Unfavorable Outcomes of Treatment for Patients with Bleeding from Chronic Gastroduodenal Ulcers: an Analysis of the Causes and Ways to Overcome Them

P.G. Kondratenko, Ye.Ye. Radenko, S.O. Zharikov

Abstract


Aim: to identify the main causes of unfavorable outcomes of the treatment of the patients with acute gastroduodenal ulcer bleeding and develop preventive measures to improve the quality of treatment of the patients suffering from this disease.
Material and Methods. This retrospective analysis included 1755 patients with ulcer bleeding etiology from 2007 to 2011. The age of the patients varied from 15 to 93 years old. 39 (2.2 %) patients were 20 years old and younger, 518 (29.5 %) — 20 to 45 years old, 488 (27.8 %) — 46 to 60 years old, 492 (28.1 %) — 61 to 74 years old and 218 (12.4 %) — older than 75 years old. Concomitant diseases were detected in 734 (41.8 %) patients. Cardiovascular diseases were most common (49.3 % of the patients). The duration of the pre-admission period was from 1 hour to 21 days. 985 (56.1 %) patients were admitted 24 hours after the first signs of the bleeding, 511 (29.1 %) — in the period from 25 to 72 hours, 259 (14.7 %) — after more than 72 hours. Mild hemorrhage was detected in 484 (27.5 %) of the patients, moderately severe — in 763 (43.5 %), severe — in 392 (22.3 %) and critical — in 116 (6.6 %). The ulcer sited in the stomach in 417 (23.8 %) patients, and in duodenum in 1338 (76.2 %).
The Results and Consideration. The patients operated because of acute gastroduodenal ulcer bleeding were 5.9 %. 49 (35 %) patients were operated because of recurrence hemorrhage. Total mortality in the group of the patients with bleeding from chronic stomach ulcer and duodenum was 4.8 % (85 patients). The mortality rate of the patients with the ulcer sited in the stomach was higher than in patients with the ulcer sited in the duodenum. It can be explained by the fact that stomach ulcer with severe concomitant diseases is more frequent in elderly patients. Lethality in patients with conservative treatment was 4.7 %, and postoperative — 6.7 %. 7 (14.3 %) patients operated because of recurrence hemorrhage died.
It was detected that the most of the deaths were caused by decompensation of somatic pathology accompanied by severe posthemorrhagic anemia — 36 patients (42.3 % of all the dead), and decompensated hemorrhagic shock, developed during pre-admission period in 21 (24.7 %) patients. Recurrence hemorrhage was detected in 140 (7.9 %) patients and it considerably influenced on the development of unfavorable outcomes of the disease. In this subgroup 28 patients died, lethality formed 20 %. In 7 patients the recurrence hemorrhage was a target and fatal factor in developing critical posthemorrhagic anemia which resulted in failure of unstable balance of homeostasis, progression and decompensation of concomitant somatic disease and death. Hemorrhagic shock caused by recurrence hemorrhage was the main cause of the fatal outcomes in 14 (16.5 %) patients.
The study shows that recurrence hemorrhage is mainly caused by such factors as size and depth of the ulcer and adequacy of antisecretory drug therapy and endoscopic prevention of recurrence hemorrhage. Absence or inadequacy of drug therapy increases the risk of recurrence hemorrhage twice, up to 32.7 %. In the same time combination of bolus and prolonged use of proton pump inhibitor (80 mg IV bolus, then 8 mg/h during 2–3 days) allows reduce risk of hemorrhage development to 5.7 %.
Conclusion. The main cause of death of the patients with acute gastroduodenal ulcer bleeding was decompensation of severe concomitant disease (50.6 % of all the dead patients) and decompensated hemorrhagic shock which developed during pre-admission period as well as the result of recurrence hemorrhage during the treatment (41.2 %). The factors influencing on the development of unfavorable outcomes of the treatment are: duration of pre- admission period, intensity of bleeding, the stage of compensation of concomitant disease, topographic characteristics of the source of bleeding, quality of endoscopic hemostasis, and infusion and drug therapy including antisecretory drug therapy. The performance of adequate antisecretory therapy reduces the risk of recurrence hemorrhage from 32.7 to 15.8 %. The combination of bolus and prolonged use of proton pump inhibitor allows reduce the risk of recurrence hemorrhage twice (to 5.7 %). Endoscopic hemostasis can be regarded as adequate in combination of injection treatment with diathermocoagulation or thermocautery. During endoscopic monitoring the preference should be given to coagulation methods, i.e. diathermo- and hydrodiathermocoagulation.


Keywords


acute ulcer gastroduodenal bleeding; causes of fatal cases

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DOI: https://doi.org/10.22141/1997-2938.1.24.2014.82878

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