Professor A.A.Sheptulin MMA of I.M.Setchenov

About bleedings from the bottom departments of a gastroenteric path (ZHKT) it is accepted govorit when the bleeding source settles down in intestines distalnee sheaves Trejttsa. Bleedings from bottom departments ZHKT can be obvious (moderately expressed or massive) or latent (occult).

Principal causes of bleedings from bottom departments ZHKT (their comparative frequency mozhet to vary depending on age) are presented as follows:

• angiodisplazii a thin and thick gut;
• divertikulez intestines (including divertikul Mekkelja);
• tumours and polyps of a thick gut;
• tumours of a thin gut;
• chronic inflammatory diseases of intestines;
• infectious kolity;
• ischemic defeats of intestines;
• radiating kolit;
• intestines tuberculosis;
• hemorrhoids and analnye cracks;
• alien bodies and intestines traumas;
• aortokishechnye fistulas;
• gelmintozy.

Kavernoznye gemangiomy and angiodisplazii a mucous membrane thin and thick kishok (arteriovenoznye malformatsii) appear the reason massive intestinal krovotecheny in 30 % of cases. Allocate three types angiodisplasticheskih defeats kishechnika.

Angiodisplazii I type come to light mainly at older persons and lokalizujutsja in a thick gut. The sizes of the amazed vessels usually do not exceed 5 mm, that complicates their diagnostics even at laparatomii. Frequent happens sochetanie the specified vascular changes to a stenosis of a mouth of an aorta or prolapsom mitralnogo the valve.

Angiodisplazii II type have, as a rule, congenital character, vyjavljajutsja at persons 50 years are younger, are localised in a thin gut, have bolshy razmer in comparison with angiodisplazijami I type and are usually well visible on operatsii.

To angiodisplazijam III type , designated usually as a syndrome Vebera - Oslera - Randju, concern teleangioektazii which can settle down v any department ZHKT and be combined with teleangioektaziej a cavity mucous membrane rta, nasopharynxes, and also integuments. This syndrome is inherited on / to rautosomno-prepotent type, and its signs at relatives of the patient more often udaetsja to reveal at gathering of the family anamnesis.

Divertikulez intestines as the reason of massive intestinal bleedings obnaruzhivaetsja in 17 % of cases. Thus, despite more frequent localisation divertikulov in the left half of thick gut, as a bleeding source serve preimushchestvenno divertikuly the right half. Bleedings arise at nalichii divertikulita is more often, but can be observed and in the absence of an inflammation, razvivajas owing to travmatizatsii blood vessels. At the majority of patients with divertikulami bleeding intestines arise unitary, however at 20 - 25 % patsientov are marked repeated gemorragii.

Massive bleedings at children and persons of young age in rare instances can byt are called izjazvlenijami a mucous membrane divertikula podvzdoshnoj guts (divertikula Mekkelja). Izjazvlennye malignant tumours and polyps of a thick gut seldom vystupajut the reason of massive intestinal bleedings, more often promoting development umerenno the expressed or latent bleedings.

Bleedings can meet at inflammatory diseases kishechnika (nonspecific ulcer prick or illnesses the Crone), ostryh infectious kolitah (for example, psevdomembranoznom prick), opuholjah a thin gut (limfomy), intestines tuberculosis .

Other reasons of bleedings from bottom departments ZHKT can be sharp ishemicheskie intestines defeats , resulting a thrombosis or embolii branches mezenterialnyh arteries (at an atherosclerosis, vaskulitah, a trauma zhivota); Radiating kolit, developing at the patients receiving courses beam terapii concerning malignant new growths of bodies of a belly cavity and zabrjushinnogo of space (including tumours of gynecologic and urological spheres); analnye cracks; alien bodies in intestines and the intestinal stones calling obrazovanie prolezhnej and izjazvleny walls of a gut; gelmintozy (for example, ankilostomidoz); in rare instances - amiloidoz and intestines syphilis.

profuznoe the intestinal bleeding can develop as a result of rupture anevrizmy belly department of an aorta in a gleam of duodenal or thin guts, kotoroe arises spontaneously or it appears late complication rekonstruktivnyh the operations spent on an aorta. Sometimes an intestinal bleeding nabljudaetsja at sportsmen during run on marathon distances.

At 5 - 10 % of patients with bleedings from the bottom departments ZHKT arriving in statsionar, the reason gemorragii to reveal and it is not possible, despite carrying out kompleksnogo tool inspection.

In many cases obvious bleedings happen moderately expressed and is frequent not soprovozhdajutsja the general symptoms (for example, falling of arterial pressure). Inogda patients inform on intestinal bleedings periodically arising at them lish at careful inquiry. Massive intestinal bleedings are less often observed. Pod them understand such cases of bleedings at which are observed gipovolemija, arterialnaja the hypotonia, a tachycardia and for level stabilisation gematokrita (on 30 %) is required transfusion not less than 2 doses of blood.

Certain diagnostic value has colour of allocated blood. To thicket vsego at intestinal bleedings occurrence of not changed blood (gematohezija) is marked. Schitaetsja the fair corrected, which says, that the blood is more light allocated of prjamoj a gut, the distalnee the bleeding source is located. Dejstvitelno, scarlet blood is peculiar mainly to the bleedings connected with porazheniem sigmovidnoj of a gut, whereas dark red blood (Burgundian vina) specifies colours usually in localisation of a source of a bleeding in more proksimalnyh departments of a thick gut. At the same time the bleedings caused porazheniem of a thin gut, can be demonstrated in some cases in a kind meleny, togda as typical gematohezija can to accompany, on the contrary, bleedings from verhnih departments ZHKT (tab. 1).

At the bleedings connected with defeat perianalnoj of area (hemorrhoids, treshchiny), allocated blood (in the form of traces on a toilet paper or the thaw, popadajushchih on toilet bowl walls) usually is not mixed with kalom, which in such cases sohranjaet brown colouring inherent in it. If a bleeding source raspolagaetsja proksimalnee rektosigmoidnogo department of a thick gut, blood byvaet more or is less in regular intervals mixed with kalom so to identify ego normal brown colouring, as a rule, it is not possible.

Presence of pains in a stomach, previous an episode of an intestinal bleeding, svidetelstvuet in favour of sharp infectious or chronic inflammatory zabolevany intestines, sharp ischemic defeats of a thin or thick gut. Vnezapnye sharp pains in a stomach, accompanied then an intestinal bleeding, mogut to be caused rupture aorta aneurysms in a gleam duodenal kishki. Pains in the field of a rectum, accompanying the certificate defekatsii or usilivajushchiesja after it, are observed usually at a hemorrhoids or a crack back prohoda. Bezbolevoe the massive intestinal bleeding can be marked at divertikuleze intestines, teleangiektazijah, izjazvlenii divertikula Mekkelja (tab. 2).

other clinical symptoms, soputstvujushchie to intestinal bleedings have the Important diagnostic value. Sharply arisen fever, pains i n a stomach, tenezmy and a diarrhoeia are peculiar to infectious diseases of a thick gut. Long lihoradka, potlivost, the weight loss, a diarrhoeia are present often in clinical kartine intestines tuberculosis. Nalich ie fevers, an arthritis, aftoznogo a stomatitis, uzlovatoj eritemy, primary sklerozirujushchego holangita, defeats of eyes (irita, iridotsiklita) it is characteristic for chronic inflammatory diseases kishechnika.

the Combination gematohezii, pains in a stomach, diarrheas, fevers, gemorragicheskih vysypany on symmetric sites of integuments, a polyarthritis, changes in analizah urine (gematurija, proteinurija) can speak about presence at the patient gemorragicheskogo vaskulita (illnesses SHenlejna - Genoha). At radiating proktite available symptoms (the speeded up chair, tenezmy) are quite often combined with klinicheskimi displays of a beam enteritis (a plentiful watery chair, steatoreja, priznaki a syndrome malabsorbtsii).

To the diagnostic methods applied to an establishment of a source krovotecheny from bottom departments ZHKT, concern:

• manual rektalnoe research;
• research kala on the latent blood;
• anoskopija;
• rektoromanoskopija;
• kolonoskopija;
• angiografija;
• stsintigrafija;
• a computer tomography and a nuclear magnetic resonance.

the Establishment of a possible source of a bleeding from bottom departments ZHKT predpolagaet careful gathering of the anamnesis diseases (for example, vyjavlenie previous courses of beam therapy concerning a cancer prostaty or zhenskih genitals, detection of the burdened heredity in the relation kolorektalnogo a cancer or presence family a polypose of a thick gut etc.) . Ankilostomidoz meets at the persons which trade is connected with job in mines, tonneljah, on plantations.

In some cases valuable diagnostic data it is possible to receive at the general obsledovanii the patient . So, detection teleangiektazy on a skin and vidimyh the mucous can testify to presence same teleangiektazy on slizistoj to intestines cover. Revealing of a syndrome of a portal hypertensia at bolnogo with a cirrhosis is capable to explain the reasons persistent gemorroidalnyh krovotecheny etc.

At suspicion on communication gematohezii with defeat of a rectum of the reason krovotechenija (gemorroidalnye sites, analnye cracks, malignant tumours and vorsinchatye adenomas) can be established already at rektalnom manual issledovanii , and also at anoskopii (in the conditions of good illumination). At etom it is important to mean, that detection gemorroidalnyh sites yet does not exclude nalichija any other reason of intestinal bleedings (in particular, malignant opuholi).

More than at 70 % of patients the source of an intestinal bleeding manages to be found out pri endoskopicheskom research a thick gut (rektoromanoskopija ili high kolonoskopija) (fig. 1-2). Modern endoskopicheskaja the technician pozvoljaet in details to examine not only a thick gut, but also various departments tonkoj guts on enough protjazhennom a site. So, at nonspecific jazvennom prick in process endoskopicheskogo researches it is possible to reveal giperemiju, a hypostasis and granularity of a mucous membrane, its easy vulnerability, dot krovoizlijanija, and in more expressed stages of disease - ulcers with purulent ekssudatom and pseudo-polyps. Aftoznye the ulcers changing a relief mucous intestines po to type of a cobblestone road, and intestinal fistulas at illness the Crone are marked less often, chem at nonspecific ulcer prick, accompanied intestinal krovotechenijami. The diagnosis proves to be true histologic research, at kotorom characteristic abscesses kript (are found out at nonspecific ulcer kolite) and epitelioidno-cellular granulemy (at illness the Crone).

At patients with ischemic kolitom at endoskopicheskom research come to light otek and cyanotic colouring of a mucous membrane of intestines, podslizistye gemorragii, poverhnostnye ulcers. Thus in 85 % of cases of change are localised in area selezenochnogo a bend obodochnoj guts and distalnee it.

For intestines tuberculosis the picture of ulcers and psevdopolipov is characteristic endoskopicheskaja. The specific nature of changes proves to be true at detection mikobaktery a tuberculosis in intestinal contents and epitelioidnyh granulem with mnogojadernymi cages Pirogova-Langhansa at histologic research. Radiatsionnyj kolit it is characterised granulematoznym by mucous membrane defeat tolstoj guts, occurrence of hemorrhages, ulcers, sites ischemic nekroza.

At gemorragijah, connected with divertikulezom a thick gut, endoskopicheskoe issledovanie allows to reveal signs of the active or taken place bleeding, shodnye with those at bleedings from top departments ZHKT of an ulcer aetiology (not bleeding vidimye blood vessels, a fresh blood clot in divertikule, etc.) .

If at use endoskopicheskih methods a source intestinal krovotechenija to establish it is not possible, are applied selective angiografija i stsintigrafija .

At angiografii with filling of pool top and bottom bryzheechnyh arteries mozhno to find out an exit of contrast substance from blood vessels (ekstravazaty) v intestines gleam. The method appears useful in diagnostics intestinal krovotecheny, connected with divertikulezom and angiodisplaziej, and gives positive rezultaty in 40 - 85 % cases if volume krovopoteri exceeds 0,5 ml 1 minute

Stsintigrafija, spent with eritrotsitami, mechennymi pertehnetatom tehnetsija (99тТс) or trombotsitami, mechennymi 111In, allows to reveal a source krovotechenija if the volume krovopoteri exceeds 0,05 - 0,1 ml 1 minute Stsintigrafija it is considered more sensitive method of diagnostics intestinal krovotecheny, than angiografija, and besides concerns noninvasive methods. Vmeste with that stsintigrafija demands more time for carrying out and, besides, soprovozhdaetsja accumulation of radioactive isotopes in a liver and a spleen, that mozhet to mask ekstravazaty the given area and, thus, to complicate interpretatsiju results of research.

Traditional methods of radiological research (irrigoskopija, in that chisle and with double kontrastirovaniem) do not reveal directly a source krovotechenija, however can help with diagnostics of the diseases, capable to be it prichinoj (for example, tumours).

Under indications can be used and other methods of research : ultrasonografija (switching on endoskopicheskuju), definition rakovo-embrionalnogo antigena, research kala on the pathogenic microflora, special serologicheskie issledovanija. In diagnostics aortokishechnyh fistulas it can appear useful primenenie a computer tomography or a magnetic resonant tomography.

If the listed diagnostic methods do not allow to find out the reason krovotechenija at its continuation and anaemia progressing the attention to the question about provedenii diagnostic laparotomii is brought. At diagnostic laparotomii also far not always it is possible to reveal a bleeding source, however ee efficiency can be raised at intraoperatsionnom carrying out endoskopicheskogo intestines researches.

Occult intestinal bleedings are distinguished only at detection polozhitelnoj reactions kala on the latent blood. Tests for revealing of the latent blood shiroko are used now in skriningovyh the researches spent with tselju of early recognition kolorektalnogo of a cancer.

In 80 % of cases sharp intestinal bleedings stop spontaneously. Pri moderately expressed bleedings spend conservative therapy, character kotoroj it is defined by the disease which has served by the reason of their development.

When intestinal bleedings happen are caused divertikulezom, ih the stop in 70 % of cases is reached with the help infusions vazopressina in vr emja carrying out angiografii . Thus kateter can be left in meste introductions for prolonged infuzionnoj therapies as during pervyh 48 ch the bleeding is frequent retsidiviruet. In process angiografii mezenterialnyh vessels for a bleeding stop apply also chreskate ternuju embolizatsiju (for example, right tolstokishechnoj arteries). At patients with divertikulezom intestines at which krovotechenie to stop it is not possible or the bleeding arises repeatedly during 48 ch, is accompanied by a shock and demands application a day over 6 doses of blood, provodjat surgical treatment (operation gemikolektomii or subtotalnoj kolektomii with imposing ileorektalnogo anastomoza) (tab. 3).

the Stop of the bleedings caused angiodisplazijami of a mucous membrane kishechnika, assumes application electrocoagulations (monopolar) ili laser coagulation .

At the bleedings connected with sharp ischemic defeats of intestines, in nachalnoj stages it is possible to try to restore a blood-groove with the help vazodilatirujushchih means or revaskuljarizirujushchih operations. At development oslozhneny (the gut heart attack, a peritonitis) is spent operation of a resection amazed uchastka.

At the intestinal bleedings which reason of development are the hemorrhoids, naznachajut poslabljajushchuju a diet, reception of 10 % of a solution of chloride of calcium inside, vvedenie svech with novokainom, an extract belladonny and epinefrinom in a rectum. V persistent cases at bleeding hemorrhoids (if there is no loss of sites) spend inektsionnoe treatment by means of introduction in area of skleroziruyuschikh sites of solutions (for example, ethyl spirit with novokainom). At not stopped gemorroidalnom krovotechenii apply surgical ways of treatment (operation of bandaging of their ili sites issechenie).

carrying out of basic therapy of the basic disease, posluzhivshego the reason of occurrence of intestinal bleedings is Obligatory.

the Literature

1. Jensen DM Current management of severe lower gastrointestinal bleeding. Gastrointest Endoscop 1995,41, 71-73.

2. Levine JS, Klloi H-U, Oehler G Gastroenterologische Differentialdiagnostik Stuttgart-New York, 1995.

3. Rosen AM, Fleischer DE Lower gastrointestmal bleeding updated diagnosis and management. Geriatrics 989.44, 49-60.

4. Sharma R, Gorbein M Angiodysplasia and lower gastrointestmal bleeding in elderly patients. Arch Intern Med 1995,155, 807-812

5. Waye JD Diagnosis and treatment ol lower intestinal bleeding. Current topics in gastroenterology and hepatology (EdGNJTytgat, M van Blankenstein) Stuttgart-New York, 1990, 23-3.

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