Aggressive

Active bleeding at the time of inspection (Forrest IA, Forrest IB) had 69 (7%) patients older than 60 years. We used a combination of endoscopic hemostasis in all patients favored the combination of electrocoagulation or radiokoagulyatsii with obkalyvaniem ulcers alcohol-novocaine mixture. Primary endoscopic hemostasis was effective in 89% of patients. Eight (11%) patients with active bleeding ulcers Forrest IA stop the bleeding failed, they were treated in the emergency order. In all operated patients aged ulcers were located in subkardi-cial department, or in the angle of the stomach and were larger than 2.0, see this localization of ulcers in the "Achilles' heel of the stomach" consider the most unfavorable for the development of profuse bleeding, and its recurrence in early stage . It should be noted that all operations on the active bleeding from the ulcer had been performed during the period 1990 - 2000 years. After 2001, no such cases were all active bleeding (Forrest Ia, Ib) as a gastric ulcer and in duodenal ulcer patients was stopped endoscopically, which helped to stabilize patients and prepare them for emergency surgery. This is due to the progress of endoscopic hemostasis and advanced training of physicians endoscopic services.

At high risk of endoscopic brand viagra online recurrence of bleeding, we included:

* Patients with active bleeding from an ulcer at the time of initial endoscopy and successful endoscopic hemostasis (F Ia, F Ib) - 61;

* Patients with active hemorrhage in the presence of blood clots covering the ulcer, or a small thrombosed vessel in the ulcer at the time of initial endoscopy (F IIa, F IIb) - 378 patients (Fig. 2).

At low risk of rebleeding F IIc, F III, which was noted in 552 patients prescribed standard scheme antiulcer quadrotherapy, control generic viagra endoscopy performed on 1 st and 7 th day, then - as in uncomplicated ulcers.

In our study, we used differentiated tactics in patients with high risk of rebleeding clinically distinguishing absolute and relative criteria of high risk. By the absolute criteria include:

a) the size of ulcers of more than 1.5 cm;
b) anemia HB <80 g / L with acute blood loss in the period from the onset of bleeding the first three days;
c) an aggressive course of disease;
d) the localization of ulcers in the stomach.

In the presence of both brand name levitra absolute and relative (Forrest Ia, b, Forrest IIa, b) criteria for risk of rebleeding performed surgery on an urgent basis (Fig. 3).

As shown in the diagram provided (Figure 3), one third of patients 156 (33%) at high risk of rebleeding were operated on an urgent basis in 24 - 36 hours of receipt.

If we compare the results of active-differentiated tactics in high-risk of rebleeding in the two time periods
1990-2000 and 2001-2008. It should be noted that 2 / 3 of all emergency surgical interventions in groups at high risk of rebleeding was performed in 1990 - 2000. And for the period 2001 - 2008 years. about the high risk of rebleeding was operated on only 45 elderly patients.

In 2000, the progress of conservative therapy cialis without prescription and the emergence of modern antisecretory agents (proton pump inhibitors) have reduced the number of urgent surgical intervention in patients with high risk of rebleeding in 4 times. 64,5% (283) in elderly patients, despite the high risk of rebleeding, it was decided to conservatively: in 224 of these ulcers localized in the duodenum, and at 59 - in the stomach. Reasons for choosing the conservative tactics were different: the localization of ulcers in the stomach and the high risk of rebleeding, we prefer surgical treatment. Refusal of surgery in 59 patients with gastric ulcer was justified severe comorbidity or lack of history of ulcer and symptomatic ulcers.

In 224 elderly patients with localization of ulcers in the duodenum conservative tactic is chosen deliberately. All the patients with high risk of rebleeding administered injectable forms of H2-blockers (kvamatel 20 mg 4 times a day / in - every 6 hours, zantak to 80 mg / 3 times a day - every 8 hours) or proton pump inhibitors (Loseke 40 mg x 2 times a day) for 3-5 days and performed endoscopic control of hemostasis. On 2 - 3rd day in a stable condition generic levitra patients performed intragastric pH-metry to assess the quality of antisecretory therapy (Fig. 4).

abortive clinical
control of glycemia
emerging with a level
background