Prevention of gastrointestinal bleeding as a consequence of enteral feeding after surgical treatment of complicated duodenal ulcer

Abstract

In case of complicated peptic ulcer disease, there is enteral insufficiency, which is manifested by hypoxia of the body and hemodynamic disorders [1]. In this category of patients, one or another degree of hypotrophy is determined before the operation. Forced fasting in the postoperative period causes a violation of metabolic processes and leads to an increase in the frequency of postoperative complications [2]. Therefore, for the purpose of their correction, postoperative nutritional therapy is carried out (both parenterally and enterally). An important place among the methods of combating enteral insufficiency should belong to timely and adequate enteral feeding (EF), which prevents mucosal atrophy; reduces the expressiveness of stress reactions; has an immunomodulatory effect; increases mesenteric and hepatic blood flow; prevents bacterial translocation [3]. In the modern literature, despite the large number of articles devoted to the problem of EF, there is no data on the effect of food mixtures on gastric secretion, the possible reasons for the development of hemorrhagic complications from the digestive tract have not been analyzed [4]. Objective: to prevent the development of hemorrhagic complications of the digestive tract when using EF in the early postoperative period. Methods. 60 patients operated on for a perforated duodenal ulcer were examined. All patients underwent various variants of duodenoplasty. During the operation, a thin polyvinyl chloride probe was inserted into the small intestine at the Treitz ligament. EF was started at the end of the 2nd day of the postoperative period by drip (25 ml per hour) administration of the mixture for EF in a continuous mode (for 16-20 hours). In the early postoperative period, 15 patients received H2-histamine blockers, 15 patients - proton pump inhibitors (PPI), 15 patients were not prescribed antisecretory drugs. The remaining 15 patients were injected into the probe for EF with an acidin-pepsin solution (pH=2) 4-5 times a day to selectively inhibit the intestinal phase of gastric secretion (our own method). Results. Hemorrhagic complications developed in 20% of patients who underwent EF and received H2-blockers, and in 40% of patients who did not receive antisecretory treatment. In previous studies, we established the main reason for the development of hemorrhagic complications from the upper parts of the digestive tract when using EF – the intestinal phase of gastric secretion. Stimulation of gastric acid production due to its intestinal phase was carried out by the components that were part of the mixtures for EF (protein caseinate, vegetable and animal fats, fatty acids, poly- and oligosaccharides). Standard methods aimed at the prevention of hemorrhagic complications from the gastrointestinal tract, when using enteral nutrition, are either ineffective or have a number of significant disadvantages. The use of H2-blockers allows blocking basal and stimulated secretion of hydrochloric acid due to the effect on the second (humoral) phase of secretion, however, about 20% of patients generally have tolerance to therapy with histamine H2-blockers. The use of PPI, which act on all three phases of gastric secretion, is considered optimal. However, this group of drugs also has disadvantages (hypergastinemia, functional (digestion) and organic disorders (atrophic gastritis, neoplastic processes) [5]. Studies of patients in whom the intestinal phase of gastric secretion was selectively suppressed showed that after 15 min. after enteral administration of an acidin-pepsin solution (pH=2), the basal level of stomach contents (pH=2.0) increases 2.5 times (pH=5.0), stably remaining at the given level for 4 hours. Not a single case of the development of gastrointestinal bleeding was registered. This method is the only one known today that allows you to avoid the development of hemorrhagic complications in the upper parts of the digestive tract by selectively blocking the third (intestinal) phase of gastric secretion Conclusion. Thus, enteral administration of acidin-pepsin solution when using EF leads to selective blockade of the third (intestinal) phase and prevents the development of hemorrhagic complications in the upper parts of the digestive tract. Literature 1. Costable NJ, Greenwald DA. Upper Gastrointestinal Bleeding. Clin Geriatr Med. 2021 Feb;37(1):155-172. 2. Oğuz E, Cebeci A, Geçici CR. The relationship between nutrition and Ménière's disease. Auris Nasus Larynx. 2021 Oct;48(5):803-808. 3. Marks SL, Kook PH, Papich MG, Tolbert MK, Willard MD. ACVIM consensus statement: Support for rational administration of gastrointestinal protectants to dogs and cats. J Vet Intern Med. 2018 Nov;32(6):1823-1840 4. Stanley AJ, Laine L. Management of acute upper gastrointestinal bleeding. BMJ. 2019 Mar 25;364:l536. 5. Lee L, Ramos-Alvarez I, Ito T, Jensen RT. Insights into Effects/Risks of Chronic Hypergastrinemia and Lifelong PPI Treatment in Man Based on Studies of Patients with Zollinger-Ellison Syndrome. Int J Mol Sci. 2019 Oct 16;20(20):5128.