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Uterine bleeding is the discharge of blood from the vagina, characterized by abundance and duration. This pathological condition poses a danger to the life and health of a woman and is a sign of serious diseases of the reproductive system. To save the patient, it is important to immediately provide her with first aid and find out the cause of the bleeding. Natural bleeding from the vagina is called menstruation. Menstrual bleeding is characterized by cyclicity and repeats at regular intervals. The period between menstruation usually lasts 25–30 days. Blood from the vagina should not be released longer than 8 days, otherwise we can talk about pathology. Menstrual irregularities are a reason to immediately consult a gynecologist. The doctor will find out the cause of the pathological phenomenon and help get rid of the disease at an early stage, before complications arise.

Causes of uterine bleeding

The likelihood of uterine bleeding depends on the age of the patient. In girls from 12 to 18 years old, copious discharge of blood from the vagina is a consequence of hormonal imbalance. And hormonal imbalances at a young age arise due to:

• physical injury or emotional distress;
• deterioration of the functioning of the endocrine glands;
• poor nutrition, deficiency of vitamins in the body;
• pregnancy with complications, difficult childbirth;
• genital tuberculosis;
• bleeding disorders;
• suffered severe infectious diseases.

In mature women, uterine bleeding is a rare occurrence, usually associated with impaired ovarian function. In this case, the provocateurs of the pathological condition are:

• stress, overwork, nervous tension, mental disorders;
• uterine fibroids;
• endometriosis;
• advanced endometritis;
• uterine polyps;
• oncology of the uterus or cervix;
• tumor formations in the ovaries;
• ectopic pregnancy, miscarriage, medical or instrumental abortion;
• infectious diseases of the reproductive organs;
• climate change, unfavorable environmental situation in the place of residence, harmful working conditions;
• taking medications that can disrupt the systemic functioning of the hypothalamus and pituitary gland.

Uterine bleeding is often observed in women during menopause. This is due to a decrease in the synthesis of gonadotropin by the pituitary gland. As a result, the level of sex hormones in the female body begins to jump, the menstrual cycle is disrupted, and the formation of follicles in the ovaries is disrupted. Frequent causes of bleeding from the uterus at the age of decline of reproductive function are:

Danger

Dysfunctional uterine bleeding is not a harmless disease. During the juvenile period it can lead to:

• anemia;
• hormonal disorders;
• infertility;
• endometriosis.

In women of reproductive age, the disease can be caused by:

• infertility;
• anemia;
• endometrial cancer, breast cancer;
• fibrocystic mastopathy;
• uterine fibroids.

In premenopausal and menopausal patients, dysfunctional uterine bleeding can cause anemia, cancer, and also cause the growth of existing tumors into neighboring organs. from a gynecology clinic at the first symptoms of the disease.

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Symptoms of uterine bleeding

• weakness;
• fainting;
• dizziness;
• nausea;
• paleness of the skin;
• cardiac tachycardia;
• lowering blood pressure.
• copious bleeding from the vagina;
• presence of clots in blood discharge;
• change the pad every 2 hours, even more often;
• duration of bleeding more than 8 days;
• increased bleeding after sexual intercourse;
• painless bleeding when the pathology is of dysfunctional origin;
• discrepancy between the onset of bleeding and the period of menstruation.

The duration of menstruation normally does not exceed 8 days, and bleeding that persists longer than normal is pathological. Vaginal bleeding should be considered unhealthy if the period between which is less than 21 days. During menstruation, 80–120 ml of blood flows per day; with uterine bleeding, the daily blood volume is more than 120 ml.

How to make a diagnosis

The doctor examines the patient, assessing his external condition, the shade of the skin and mucous membranes. Then he measures blood pressure - often it is low.

In the clinic, the patient undergoes a general blood test. Using it you can quickly get an idea of ​​the level of hemoglobin and the volume of other blood cells. Additionally, the diagnosis is made by biochemical analysis, but it is usually prescribed several days after the onset of blood loss, since the chemical composition of the blood changes only over time.

The main diagnosis concerns the detection of the very cause of the violation of the integrity of blood vessels. To do this, doctors use the following hardware examinations.

• Endoscopy - examination of the esophagus, stomach, duodenum using a flexible tube with a miniature camera allows you to quickly detect a problem area;
• Contrast radiography - an effective method for detecting bleeding in the gastrointestinal tract involves injecting a safe contrast solution into the organ, followed by an X-ray;
• Magnetic resonance imaging is a modern method that allows you to obtain comprehensive information about the condition of all tissues of a particular organ of the gastrointestinal tract.

Types of uterine bleeding

Bleeding from the uterus, depending on the age of the patient, is divided into five types.

1. During infancy. In the first week of life, a newborn girl may experience slight bleeding from the vagina. This is not a pathological phenomenon; the child does not require medical intervention. Infant bleeding is caused by a sharp change in hormonal levels in a newborn girl and disappears on its own.
2. During the period before puberty. During this period, vaginal bleeding in girls is rare. The cause of the pathological condition is most often a hormone-dependent ovarian tumor, due to which the gonad synthesizes too many hormones. As a result, the girl experiences false maturation of the reproductive system.
3. During puberty. Uterine bleeding during puberty, which occurs between 12 and 18 years of age, is called juvenile bleeding.
4. During the reproductive period. Bleeding from the uterus, observed between 18 and 45 years, can be organic, dysfunctional, breakthrough, or caused by pregnancy and childbirth.
5. During menopause. During the period of decline of reproductive function, bleeding from the vagina is most often associated with pathologies of the genital organs or with a decrease in the synthesis of hormones.

Dysfunctional bleeding

This type of uterine bleeding observed during the reproductive period is the most common. The pathological condition is diagnosed in both girls and older women during menopause. The cause of dysfunctional bleeding is a failure in the synthesis of sex hormones by the endocrine glands. The endocrine system, including the pituitary gland, hypothalamus, ovaries and adrenal glands, controls the production of sex hormones. If the operation of this complex system malfunctions, the menstrual cycle is disrupted, the duration and abundance of menstruation changes, and the likelihood of infertility and spontaneous abortion increases. Therefore, if there are any changes in the menstrual cycle, you should immediately contact a gynecologist. Dysfunctional uterine bleeding can be ovulatory or anovulatory. Ovulatory bleeding is manifested by a change in the duration and abundance of blood discharge during menstruation. Anovulatory bleeding is observed more often and is caused by the lack of ovulation due to impaired synthesis of sex hormones.

Organic bleeding

Such bleeding is caused either by severe pathologies of the reproductive organs, or by blood diseases, or by serious disturbances in the functioning of internal organs.

Breakthrough bleeding

Such uterine bleeding is also called iatrogenic. They are diagnosed after exceeding the dosage and course of taking certain medications, frequent use of hormonal contraceptives, as well as after surgery to install an IUD and after other surgical manipulations on the organs of the reproductive system. When taking hormonal medications, scanty bleeding is usually observed, which means that the body is adapting to synthetic hormones. In this situation, it is recommended to consult a doctor about changing the dosage of the medication. In most cases, with breakthrough bleeding, gynecologists advise patients to increase the dosage of the hormonal drug for a certain time. If after this measure the amount of blood released does not decrease, but increases, then you need to urgently undergo a medical examination. In this case, the cause of the pathological condition may be a serious disease of the reproductive system. If uterine bleeding occurs after the installation of the IUD, then the contraceptive device most likely injured the walls of the uterus. In this situation, you should immediately remove the IUD and wait for the uterine walls to heal.

Bleeding due to pregnancy and childbirth

In the first months of pregnancy, bleeding from the uterus is a sign of either a threatened spontaneous abortion or an ectopic fetus. In these pathological conditions, severe pain in the lower abdomen is noted. A pregnant woman who has started uterine bleeding should immediately consult a supervising doctor. If a spontaneous abortion begins, the fetus can be saved if proper treatment is started in time. In the last stages of a miscarriage, you will have to say goodbye to the pregnancy; in this case, curettage is prescribed. With an ectopic pregnancy, the embryo develops in the fallopian tube or cervix. Menstruation is delayed, some symptoms of pregnancy are noted, but no embryo is found in the uterus. When the embryo reaches a certain stage of development, bleeding occurs. In this situation, the woman requires urgent medical attention.

In the third trimester of pregnancy, uterine bleeding is deadly for both the mother and the developing child in the womb.

The causes of the pathological condition in the late stages of gestation are placental previa or placental abruption, rupture of the uterine walls. In these cases, the woman urgently needs medical attention; a caesarean section is usually performed. Patients who are at high risk of the above pathologies should be kept in conservatory care. Uterine bleeding can also occur during childbirth. In this case, its causes may be the following pathological conditions:

• placenta previa;
• blood clotting disorder;
• low contractility of the uterus;
• placental abruption;
• afterbirth stuck in the uterus.

If bleeding from the uterus occurs a few days after birth, you should immediately call an ambulance. The young mother will require emergency hospitalization.

Diagnosis of the causes of menorrhagia and metrorrhagia

The gynecologist determines the cause of bleeding based on test results and ultrasound.

• A gynecological examination in a chair will show whether there is prolapse of the genital organs, neoplasms or erosion on the cervix. During pregnancy, cervical insufficiency is clearly visible. Also, already at this stage, injuries from the spiral, after sexual intercourse, etc. are visible;
• Colposcopy. A gynecologist conducts an examination with a device equipped with magnifying glasses. Using a colposcope, internal pathologies of the cervix are identified, and the nature and stage of erosion is determined.
• An ultrasound of the uterus will determine whether there are injuries, neoplasms, or inflammation of the female internal organs.
• Smears for microflora and cytology show STI infections (STDs), precancerous conditions, and cancer.
• A blood test for hormones will determine whether there is a hormonal imbalance.

If this is not enough, you will have to undergo an MRI (tomography) to obtain images of the organs in 3D format at high magnification.

First emergency aid before doctors arrive

Heavy bleeding from the vagina must be stopped or at least reduced before doctors arrive. This is a matter of life and death for a woman. In most cases, with proper first aid, bleeding stops, but in 15% of cases the pathological process ends in death.

Every woman should know how to help herself before the doctors arrive, what she can do and what she can’t do.

A sick woman, while waiting for doctors at home, should do the following:

• lie on your back, remove the pillow from under your head;
• place a high cushion made of towels or a blanket under your shins;
• Place a cold water bottle or an ice-filled heating pad on your stomach;
• drink cold still water.

It is strictly prohibited:

• be in a standing and sitting position;
• lie with your legs pressed to your stomach;
• take a hot bath;
• do douching;
• put a heating pad on your stomach;
• drink hot drinks;
• take any medications.

Sequence of assistance

If the patient received anticoagulants before bleeding occurred, they should, in most cases, be discontinued. Assess the severity of the condition and the estimated amount of blood loss based on clinical signs. Vomiting blood, loose stools with blood, melena, changes in hemodynamic parameters - these signs indicate ongoing bleeding. Arterial hypotension in the supine position indicates large blood loss (more than 20% of the blood volume). Orthostatic hypotension (a decrease in systolic blood pressure above 10 mm Hg and an increase in heart rate by more than 20 beats per minute when moving to a vertical position) indicates moderate blood loss (10-20% of blood volume);

In the most severe cases, tracheal intubation and mechanical ventilation may be required before endoscopic intervention. Provide venous access with a peripheral catheter of sufficient diameter (G14-18); in severe cases, install a second peripheral catheter or perform catheterization of the central vein.

Take a sufficient volume of blood (usually at least 20 ml) to determine the group and Rh factor, combine blood and conduct laboratory tests: general blood count, prothrombin and activated partial thromboplastin time, biochemical parameters.

Drug therapy

Treatment of diseases that cause bleeding from the uterus is carried out in a hospital setting. Additionally, the doctor prescribes medications to the patient to help stop bleeding. Hemostatic medications are taken only on the recommendation of a medical specialist; taking medications at your own discretion is strictly prohibited. Below is a list of medications most commonly used to stop bleeding.

• Etamsylate - This drug stimulates the synthesis of thromboplastin and changes the permeability of blood vessels. Blood clotting increases, resulting in decreased bleeding. The medication is intended for intramuscular injection.
• Oxytocin is a hormonal drug often used during labor to improve uterine contractility. As a result of contraction of the uterine muscles, bleeding stops. The drug oxytocin is prescribed for intravenous administration with the addition of glucose and has a large list of contraindications.
• Aminocaproic acid - This medicinal substance prevents blood clots from dissolving under the influence of certain factors, thereby reducing bleeding. The medicine is either taken orally or administered intravenously. Treatment of uterine bleeding with aminocaproic acid is carried out under close medical supervision.
• Vikasol - The drug is based on vitamin K. With a deficiency of this vitamin in the body, blood clotting worsens. The medication is prescribed to patients who have a tendency to uterine bleeding. However, vitamin K begins to act only 10–12 hours after entering the body, so it is not advisable to use the drug to stop bleeding in emergency cases.
• Calcium gluconate - The drug is prescribed for calcium deficiency in the body. Deficiency increases the permeability of vascular walls and impairs blood clotting. This medicine is also not suitable for use in emergency cases, but is used to strengthen blood vessels in patients prone to bleeding.

What symptoms to look out for

Patients with the diagnoses we listed above should be especially monitored for the appearance of alarming symptoms. If you are taking medications for the liver and gastrointestinal tract, carefully monitor your well-being. If you are concerned about the changes discussed below, consult your doctor. However, knowing these signs is useful for every person, since many diseases of the lower and upper gastrointestinal tract develop without obvious painful sensations. Often their first manifestation may be the symptoms of bleeding.

Weakness

This is the main sign of any prolonged bleeding. Weakness gradually increases, the patient's skin turns pale, he feels cold sweat, a ringing in the ears, and trembling of the limbs. The weakened state may last for several minutes, after which it passes and returns periodically. If blood is bleeding actively, fainting or semi-fainting and even shock are possible.

Vomit

This symptom accompanies severe blood loss - more than 0.5 liters. If the vomit is dark cherry in color, it is most likely coming from a vein near the esophagus. If unchanged blood is clearly visible in the vomit, the integrity of the artery in the esophagus is most likely compromised. If the patient vomits so-called “coffee grounds” of brown color, the problem lies in the gastric vessels. Only a doctor can accurately determine the nature, location and intensity of blood loss.

Chair

Traces of blood in the stool may appear within a few hours or 1-2 days after the integrity of the blood vessels is damaged. With significant problems with the stomach or duodenum, as well as blood loss in a volume of more than 0.5 liters, you can observe melena - loose stools that resemble tar in color and consistency. If the blood loss is smaller, which often happens, for example, with intestinal bleeding, then the stool remains formed, but its color darkens.

Please note that darkening of the stool can occur due to eating foods that contain dark coloring substances, for example, blueberries and cherries. Dark stools are not an absolute sign of the presence of blood in the stool and problems in the upper or lower gastrointestinal tract. The diagnosis can only be made by a qualified specialist.

Treatment with folk remedies

To stop and prevent uterine bleeding, you can use decoctions and infusions of medicinal plants. The most popular and effective folk recipes for stopping bleeding are listed below.

• Yarrow infusion - You need to take 2 teaspoons of dried plant material, pour a glass of boiling water. The solution is infused for about an hour, then filtered. The infusion is taken a quarter glass 4 times a day before meals.
• Nettle decoction - Take a tablespoon of dried nettle leaves and pour a glass of boiling water. The solution is simmered over low heat for 10 minutes, then filtered. The prepared decoction is taken one tablespoon 3 times a day before meals.
• Infusion of shepherd's purse - Take a tablespoon of dried plant material and pour a glass of boiling water. The container with the solution is wrapped in a warm towel and left for an hour to infuse. The finished infusion is filtered and taken a tablespoon 3 times a day before meals.

It must be remembered that folk remedies cannot be a complete replacement for medications; they are used only as an addition to the main therapy. Before using herbal remedies, you should definitely consult a medical specialist to exclude intolerance to the medicinal plant and other contraindications.

Who is at risk?

Basically, diseases that lead to bleeding are observed in adults. Moreover, according to statistics, men are 2 times more likely than women to be diagnosed with problems with the gastrointestinal tract - the stomach, duodenum. As we noted above, ulcerative pathologies hold first place in terms of the number of diseases. The peak age for diseases is 40-45 years.

However, the problem is not limited to adults. The diagnosis associated with ulcerative lesions of the gastrointestinal tract is often made to adolescents who uncontrollably consume junk food and drinks. Cases of the formation of intestinal polyps are also common.

Gastric and intestinal bleeding is increasingly being detected even in newborns. Basically, they are caused by intestinal volvulus. In 3-year-old children, leakage can be caused by the formation of a diaphragmatic hernia, as well as abnormalities in the development of the organs of the lower gastrointestinal tract.

Preparation for gastroscopy

After relative stabilization of the patient’s condition (SBP more than 80-90 mm Hg), it is necessary to conduct an endoscopic examination, and, if possible, determine the source and stop the bleeding.

The following procedure can facilitate gastroscopy against the background of ongoing bleeding. 20 minutes before the intervention, the patient is given intravenous erythromycin by rapid infusion (250-300 mg of erythromycin is dissolved in 50 ml of 0.9% sodium chloride solution and administered over 5 minutes). Erythromycin promotes rapid evacuation of blood into the intestine, and thereby facilitates the identification of the source of bleeding. With relatively stable hemodynamics, 10 mg metoclopramide is used intravenously for the same purposes.

In patients with valvular heart disease, antibiotic prophylaxis is recommended before performing gastroscopy. Sometimes, to remove blood clots from the stomach (to facilitate endoscopic examination), a large-bore gastric tube (24 Fr or larger) must be inserted. It is recommended to lavage the stomach with water at room temperature. After the procedure is completed, the probe is removed.

Using a gastric tube for the purpose of diagnosing and controlling bleeding (if endoscopic examination is possible), in most cases, is considered inappropriate.

Treatment of ulcer bleeding and prevention of relapse: a therapist’s view

I.V. MAYEV

1, corresponding member.
RAMS, Doctor of Medical Sciences, Professor, A.Yu.
GONCHARENKO 1, Ph.D., Associate Professor,
D.T.
DICHEVA 1, Ph.D., Associate Professor,
D.N. ANDREEV
1,
V.S.
SHVYDKO 2, Ph.D.,
T.A.
BURAGINA 1,2 1
Department of Propaedeutics of Internal Diseases and Gastroenterology of the State Budgetary Educational Institution of Higher Professional Education "MGMSU named after.
A.I. Evdokimov" of the Ministry of Health of Russia 2
Federal Clinical Institution "Main Clinical Hospital of the Ministry of Internal Affairs of Russia" Gastroduodenal bleeding can complicate various diseases of the esophagus, stomach, duodenum, hepatopancreatobiliary system, and how oriented the clinician is in modern diagnostic methods and adequate choice of treatment tactics ultimately depends life of the patient [1].
According to modern data, bleeding from the upper gastrointestinal tract (GIT) occupies a dominant place in the structure of all gastroduodenal bleeding and accounts for 80–90% of cases [2]. The annual incidence among the adult population ranges from 48 to 160 cases per year per 100 thousand people [3, 4]. The urgency of the problem is emphasized by the mortality rate, which ranges from 6 to 14%, and in the group of patients with severe bleeding reaches 50% [2, 3, 5].

Among the causes of bleeding from the upper gastrointestinal tract, two large groups are distinguished: bleeding of an ulcerative nature (44–49% of cases) and bleeding of a non-ulcerative nature (51–56% of cases) (Table 1) [1].

It is worth noting that today in the world peptic ulcer of the stomach and duodenum is one of the most common diseases (from 5 to 15%, on average 7–10% of the adult population) and ranks second after coronary heart disease [6, 7]. In the Russian Federation, the incidence of gastric and duodenal ulcers was 157.6 per 100 thousand population [7, 8].

Recently, foreign literature has often noted a tendency towards a decrease in the prevalence of gastric and duodenal ulcers in Western Europe and North America, but this process does not correlate with the frequency of ulcer bleeding [3, 5]. At the same time, despite the effectiveness of modern therapy, the number of patients with ulcer bleeding is increasing [9]. According to Russian authors, over the past 8–10 years, the number of patients with ulcer bleeding has increased 1.5 times [1].

It appears that the reasons for the high incidence of ulcer bleeding in Europe and North America and Russia are different. Thus, in Russia, the high frequency of ulcer bleeding is most likely associated with the low social level of the population, which in turn causes a high prevalence of major risk factors, such as smoking, infection with Helicobacter pylori (H. pylori), etc. [10, 11] . In contrast, consumption of nonsteroidal anti-inflammatory drugs (NSAIDs) has increased rapidly in Western European and North American populations in recent years [5]. Taking NSAIDs increases the risk of developing erosive and ulcerative lesions of the mucous membrane by 3–5 times, and the risk of bleeding and perforation by 8 times [12].

The mechanism of bleeding formation in gastric and duodenal ulcers is caused by a deep ulcerative defect, when the bottom of the ulcer reaches the wall of the blood vessel. Thinning and necrosis of the vascular wall occurs indirectly, initiating bleeding. Thus, it has been shown that the source of bleeding of an ulcerative nature can be both arrosive vessels of various diameters located at the bottom of the ulcer, and the edges of the ulcer crater themselves, bleeding diffusely due to inflammatory-destructive changes in the wall of the affected organ. It is worth noting that most often massive and life-threatening bleeding comes from callous ulcers of the lesser curvature of the stomach and the posteromedial part of the duodenal bulb, which is associated with the peculiarities of the blood supply to these zones [1, 2, 13].

The main risk factors for bleeding of a ulcerative nature include old age, as well as the use of NSAIDs, anticoagulants and glucocorticoids [5]. In men, gastroduodenal bleeding occurs 2.5–3 times more often than in women [3].

The severity of clinical symptoms reflects the patient’s individual reaction to blood loss and is determined both by the intensity and massiveness of the bleeding itself, and by the initial state of the body and its compensatory capabilities. The most striking clinical manifestations are observed with massive bleeding with a loss of about 25% of the blood volume within a fairly short time interval (minutes to hours) [1]. In such cases, the clinical picture corresponds to hemorrhagic (hypovolemic) shock and is manifested by hypotension, tachycardia, marbling of the skin, and a decrease in central venous pressure.

Symptom complexes of acute gastroduodenal ulcerative bleeding can be divided into general, characteristic of any blood loss, and specific, characteristic of intraluminal bleeding.

General symptoms of blood loss are varied and include severe general weakness, dizziness, a feeling of darkening in the eyes, palpitations, and shortness of breath. With massive bleeding, loss of consciousness may occur due to increasing circulatory hypoxia.

Symptoms that characterize intraluminal bleeding include vomiting blood (hematemesis) and black, tarry stools (melena). It is believed that for such characteristic signs of intraluminal bleeding to appear, a loss of about 500 ml of shed blood is necessary. Vomiting of blood is usually always associated with melena. A characteristic sign of gastric bleeding is vomit in the form of coffee grounds, which is determined by the formation of hematin chloride during the interaction of blood hemoglobin with hydrochloric acid of the stomach. Melena appears no earlier than 8 hours after the start of bleeding. It is worth noting that with massive bleeding (in the case of intraluminal release of more than 1500 ml of blood), melena does not form, and the release of slightly changed scarlet blood (hematochezia) may be observed from the rectum [2, 13, 14].

Depending on the volume of blood loss and BCC deficiency, 3 degrees of severity of acute gastroduodenal bleeding are distinguished (Table 2). To calculate BCC, the Algover-Burri shock index (1967), determined by the ratio of pulse rate and systolic blood pressure, is often used. With an index of 0.8 or less, the volume of blood loss is equal to 10% of the bcc, with 1.3–1.4 – 30%, with 1.5 and above – 50% of the bcc or more [2].

In the diagnosis of gastroduodenal bleeding, the patient's medical history is of great importance. Taking into account the fact that in the prevailing number of patients bleeding occurs against the background of an exacerbation of peptic ulcer disease, it is possible to identify clinical manifestations characteristic of this disease (the presence of “hungry” pain, often accompanied by heartburn, relieved after taking antacids and proton pump inhibitors (PPIs), often associated with seasonal nature) [1, 6, 13].

Instrumental research methods are aimed at identifying the exact location of the bleeding area. Today, the leading instrumental method for diagnosing gastroduodenal bleeding is emergency esophagogastroduodenoscopy (EGD) [1–3, 10, 14]. This method makes it possible to most accurately verify the source and nature of bleeding, as well as assess the risk of early relapses. Also, the endoscopic picture underlies the classification of the activity of gastroduodenal ulcerative bleeding (according to JA Forrest, 1974) [15]. In accordance with this classification, it is customary to distinguish between active (Forrest Ia/Ib) and ongoing (Forrest II/III) bleeding (Table 3). The use of this classification allows us to unify the description of a bleeding gastroduodenal ulcer, and therefore avoid discrepancies and unambiguously interpret the intensity of bleeding and its source. Based on the above indicators, the endoscopist assesses the potential for recurrent bleeding.

Methods of conservative hemostasis are aimed at creating conditions for the formation, retraction and organization of a thrombus in the lumen of a bleeding vessel, preventing lysis and dislocation of the thrombus, and realizing the tissue reparative potential of the gastric and duodenal wall in the periulcerous zone [16]. In some cases, combined endoscopic hemostasis is chosen, combining the injection of adrenaline and an alcohol-novocaine mixture into the edges of the ulcer with argon plasma coagulation or diathermocoagulation. However, the success of therapy for gastroduodenal bleeding lies in the combination of endoscopic hemostasis with adequate drug therapy, the basic drugs of which are antisecretory drugs [2, 10, 14, 16].

The basis for prescribing antisecretory drugs that inhibit the production of hydrochloric acid is a decrease in the activity of pepsin or its inactivation when the intragastric pH increases >4 units, which leads to a decrease in the aggressive properties of gastric juice due to impaired activation of pepsin, reduces the reverse diffusion of hydrogen ions and their damaging effect on gastric mucosa. In addition, under conditions when pH (6.0–7.0 units), the contents of the stomach shift to the alkaline side, the lysis of fresh blood clots is blocked, which allows for complete vascular-platelet hemostasis [17]. Because of this, it is important to choose antisecretory drugs that ensure the longest possible alkalization in the gastric cavity. These antisecretory drugs include the PPI class, while the use of the older class of histamine H2 receptor blockers is not currently recommended [16, 18].

The main positions on the use of PPIs as part of drug therapy for gastroduodenal bleeding were regulated by the international consensus on the management of patients with non-variceal bleeding from the upper gastrointestinal tract in 2010 [18].

According to provision A8 of the above-mentioned document, the infusion of PPIs before the initial endoscopic examination is fully justified, which reduces the frequency of the need to use endoscopic methods of hemostasis (level of evidence 1b) [18]. It is important to emphasize that such tactics should in no case be considered as an excuse for delaying emergency endoscopic examination [19].

Statement C3 states that after successful endoscopic hemostasis, an intravenous bolus followed by a continuous infusion of PPI is recommended. This approach reduces the risk of rebleeding and therefore mortality in this group of patients (level of evidence: 1a) [18].

In a large Cochrane meta-analysis of 5,792 patients, high-dose intravenous PPI therapy (80 mg bolus and 8 mg per hour continuous infusion) resulted in a reduction in rebleeding rates (RR 0.43, CI 0.27 to 0.67) , surgical interventions (RR – 0.60 CI 0.31–0.96) and mortality (RR – 0.57, CI 0.34–0.96). And low doses of PPI, both intravenously and orally, reduced the incidence of rebleeding, but did not reduce the mortality rate [20].

According to provision B6, in the case of a thrombus-clot tightly fixed to the ulcer crater, endoscopic hemostasis may not be performed, since intensive intravenous high-dose PPI therapy may be sufficient (evidence level 2b) [18]. Thus, according to a meta-analysis by Laine L. et al. (2009), who summarized data from 5 randomized controlled trials (189 patients), did not find a significant advantage of endoscopic treatment compared with medication (OR – 0.31, CI: 0.06–1.77) [21].

In position C4, it is recommended to continue treatment with daily single doses of PPI orally even after the patient is discharged from the hospital. The duration of such treatment is determined by the etiology of the disease (level of evidence: 1c) [18]. Thus, patients requiring treatment with NSAIDs may require long-term secondary prevention [22]. A number of experts suggest twice-daily dosing of PPIs for convalescents, which helps prevent acid breakthroughs during treatment [23]. Important characteristics when choosing a PPI are the range of dosage forms (intravenous, oral or nasogastric tube) and pharmacokinetic properties that allow its use in patients with multiple organ dysfunction (renal and hepatic). Intravenous forms exist for omeprazole, pantoprazole, esomeprazole and lansoprazole. Pantoprazole (the drug Controloc), starting from the first dose, has high bioavailability (77%), due to which it quickly exerts a pronounced suppression of hydrochloric acid secretion. Intravenous pantoprazole 80 mg followed by infusion over 24 hours at a rate of 8 mg/hour maintained intragastric pH above 4 for 99% of the 24-hour period and above 6 for 84% of that time in 8 healthy volunteers. . After endoscopic examination and hemostasis, intravenous administration of pantoprazole at a dose of 80 mg followed by continuous infusion at a rate of 8 mg/h for 3 days in 14 patients with gastric and duodenal ulcers complicated by bleeding increased the median intragastric pH to 6.3 (monitoring – more than 48 hours). In this study, the median relative time the pH was above 4, 5, and 6 was 97.5; 90.5 and 64.3% respectively.

Controloc has constant, linear, predictable pharmacokinetics. When doubling the dose of PPIs, which have nonlinear pharmacokinetics, their serum concentrations will be either lower or higher than expected, i.e., they are unpredictable. This may affect the safety of using the drug. In elderly patients or with severe renal failure (creatinine clearance - 0.48–14.7 ml/min) there is no need to adjust the dose of pantoprazole. After its intravenous administration at a dose of 30 mg/day for 5 days in patients with hepatic impairment (Child-Pugh class A and B), the AUC and half-life values ​​increased 5-6 times compared with those in healthy volunteers. Pantoprazole is the only PPI drug that is not involved in known metabolic pathways of interaction with other drugs. Compared to other PPIs, pantoprazole, due to the specificity of phases I and II of biotransformation, has a lesser effect on the cytochrome P-450 system. In particular, it inhibits the cytochrome P-450 system to a lesser extent than omeprazole or lansoprazole. Due to the severity of the condition, a large number of drugs are being actively used with antisecretory drugs. The most serious consequences of polypharmacy are an increased risk of adverse reactions and drug interactions. So, when taking two drugs, the potential risk of their interaction is 6%, and when taking five – 50%. To prevent these adverse effects (regardless of the number of medications taken at the same time), it is preferable to take a drug that has the potential to interact poorly with other medications. In particular, pantoprazole does not interact clinically with drugs used in intensive care such as antacids, caffeine, metoprolol, theophylline, amoxicillin, clarithromycin, diclofenac, naproxen, diazepam, carbamazepine, digoxin, nifedepine, warfarin, cyclosporine, tacrolimus and etc.

The dosage regimen of the drug - bolus or intravenous infusion - is determined individually and depends on the level of risk factors for the development of stress damage to the gastrointestinal tract. According to the results of a number of meta-analyses of clinical studies, PPI therapy in critically ill patients for the prevention of erosive and ulcerative lesions of the upper gastrointestinal tract leads to a reduction in the need for transfusion therapy, the duration of hospitalization and the incidence and relapse of the gastrointestinal tract.

Experts who participated in the development of international consensus recommendations for the management of patients with nonvariceal upper gastrointestinal bleeding pay great attention to the role of H. pylori eradication. The prevalence of this infection in patients with upper gastrointestinal bleeding is quite high and varies from 43 to 56% [24, 25].

Statement D5 states that all patients who have suffered ulcer bleeding should be tested for the presence of H. pylori and, if detected, receive eradication therapy with mandatory confirmation of the success of anti-Helicobacter pylori treatment (evidence level 2a) [18].

In accordance with the Maastricht IV consensus (2010), regulating the standards for diagnosis and treatment of H. pylori infection, in regions with low H. pylori resistance to clarithromycin (less than 20%), triple therapy is regulated as first-line eradication therapy, including PPI, clarithromycin and amoxicillin. In regions with high resistance of H. pylori to clarithromycin (more than 20%), quadruple therapy with bismuth preparations (PPI + metronidazole + tetracycline + bismuth tripotassium dicitrate) or sequential eradication therapy (first 5 days - PPI + amoxicillin, the next 5 days – PPI + clarithromycin + tinidazole/metronidazole) [26, 27].

In case of failure of eradication with first-line treatment regimens, the expert council of the Maastricht IV consensus regulates the transition to second-line regimens. Thus, quadruple therapy based on bismuth preparations is a priority for regions with a low prevalence of resistant strains of H. pylori to clarithromycin, and triple therapy with levofloxacin (PPI + amoxicillin + levofloxacin) is proposed as an alternative. As for regions with high resistance of H. pylori strains to clarithromycin, according to the Maastricht IV consensus, the second-line therapy, if first-line quadruple therapy is ineffective, is triple therapy with levofloxacin (PPI + amoxicillin + levofloxacin) [26, 27].

Returning to the therapeutic aspects of the treatment of gastroduodenal bleeding, one cannot fail to mention provision D6 of the international consensus on the management of patients with nonvariceal upper gastrointestinal bleeding, according to which H. pylori - a negative result should be reconfirmed after the bleeding has stopped (evidence level 1b) [18] . In the setting of acute bleeding, test results for H. pylori may be falsely negative, although the biological mechanisms in this case are not well understood. The likely mechanism for this phenomenon may be related to the buffering effect of blood, since in a more alkaline environment false negative results are obtained more often [28]. A systematic review of 23 studies conducted for consensus review showed a high positive predictive value (0.85–0.99) of diagnostic tests for H. pylori infection (including serology, histology, urea breath test, rapid urease test, antigen test). stool and culture) with a low predictive value of these tests (0.45–0.75) in conditions of gastroduodenal bleeding. In this group of patients, false-negative results were 25–55% [29].

The development of standardized approaches to the management of patients with non-variceal gastroduodenal bleeding aims to reduce the rate of rebleeding, surgical interventions and mortality. A consensus statement on the management of patients with nonvariceal upper gastrointestinal bleeding was developed by a reputable community of experts based on the analysis of extensive statistical data. The basis for success is timely examination of the patient and initiation of adequate drug treatment, discussed above.

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