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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