, for a few seconds he lost
consciousness. There was ample tarrystools. On examination, the emergency doctor:
Ps-100 impacts. in a minute.
The patient was pale. In the epigastric region is very little pain. Symptoms of irritation of
the peritoneum is not.
1. What you suspect a complication of BU?
2. Which term you use more research to prove your hypothesis?
3. Where and how do you send to patient care?
3. situational problem
The patient has a gastric ulcer for a long time. Periodically (2 times per
year) exacerbations. The last time the pain decreased and were accompanied by
weakness, dizziness. Later joined bydiffuse pain throughout the abdomen. The
patient took a forced position: lying with those given to the
stomach down, pinched features.
● What you suspect a complication:
● How to diagnose perforation and bleeding in the hospital:
● Clinical management of patients with perforated ulcer bleeding:
4. situational problem
Patient 50 years old, long suffering from gastric ulcer, noted that the last 2 days of pain
in, itbecame less intense, there was increasing weakness, and dizziness. There
was ample tarrystools. Taken to the hospital ambulance. The patient was pale. In the
epigastric region is very little pain. Symptoms of irritation of the peritoneum is
not. Hemodynamic indicators suggest a deficit of 25% of BCC. According to
the picture EGDFS leakage of blood from the wounds.
1. What degree of bleeding in this situation corresponds to Gorbashko:
2. Classify this bleeding in Forest:
3. Types of operations:
5. situational problem
Patient 35 years old treated for a long time about the rheumatism. Im taking
antibiotics courses,regularly takes aspirin regularly is on the spa
treatment. Suddenly there was vomiting in a patienton a type of "coffee
grounds". Previously, this has not happened. Complaints from the gastrointestinal
tract as well was not.
1. What do you suspect?
2. How to find out exactly why?
3. What should I do first?
TEST
1. Scarlet frothy blood is:
A * with pulmonary hemorrhage
BS in esophageal bleeding
C. for gastric
D. at a bleeding bowels
2. The most valuable method to identify the source of bleeding from the stomach
A. * esophagogastroduodenoscopy
B. sigmoidoscopy
C. sensing stomach
D. fibrokolonoskopiya
E. definition bcc
3. The most common causes GDK:
A * a stomach ulcer and duodenal
B. hemorrhagic gastritis
C. Mallory-Weiss syndrome
D. erosive gastritis
E. gastric cancer
4. Black stool is observed:
* A case of bleeding gastric and duodenal ulcer 12i
B. bleeding in the colon cancer
S. bleeding in ulcerative colitis
D. when the hemorrhoidal bleeding
E. bleeding with anal fissure
5.Chto GPs should make patients with gastrointestinal tract:
A. * haemostatics conduct and result in a surgical hospital
B. gastric lavage with warm water
S. reassure the patient and leave the house with the recommendation to seek medical
advice
D. treatment with home remedies and monitoring at home
E. recommend a spa treatment
6.Posle started bleeding ulcer in patients with abdominal pain, most often:
* A decrease or disappear
B. amplified
C. take the burning character
D. dagger character
7.Krovavaya vomiting is most often:
* A case of bleeding gastric ulcer
BS in pulmonary hemorrhage
S. gastritis Menitre
D. hemorrhage in ulcerative colitis
8.Sindrom Mallory-Weiss law is:
* A gap mucosa at the junction of the esophagus to the stomach
B. hypertrophic gastritis
S. erosive esophagitis
D. gastric polyp
E. BPB stomach
9.Indeks "shock"
* A ratio of pulse to systolic BP
B. the ratio of Ag to Hb
C ratio of Hb to BP
DA ratio to Hb Ht
10.Razvitiyu Mallory-Weiss syndrome contributes to:
A. * Alcoholism
B. Peptic ulcer
S. Hiatal hernia
D. Stomach
E. Gastric Lymphoma
11. Symptoms of hypovolemia occurs when intestinal bleeding than:
A. * 500 ml
AB 300 ml
C. 100 ml
D. 750 ml
E. 1000 ml
12. When peptic ulcer complicated by gastrointestinal bleeding, the pain:
A. * Disappears
B. There is a growing
S. Irradiruet back
D. is concentrated in the umbilical region
E. The nature of the pain does not change
13. When a bleeding ulcer and gastric body a small degree of operational risk is shown:
A wedge excision of bleeding ulcer with pyloroplasty and vagotomy stem
B. * resection of the stomach with bleeding ulcer
S. wedge excision of bleeding ulcer with DBS
D. flashing bleeding ulcer with pyloroplasty and vagotomy stem
E. excision of ulcer
14. Regurgitation frothy blood is bright red, increasing cough, typical:
A bleeding gastric ulcer
B. cardia tumors
V. syndrome Mallory - Weiss
C. * pulmonary hemorrhage
D. syndrome Rendu - Osler
15.Ustanovit gastroduodenal bleeding source allows you to:
A. X-ray examination of stomach
B. laparoscopy
S. nasogastric tube
D. * EGD
E. redetermination of hemoglobin and hematocrit
16.Ischeznovenie pain and the appearance of "meleny" duodenal ulcer with
characteristic:
A. piloroduodenalnogo stenosis
B. ulcer perforation
S. malignant ulcers
D. * bleeding
E. penetration into the pancreas
17.Sindrom Mallory-Weiss - is:
A. Varicose veins of the esophagus and cardia complicated by bleeding
B. Meckel diverticulum bleeding ulcer
S. bleeding from the mucous on the basis of hemorrhagic angiomatosis (Osler-Rendu
disease)
D. * cracks in the cardia of the stomach bleeding
E. hemorrhagic erosive gastro
18.Naibolee penetriruyushey frequent complication of gastric ulcer is:
A development of pyloric stenosis
B. malignancy ulcers
C. fistula formation mezhorgannogo
D. * profuse bleeding
19.Dlya bleeding ulcer 12 duodenal ulcer is not typical:
A vomit-colored coffee grounds
B. * strengthening of abdominal pain
C. decrease the hemoglobin
D. melena
E. reduction in BCC
F. perforation
20.Pri relapse of ulcerative gastroduodenal bleeding is shown:
A. * emergency surgery
B. urgent surgical intervention
S. Selective endovascular haemostatic therapy
D. repeated endoscopic hemostatic therapy
E. Intensive conservative hemostatic therapy
21.Pri risk of relapse of ulcerative gastroduodenal bleeding is recommended:
A very conservative therapy
B. emergency surgery
C. * emergency operation
D. Systematic endoscopic control
E. surgery routinely
22.Divertikul Meckel most often seen:
A bloody vomit
B. * intestinal bleeding
Small bowel obstruction pp.
D. constipation
E. diverticulitis
23.Pri bleeding after a bowel movement in the form of streams of blood and itching in
the anal area can be thought of:
A fistula of adrectal
B. * of hemorrhoids
C. of rectal cancer
J. of colon polyps
E. of anal fissure
24.Bolnoy, long treated by over-spastiches whom colitis, the night felt a rumbling in the
stomach, followed by Oprah-curled dark liquid blood with clots. In the analysis of
pathological blood-energy does not.
Your first diagnosis:
A) Dysentery.
* B) Ulcerative colitis.
C) The tumor Sigma.
D) Diverticulosis of the colon.
E) Thrombosis of mesenteric vessels.
25.Bolnoy suffers from peptic ulcer 12 duodenal ulcer for 12 years. Repeatedly treated
in gastroenterology departments. During defecation felt a sharp weakness, dizziness,
lost consciousness briefly. Pulse 100 beats. per minute, blood pressure 100/60 mm
Hg Rectal - melena.
What is the complication of peptic ulcer disease 12 points in the patient?
* A) Bleeding
B) Penetration of ulcers.
C) perforation.
D) Piloroduodenalny stenosis.
E) malignancy ulcers.
26.Bolnoy complained of vomiting blood. For 10 years, suffering from duodenal
ulcer. Three days before vomiting blood appeared epigastric pain. Skin pale-term, pulse
110 per minute.After vomiting blood, the pain has not diminished. Two days after
admission it has increased, there was a voltage-tion of the muscles of the abdominal
wall. The abdomen is involved in the act of breathing, symmetry of the metric. On
palpation a soft, slightly swollen, a symptom of dubious SHCHetkina.
Put a preliminary diagnosis:
A) Penetration of ulcers in the pancreas.
B) Penetration ulcer and pyloric stenosis.
* C) Perforation against bleeding.
D) Stenosis of the stomach against bleeding.
E) bleeding during perforation.
27.Bolnoy complains of weakness, dizziness, pain in epigas-metry, black stools,
nausea. Ill a week ago, when there was pain in the abdomen. Three days ago, there
were weakness and melena. After that, the pain disappeared. In the past, marked
epigastric pain, usually in spring and autumn. Not surveyed.
Your first diagnosis:
* A) Ulcer. Bleeding
B) Cirrhosis BPB bleeding
C) Cancer of stomach bleeding
D) A tumor of stomach bleeding
E) Erosive gastritis bleeding
28.Bolnoy complaining of general weakness, dizziness, epigastric pain, nausea, black
stool. Ill two weeks ago when there was pain in the abdomen. Three days ago, there
were general weakness, malaise and tarry stools. After that, several pain to
decrease. Previously noted abdominal pain on an empty stomach and at night. The
abdomen is not swollen, symmetrical, and participates in the act of breathing. On
palpation a soft, slightly painful in the epigastrium.Liver at the edge of the costal arch
and spleen not palpable.
A) The hemorrhagic gastritis.
B) Bleeding from esophageal varices.
C) The tumor stomach bleeding.
* D) Bleeding ulcer aetiology
E) Mallory-Weiss syndrome.
29.U woman with hypertension during a hypertensive crisis appeared vomiting
blood. When urgent endoscopy in the esophageal-gastric junction and gastric cardia
revealed two linear mucosal break up to 10 mm with bleeding of them.
A) Erosive esophagitis.
* B) Mallory-Weiss syndrome.
C) Disease Rendu-Osler
D) Zollinger-Ellison syndrome.
E) The acute gastric ulcer.
30.U patients after consumption of alcohol for the first time there was blood flow,
manifested by vomiting and blood clots. When urgent endoscopy diagnosed with linear
gap kardial mucosa of the stomach-tion length of 15 mm. Bleeding continues. Blood
pressure 100/60 mm Hg. Pulse 90 minutes.
Define the rational way to stop the bleeding:
A) Hemostatic therapy.
B) Endoscopic hemostasis.
C) laparotomy, gastrotomy.
D) cryoinfluence the source of bleeding.
* E) Statement of the probe Blackmore.
9.Type control: • oral,
•-written,
• - test,
• - case studies,
• - the implementation of practical skills (drawing algorithm).
Test Questions:
1. The concept of the syndrome gastrointestinal bleeding;
2. Causes of gastrointestinal bleeding;
3. Methods of diagnosis (classification according to the degree of blood loss
andendoscopic classification of Forest.
4.Taktika GPs in the provision of first aid with the syndrome of gastrointestinal
bleeding (in the stage of admission)
5.Klinika and differential diagnosis of gastrointestinal bleeding;
6.Taktika Syndrome gastrointestinal bleeding (in hospital);
7.Konservativnoe treatment of the syndrome gastrointestinal bleeding;
8.Pokazaniya for the operation and nature of operations at FCC;
9.Posleoperatsionnoe management and rehabilitation of patients with the syndrome
ofgastrointestinal bleeding.
8. Criteria for evaluation of the current control;
№ %
assessment The level of knowledge students
Complete the correct answer to questions on gastrointestinal
bleeding, gastrointestinal bleedingsyndrome concepts of
classification, diagnosis, Diff. Diagnostics, Diagnostic,
treatment,gastrointestinal bleeding. To summarize and correctness of
the decision. To think creatively.Independently analyzed. Selfexcellent
supervised patients correctly perform practical skills in an
1 96-100%
«5»
objectiveexamination of the patient, correctly interprets the data
from clinical and biochemical tests and
instrumental investigations. Independently and competently determin
e the tactics of the patients.Actively participate in interactive
games. Correctly solves situational problems with a creative
approach with full justification of the answer.
Complete the correct answer to questions on gastrointestinal
bleeding, gastrointestinal bleedingsyndrome concepts of
classification, diagnosis, differential. Diagnostics, Diagnostic,
treatment,gastrointestinal bleeding. Summarizes the
correct decision. To think
excellent
creatively. Independentlyanalyzed. Self2 91-95%
«5»
supervised patients correctly perform practical skills in an
objective examination ofthe patient, correctly interprets
the data from clinical and biochemical tests and
instrumentalinvestigations. Independently and competently det
ermine the tactics of the patients. Activelyparticipate in
interactive games. Correctly solves situational problems with a
3
86-90%
excellent
«5»
4
81-85%
well «4»
5
76-80%
well
«4»
6
71-75%
well «4»
7
66-70%
satisfactoril
y «3»
8
61-65%
satisfactoril
creative approachwith full justification of the answer.
Admitted a mistake in the interpretation of biochemical tests
Complete the correct answer to questions by FCC, the
concept ZhKK.Klassifikatsii, diagnosis,
differential. Diagnostics, Diagnostic, treatment, gastrointestinal
bleeding. Summarizes the correct decision. To think
creatively. Independently analyzed. Selfsupervised patients correctlyperform practical skills in an
objective examination of the patient, correctly interprets
the data from clinical and biochemical tests and
instrumental investigations. Independently andcompetently det
ermine the tactics of the patients. Actively participate in
interactive games.Correctly solves situational problems with a
creative approach with full justification of the answer.
Committed 2.3 errors in solving situational problems, but with
the right approach.
Proper full coverage of the issue. Student knows, the
exchange of BCC in the body, the concept of gastrointestinal
bleeding syndrome, the symptoms ZhKKdiagnostiku,
differential. diagnosis,classification ZhKKprichin ZhKKkliniku,
diagnosis, tactics, the introduction of the
sick, takespractice, properly perform practical skills in
the supervision of patients with ZhKKgramotnointerprets data
from clinical and biochemical tests and
instrumental investigations, but there are3.2 errors,
inaccuracies. Solve situational problems correctly, but
the rationale for not adequatelyanswer.
Proper lighting is not a complete question. The
student knows; classifications gastrointestinal
bleeding diagnosis, differential. diagnosis of gastrointestinal
bleeding syndrome tacticsintroduction patients understand
the essence of the issue, said confidently, has a precise view
oncase studies give an incomplete solution, active
in interactive games.
Proper lighting is not a complete question. The
student knows; classifications gastrointestinal
bleeding diagnosis, but not
complete lists dif.diagnostiku FCC knows BCC, but
the difficulty in determining the tactics of the
patients. Understands the issue, said confidently,
takes practice.However, when performing practical
skills makes mistakes, the case studies give an incomplete
description.
Correct answers half the questions. The student knows
the essence of the syndromeZhKKklassifikatsy, the
reasons but confused in the methods of investigation of
patients and differentiation. diagnosis is accurate
representations only certain issues topics. Solve situational
problems correctly, but there is no justification for an
answer. Applies in practice, but not properlytake into account
some practical skills.
Correct answers half the questions. The student knows
y «3»
9
10
55-60%
54and below
the essence of
the syndrome ZhKKnoconfused classification prichiny.Ploho v
ersed in the differential. algorithm for diagnosis andtreatment
of patients. Says uncertainly, is accurate
representations only on certain issues topics.Applies in
practice, but does not correct skills. Mistakes in
solving situational problems.
satisfactoril
y «3»
Correctly answers the questions raised by half, making
mistakes in determining the syndromeclassification, diagnosis,
differential. diagnostic and treatment
algorithm. Says uncertainly. Has apartial view on the
subject. Applies in practice, but allows a lot of mistakes in the
performance of practical skills. Solve situational problems is
not true.
unsatisfacto
rily «2»
The student does not have an exact representation of the
syndrome does not know the classification, diagnosis,
differential. diagnosis, patients tactics. Does not apply in
practice.
The literature on the topic:
1.Aripov WA, Karimov SH.I. Emergency abdomen surgery .T.1991.
2. Karimov SH.I Surgical disease .T.2005g.
3. Kuzin MI Surgical disease.M.1987g.
4.Savelev VS manual emergency abdominal surgery .M.2004g.
5. . Savel'ev VS, Kiriyenko AI Surgical diseases (2 m). M.2006, the
8. Gorbashko AI Diagnosis and treatment of bleeding AL 1982
9. Clinical guidelines for practitioners of evidence-based medicine. M.2002, the
10. Nurmukhamedov RM Yunusov II Acute surgical abdominal disease .T.1998y.
11. . Nurmukhamedov RM Hozhiboev MH Yunusov I.I.T. Clinical
guidelines for acute abdomen forpracticing physicians in 1998 th.
12. Petrov, VP, Eryuhin And Shemyakin IS Bleeding in the
digestive diseases trakta.M. 1987.g.
13. Shevchenko YL Private surgery. M.2000, the
14. Gostischev VK and other gastroduodenal bleeding ulcer etiology 2008.
15. Clinical Surgery. National leadership. t.2_2009