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Prediction and prevention of gastroduodenal peptic ulcer rebleeding


Author: Eugen Vasile Guţu
Degree:doctor habilitat of medicine
Speciality: 14.00.27 - Surgery
Year:2005
Institution:
Scientific council:

Status

The thesis was presented on the 14 September, 2005
Approved by NCAA on the 27 October, 2005

Abstract

Adobe PDF document – 1.05 Mb / in romanian

Keywords

gastroduodenal peptic ulcer, hemorrhage, rebleeding, prediction, endoscopic hemostasis, antisecretory treatment, surgery, postoperative complications, mortality

Summary

The aim of this study was to improve the treatment results of the patients with gastroduodenal peptic ulcer bleeding based on objective prediction of rebleeding and rational application of curative measures for its prevention.

The study is based on analysis of clinical, endoscopical and laboratory data of 1610 patients with chronic gastroduodenal ulcer hemorrhage. It was proved, that morphological features, which determine the high probability of chronic gastric ulcer rebleeding are the large diameter of the erodated artery and persistence of the blood flow through it, predominant magistral with diminished collateral arterial circulation nearby the ulcer base, as well as unstable and incomplete character of thrombogenesis in the vascular defect area. In this study were described an original thermometric method of objective revealing of non-bleeding visible vessel in endoscopic stigmata of recent ulcer hemorrhage and the device designed for it. It was shown, that prediction of rebleeding from chronic gastroduodenal ulcer is possible only by objective integral assessment of significant clinical, endoscopical and laboratory signs (shock on presentation, early admission, presence of blood in gastric aspirate, severe blood loss, advanced age of patients, concomitant diseases, large and deep ulcer, its situation high in the stomach or on the posterior duodenal wall, active hemorrhage or major stigmata of recent hemorrhage, as well as a value of the temperature gradient of stigmata-surrounding ulcer base Δ t° ≥ 0,4°C) using the designed original computed program. The prospective study proved, that computed prediction of rebleeding is high-effective and its results are statistically reliable and can serve as criteria for objective assessment of influence and effectiveness of different treatment modalities on the evolution and outcome of gastroduodenal ulcer bleeding episode. There are established the rebleeding residual risk values for every from subsequent days of hospitalization depending on ulcer site and bleeding activity by primary endoscopical examination data. Results of clinical application of the brand new method of endoscopic therapy based on introduction of metallic microparticles into the ulcer base tissue with recently stopped bleeding are presented in this study. This method’s haemostatic effect, which is determined by activation of the natural coagulation processes, reliable isolation of the ulcer base from aggressive impact of gastric content by a layer of particles and accelerated proliferative reaction, was assessed in an experimental study. During the large clinical trial was proved the pathogenetic motivation, safety and high efficiency of human thrombin injection for primary and repeated endoscopic hemostasis in gastroduodenal ulcer bleeding. There were established the risk factors of the rebleeding after the initial successful endoscopic hemostasis: associated pathology, shock on admission, ulcer site high in the stomach, ulcer size ≥ 1,5 cm and depth ≥ 0,4 cm, as well as positive computed prognosis of rebleeding. It was studied the efficacy of antisecretory therapy in condition of routine application of endoscopic hemostasis and was motivated the protocol of administration of gastric secretion inhibitors in the acute period of ulcer hemorrhage. There were established the election criteria of the urgent intervention volume for gastroduodenal ulcer bleeding by evaluation of “operative risk” grade, haemodynamic status, ulcer site and dimensions and also rebleeding factor consideration. The comparative features of organ preserving and resection methods of surgery for ulcer bleeding are shown. An original method of gastroduodenostomy during Billroth-I resection for giant penetrated “posterior” duodenal ulcers in circumstances of free posterior duodenal wall absence is described. In this study was motivated an accurate algorithm of diagnosis and treatment in gastroduodenal ulcer hemorrhage, which include prospective application of the computed prognosis results of rebleeding for the option of further treatment policy, large application of endoscopic methods for controlling active hemorrhage and prevention of rebleeding, evaluation of the rebleeding risk factors after initial successful endoscopic therapy, early elective surgery in patients with high risk of rebleeding and essential limitation of indications for programmed surgery. There was proved, that, as a result of changing of treatment policy, mortality in patients of the study group decreased from 6,83% in the first period of study to 1,42% in the second period, despite on increasing of patient’s poor health status during past years.