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Differential diagnosis of gastrointestinal bleedings

Table of contents
Differential diagnosis of gastrointestinal bleedings
Etiology of gastrointestinal bleedings
Bleedings at a stomach disease and a duodenum
Bleedings at gullet diseases
Bleedings at a portal hypertension
Bleedings at intestines diseases
Bleeding gastrointestinal tract at other diseases
Reasons of gastrointestinal bleeding

According to Vinogradov A. V. book. Differential diagnosis of internal diseases. Moscow: Medicine, 1980.

Long bleedings, small on volume, from a digestive tract attract attention only after lead to development of anemia. Acute massive bleedings often are complicated by a clinical picture of hemorrhagic shock. Diagnostic work of the doctor on clarification of the reason of bleeding is performed in similar cases along with medical actions for fight against shock and a bleeding stop. The volume of diagnostic testings varies from one patient to another and is defined by weight of a state. In each case it is necessary to find out the blood loss size, speed of bleeding, its reason and localization. The solution of the problems arising at the same time can be reached by consensual work of the therapist, surgeon and radiologist. They jointly make the plan of the emergency medical actions up to an operative measure.
The majority of gastrointestinal bleedings lies between the specified two extremes. Their numerous reasons are stated in the appendix. Massive hemorrhages are most often observed at acute erosion of a stomach, stomach ulcers and intestines, a portal hypertension, tumors of a digestive tract and hemorrhoids. Other reasons in practice of the therapist meet seldom.
The clinic of massive bleeding is quite uniform. Quite often among full wellbeing the patient has a weakness, dizziness, a ring in ears, integuments turn pale, become covered by a cold clammy sweat. Pulse becomes frequent and threadlike, breath superficial. Systolic arterial pressure falls for some term below 80 mm of mercury. The general weakness is expressed so sharply that the patient hardly answers questions. In more mild cases of the patient tries to rise that quite often terminates in a loss of consciousness from diffusion ischemia of a brain. The reason of extraordinary weakness and a faint becomes only obvious after emergence of a hematemesis and a tar-like chair.
The hematemesis in most cases arises soon after the beginning of profuse bleeding. Color of emetic masses depends on bleeding speed. At moderate bleedings hemoglobin from the broken-up erythrocytes manages to react with hydrochloric acid. The muriatic hematin which is formed at the same time gives to emetic masses a typical type of a coffee thick. Dark and cherry color of emetic masses indicates faster bleeding. The emetic mass of scarlet color is observed or at bleeding from a gullet, or at very plentiful and fast gastromenia when blood is thrown out, without having managed to react with hydrochloric acid. The hematemesis can be observed also at bleeding from a duodenum provided that it occurs at the open peloric channel.
Motor function of intestines is excited the more sharply, than massivny bleeding. In experiences on volunteers it was established that the tar-like chair appears after intake not less than 100 ml of a citrated blood. After intake of 1 — 2 l of blood the chair remains tar-like within 3 — 5 days, and reaction a calla is defined on the occult blood positive during 2 — 3 weeks. Follows from the provided data that the tar-like chair not always demonstrates to massive bleeding that the multi-day melena can be observed also at single massive bleeding and that positive reaction the calla on the occult blood not always indicates the proceeding bleeding.
The melena without the previous hematemesis meets in most cases at localization of a bleeding point distalny peloric department of a stomach though occasionally it is observed also at bleedings from expanded veins of a gullet and from stomach ulcer. Color of excrements, according to most of authors, is defined by localization of bleeding and duration of stay of blood in a gut. Bright red blood in a chair appears later 4 — 17 h after intake of 1 l of a citrated blood.
The tar-like chair is, as a rule, observed at localization of a bleeding point proksimalny the bauginiyevy gate, but Schiff (1970) reports that it met a tar-like chair as well at bleeding from a caecum. Release of not changed blood most often is observed at hemorrhoidal bleedings.
Weight of the general condition of the patient is defined not so much by the volume, how many blood loss speed. In experiences it was in public shown that the maximum hemodilution comes in 3 — 90 h after extraction about 1,1 l of blood. It follows from this that the hemoglobin content does not reflect weight of blood loss in blood. More reliable results gives plasma scoping during the first hours after blood loss. Rate of cordial reductions at once after blood loss is slowed down, tachycardia develops later. After developing of anemia the hyperkinetic syndrome which expressiveness in many respects defines success of the medical actions undertaken in this period develops.
After a hemorrhage the patient has a fever and an azotemia. Body temperature increases sometimes to 40 °C and remains over a week raised within several days, and in some cases even. The azotemia develops only at bleedings, from the departments of a digestive tract located above the bauginiyevy gate. At bleedings from a large intestine the content of residual nitrogen in blood remains normal. Schiff (1970) suggests even to use this test for identification of localization of a bleeding point. The azotemia and fever depend probably on absorption of products of digestion of blood. After a hemorrhage the leukocytosis which size sometimes exceeds 15 000 constantly develops. Thus, anemia, a leukocytosis, increase of residual nitrogen, fever allow to diagnose bleeding and to determine approximately its size. Therapy of bleeding cannot expect success if: its reason will not be found out.



 
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