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Non-variceal upper gastrointestinal bleeding-guidelines on management

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In gastroenterology non-variceal upper gastrointestinal bleeding is health hazard. Frequency of occurrence accounts for 40-150 cases per 100000 inhabitants with death rate of 7-14%. Researches which goal is to improve treatment effectiveness as well as to establish standardized procedures for managing patients with symptoms of non-variceal upper gastrointestinal bleeding; have been conducted since many years. At the moment of admission, designed standards enable appropriate elaboration of patients’ health state, referral to the right clinic and implementation of the most accurate treatment methods. Increase of suppression of primary bleeding as well as prevention of recurrence is associated with dynamic development of endoscopic treatment methods as well as with optimization of pharmacological treatment. In significant percentage, efficiency of non – variceal bleedings treatment depends on clinic’s character (availability of equipment, experience of personnel) and on cooperation between several specialists (including gastroenterologist, surgeon, anesthetist, operative radiologist). Aim of the work is to present the latest evaluation of the mentioned subject, based on accessible literature. This work includes the basic principles for determination of bleeding intensity and risk of its recurrence as well as directions referring to fluids resuscitation and to monitoring of patients. Information on currently applied endoscopic methods for inhibition of non variceal upper gastrointestinal bleeding (injection, mechanical and thermo-coagulation techniques), comparison of their efficiency and possibility of application is provided in the work. The paper work also presents the newest directives for pharmacological treatment and guidelines for possible surgical treatment.
Respiratory failure coincides frequently with the occurrence of gastric ulceration. In advanced respiratory insufficiency hypoxemia is often accompanied by hypercapnia, which is the stimulus for central chemoreceptors as well as for carotid body chemoreceptors. The purpose of the work was to investigate the reflex effect of stimulation of central chemoreceptors on gastric mucosal blood flow (GMBF) in the rat. Central chemoreceptors were stimulated by a gas mixture composed of 10% carbon dioxide, 50% oxide and 40% nitrogen. In artificially ventilated and spontaneously breathing animals, the stimulation of central chemoreceptors caused a significant increase in gastric mucosal vascular resistance, accompanied by a marked decline in blood flow. We hypothesize that in patients with respiratory insufficiency accompanied by hypercapnia, the reflex impairment of GMBF may contribute to gastric ulceration.
The cardiovascular effects of the stimulation of arterial chemoreceptors are different in spontaneously breathing and artificially ventilated animals. Respiratory failure and long term sojourn at high altitude coincide frequently with the occurrence of gastric ulceration. In both these situations a profound stimulation of arterial chemoreceptors is present. The purpose of the paper was to investigate the reflex effect of stimulation carotid chemoreceptors on gastric mucosal blood flow in the rat. Arterial chemoreceptors were stimulated by two methods (I) substitution gas mixture of 10% oxygen in nitrogen for room air and (II) direct injection of acid saline ( 0.05 ml, pH=6.8) into the distal part of left common carotid artery. In artificially ventilated rats stimulation of arterial chemoreceptors caused significant increase in gastric mucosal vascular resistance, accompanied by marked decline in blood flow. This effect was mediated by adrenergic mechanism. On the contrary to artificially ventilated rats, decline of gastric mucosal vascular resistance with concomitant increase in blood flow was found in spontaneously breathing animals. This effect was not abolished either by phentolamine or atropine. As vasodilatatory effect of arterial chemoreceptors stimulation was abolished by bilateral vagotomy, we postulate that non adrenergic and non cholinergic vagal fibers mediate observed vascular changes in gastric mucosa in spontaneously breathing rats. We hypothesize that in artificially ventilated patients with respiratory failure stimulation of arterial chemoreceptors by hypoxemia and or acidosis may contribute to the development of gastric mucosal lesions.
There is growing evidence that gastric vagal afferent input may contribute to the altered sensations associated with gastrointestinal disorders. The aim of our study was to evaluate gastric vagal afferents (VA) activity in rats with experimental gastric ulcer and ulcer healing. The study was carried out on rats with gastric ulcer (GU), including, a group with perivagal capsaicin pretreatment (CAP), a group with capsaicin administration in gastric ulcer (CAP+GU) animals and control rats. In all rats electrical VA activity was recorded and analysed. In GU rats recordings were carried out in chronic ulcer and ulcer healing. In GU and CAP+GU groups gastric balloon distensions with vagal recording was performed on 3rd day after ulcer induction. Usually, experimental GU healed spontaneously within 2 weeks. Three days after acetic acid application when GU fully develop, the frequency of the basal VA activity was almost 3-times higher than in the control intact rats and remained elevayed until 4th week after ulcer induction. VA response to gastric distension increased concomitantly with increased balloon volume in both GU and control animals, but it was several times higher in GU rats. Perivagal capsaicin application decreased the frequency of spontaneous VA activity and decreased the response of VA to gastric distension. In CAP+GU, spontaneous activity as well as the response to gastric distension were higher than in CAP rats. Our study shows that GU induced inflammatory changes increase sensitivity of gastric VA. Capsaicin-sensitive vagal afferent fibers may play some role in this phenomenon. Peripheral sensitization of VA persists even when gastric ulcer is completely healed.
Environmental conditioning of peptic ulcer, territorial variations in the occurrence of this disease, as well as reports indicating changes in the natural history of peptic ulcer provided incentives to undertake the present study. The aim of the study was to determine whether the above-mentioned changes in the course of peptic ulcer also concerned rural population from the agricultural region of south-eastern Poland. The study covered 1,647 patients with peptic ulcer treated in the General Surgery Ward at the Specialist Hospital in Brzozów (Rzeszów Region) between 1980-1999. The analysis was conducted based on data obtained from the documentation of the General Surgery Ward. In order to determine changes in the parameters examined taking place during the 20 year period, it was divided into 4 sub-periods of 5 years each. The total number of patients treated due for peptic ulcer was 1,647, including 470 patients with gastric ulcer (28.5%), 1,137 patients with duodenal ulcer (69.0%) and 40 with gastric and duodenal ulcer (2.5%). A decrease was noted in the number of patients treated for peptic ulcer during Period I of observation (1980-1984) and Period IV (1995-1999) - from 460 down to 348 patients p < 0.0001. Peptic ulcer more often affected males than females (70.2% and 29.8% respectively), most frequently in the age groups 41-50 (20.9%) and 51-60 (20.0%). Gastric ulcer was most often noted in the age groups 51-60 (24.4%) and 61-70 (23.8%), whereas duodenal ulcer in the age groups 42-50 (22.4%) and 31-40 (20.6%). During the study period (1980-1999), a decrease was observed in the number of patients treated for peptic ulcer. Hospitalization due to peptic ulcer decreased, mainly in patients with duodenal ulcer, and to a smaller degree among those with gastric ulcer. The relationship was observed between the incidence of peptic ulcer and the site of ulcer, sex and age of patients. Changes observed in hospitalization due to peptic ulcer among rural population in the south-eastern region of Poland was similar to those observed in other regions of Poland and the majority of European countries.
Gastric microcirculation plays an important role in the maintenance of the gastric mucosal barrier and mucosal integrity. Sensory nerves are involved in the regulation of mucosal blood circulation and mucosal defense. Therefore, the ablation of these nerves by neurotoxic doses of capsaicin provides the possibility of determination of their role in gastric mucosal integrity. Stress ulceration represents a serious gastric lesions. Results of our previous experiments have indicated that water immersion and restraint stress (WRS) led to increased oxidative metabolism. Ablation of sensory nerves by high doses of capsaicin retards healing of gastric ulcers, but the role of reactive oxygen species (ROS) in the healing process has been little studied. Therefore, the aim of our present investigations was to determine the participation of ROS in sensory nerve activity during WRS. Experiments were caried out on 90 male Wistar rats and the area of gastric lesions was measured by planimetry.Colorimetric assays were used to determine gastric mucosal levels of malondialdehyde (MDA) and 4-hydroxynonenal (4-HNE), as well as superoxide dismutase (SOD) activity. We demonstrated that inactivation of sensory nerves resulted in magnification of gastric mucosal damage induced by the WRS. In this process, oxidative stress, as reflected by an increase of MDA and 4-HNE tissue concentrations (an index of lipid peroxidation), as well as decrease of SOD activity, could play an important role. Aspirin, applied in a low dose, exerts a protective activity, possibly due to its metabolites, which possess the anti-oxidant and ROS scavanging properties. Pentoxyfilline-induced gastroprotection and hyperemia depends upon attenuation of the oxidative stress. This protection and hyperemia were, at least in part, attenuated by ASA.
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