Volume 03 Issue 11-2023
53
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
11
P
AGES
:
53-64
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
ABSTRACT
The article presents the causes of bleeding from an acute ulcerstomach when using GC hormones in patients with
Werlhof's disease. In this case, the use of tablets in the form of inhalation or intravenous administration. The
connection of indications for endoscopic examination of the gastrointestinal tract has been proven and bleeding from
a stomach ulcer from the number of platelets. Endoscopic examinations in Werlhof's disease is recommended to be
carried out in remission. Indications of splenectomy if ineffectiveness of conservative treatment.
KEYWORDS
Thrombocytopenia, glucocorticoids, acute ulcers, bleeding, tactics.
INTRODUCTION
Often, among the causes of bleeding from the upper
gastric tract (GT), erosive and ulcerative lesions of the
stomach come first. Acute ulcers of the digestive
system are observed at any age. The frequency of
acute ulcerative lesions in old age reaches 74.6%. When
complications such as bleeding occur in 60
–
70% of
cases, or perforation in 0.5
–
3% of cases, acute ulcers
are detected during examination. Often, acute
erosions and gastric ulcers, complicated by bleeding,
occur in patients after glucocorticosteroid (GCS)
therapy (6,7,9) in patients with Werlhof's disease. This
is characterized by multiple lesions. The predominant
location of ulcers is on the greater curvature of the
stomach with a latent course. Among GCS,
prednisolone (per os) is considered as a standard drug
for pharmacodynamic therapy, especially in patients
Research Article
GLUCOCORTICOSTEROID COMPLICATIONS DURING TREATMENT OF
AUTOIMMUNE THROMBOCYTOPENIA
Submission Date:
November 12, 2023,
Accepted Date:
November 17, 2023,
Published Date:
November 22, 2023
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume03Issue11-07
Mustafakulov Gaybulla Irisbaevich
Assistant Professor Of Department General Surgery No.2, Tashkent Medical Academy, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 03 Issue 11-2023
54
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
11
P
AGES
:
53-64
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
with thrombocytopenia. Hormones cause dysfunction
of the gastrointestinal tract in 24.4% of cases, and the
ulcerogenic effect of drugs, especially when
administered orally, occurs in 3.5-7.5%. Complications
of GCS therapy in the gastrointestinal tract are
associated with duration, large doses and improper
administration of GCS hormones per os (1,2,6,7,8).
According to G.M. Chernyavskoy et al. (1996), in 26.9%
of patients, N.A. Romanova et al. (1996), in 15.4% of
patients treated with GCS for another pathology, a
gastric ulcer was detected. The cause of gastric ulcer
development is gastric hypersecretion. The acid-
forming function of the stomach, according to
intragastric pH-metry, was significantly increased (pH
1.1±0.06) in all patients (Vakhrushev Ya.M. et al., 1997).
Recently, a number of works have appeared (L. M.
Kaskevich, O. S. Radbil and S. G. Vainshtein, Grosa,
etc.), which develop the Bojanowicz hypothesis,
according to which one of the main mechanisms of the
pathogenesis of peptic ulcer disease is dyscorticism
(increased
glucocorticoid
and
decreased
mineralocorticoid functions of the adrenal cortex).
Certain drugs (caffeine, synthetic hormones of the
adrenal cortex - glucocorticoids, reserpine) stimulate
increased formation of hydrochloric acid by the
parietal cells of the stomach. In addition,
glucocorticosteroids stimulate the secretion of pepsin
and
gastrin,
which
further
increases
the
aggressiveness of gastric contents. In some cases,
stomach ulcers after taking corticosteroids were
complicated by perforation or bleeding. According to
the literature, about 5% of patients with Werlhof's
disease experience acute gastric bleeding (GI).
Mortality in gastrointestinal tract infections from acute
ulcers in patients in intensive care units reaches 80%,
and the number of patients with thrombocytopenia is
growing every year. Standard treatment begins with
corticosteroids and hormonal therapy (per os) (7,8,9).
In the acute period or relapse of Werlhof's disease, any
injury to the mucous membrane leads to an increase or
relapse of GI. Considering this tactic, the management
of
patients with
gastrointestinal
tract with
thrombocytopenia has its own characteristics.
Therefore, the search for the development of methods
for preventing relapse and methods for conservative
and
surgical
treatment
of
gastroduodenal
gastrointestinal tract with thrombocytopenia is today
an urgent problem in surgical hematology and general
surgery.
MATERIALS AND METHODS
In a study of Verlhof's patients, the medical history of
67 (70.5%) of 95 patients revealed a hormonal
complication from the gastrointestinal tract. Taking
GCS
hormones
enterally
often
resulted
in
complications from the ventricle, in particular in the
form of gastritis in 28 (75.7%), gastric ulcers in 9 (24.3%),
in addition, ulcers of the duodenum (or exacerbations
of the duodenum) were detected ) in 5 (5.3%),
exacerbation of colitis in 4 (4.2%), gastrointestinal tract
Volume 03 Issue 11-2023
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VOLUME
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SJIF
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(2023:
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OCLC
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1121105677
Publisher:
Oscar Publishing Services
Servi
discomfort in 14 (10.5%), stomach pain in 7 (5, 3%). In
total, 37 (55.2%) of 67 patients with Werlhofam
diseases had gastric complications after enteral
administration of corticosteroids. Bleeding from an
acute gastric ulcer was noted in 7 (18.9%) patients. In 7
patients with gastrointestinal tract upon admission to
the clinic, the platelet count was from 1 unit. up to -
21x10 9/l. PS
–
from 92 to 120 beats per minute. A/D
from 110/65 to 90/60 mm. rt. Art. One had severe, 3 had
moderate, and 3 had mild posthemorrhagic anemia. All
patients
received
conservative
treatment:
restoratives, hemostatic and vascular-strengthening
drugs, corticosteroids hormones - prednisolone or
dexamethasone in tablets, intravenous injections or
inhalation with simultaneous treatment of erosion and
gastric ulcers. GCS were prescribed at 1-1.5 mg/kg per
day. The duration of the disease ranged from 6 months
to 20 years and during this period the patients received
hormonal treatment from 1 to 3-7 or more times. With
parenteral administration of glucocorticoids there
were bruises at the injection sites, and in 6 patients
there
was
a
hematoma
after
intravenous
administration. According to the coagulogram,
hypocoagulation was recorded in all cases. In the
myelogram: the bone marrow puncture in all patients
is quite cellular, the type of hematopoiesis is
normoblastic, the content of lymphocytes is normal,
there are enough or many megakaryocytes, but most
of them do not contain plates. In patients with gastric
bleeding, the platelet count was below 30x10 9 / l.
Endoscopic examination of patients with gastric
bleeding was carried out with continued gastric
bleeding under enhanced hemostatic therapy in one
patient, in other cases after clinical remission.
Example 1. Patient A.V. 32 years old. Case history No.
1865. Complaints upon admission: blue bruises in the
extremities, pain in the epigastric region, black stool.
From the anamnesis: he has been ill for about 4 years
and has received hormonal treatment several times.
The skin and mucous membranes are pale. Ps
–
90
beats per minute, BP
–
100/65 mm Hg, Cor
–
without
any changes. Tongue is wet. The abdomen is involved
in the act of breathing, soft, there was pain in the
epigastric area. The liver is not enlarged. The stool is
loose, regular, black. The patient underwent
examinations: general blood and urine analysis,
biochemical studies, coagulogram, chest studies,
ultrasound examination of the abdominal organs,
endoscopic
studies,
bone
marrow
studies.
Examination: complete blood count, Hb
–
95 g/l,
erythrocytes
–
3.4 million, color index
–
0.6, leukocytes
–
7.0 x 109/l, platelets
–
15.0 x 109/l, segmented
–
66 %,
eosinophils
–
1%, lymphocytes
–
27%, monocytes
–
5%,
ESR
–
7 mm/h. Coagulograms: KKV - 46, prothrombin
index - 89%, plasma tolerance to heparin
–
13,40,
plasma fibrinogen - 2.12 g/l, fibrinolytic activity - 150,
blood clot retraction - 0.28.
The patient received the following treatment:
hemostatic agents, restorative and glandular
Volume 03 Issue 11-2023
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International Journal of Medical Sciences And Clinical Research
(ISSN
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VOLUME
03
ISSUE
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SJIF
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(2021:
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(2023:
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)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
preparations, antiulcer therapy and was treated for 5
days with inhalation of dexamethasone 12 mg. The
bleeding has stopped, the stool is normal. Ps
–
78
beats. per minute, blood pressure
–
120/8 mm Hg. Art.
Hb
–
121 g/l, platelets
–
52.8 x 109/l, leukocytes
–
6.0 x
109/l, hemorrhagic syndrome was relieved, single skin
ecchymoses remained. Discharged with clinical
remission on day 10. EFGDS (5-day)
–
Moderate
catarrhal gastritis. In the area of the cardiac part of the
stomach there is multiple erosion and an acute ulcer;
there is also a fresh thrombus and in places covered
with a pinpoint fibrin coating.
Diagnosis: Werlhof's disease, chronic, in the acute
stage.
Complication: Acute (steroid) ulcer (multiple erosion)
of the stomach. Moderate posthemorrhagic anemia.
Example 2. Patient K.N., 21 years old. Case history No.
2124. Upon admission, complaints of weakness,
fatigue, dizziness, headache, pain in the epigastric
area, prolonged and profuse mensis, bruises and small
rashes on the div, black stool. From the anamnesis:
she has been ill for 1.5 years, received treatment
several times with a temporary effect, received
hormonal medications per os, over the last 2 weeks the
above complaints have reappeared. In the last 6
months, the patient developed a steroid gastric ulcer,
diagnosed after endoscopy. The condition upon
admission was severe. The skin and mucous
membranes are pale blue, small hemorrhagic rashes in
the extremities, bruises up to the size of the palm,
more on the lower extremities, at the injection site and
in places in the anterior abdomen. Subcutaneous fatty
tissue is developed, moon-shaped face, lymph nodes
are not palpable. PS
–
105-115 beats per minute,
rhythmic, blood pressure
–
85/60 mm Hg. Cor
–
muffled
tone, systolic murmur at the apex. Pulmonis
–
vesicular
breathing on both sides. The tongue is moist, the
abdomen is enlarged in volume due to the
subcutaneous fat layer, participates in the act of
breathing, soft, pain in the epigastric region, tense
muscles, no irritation of the peritoneum. The liver and
spleen are not palpable. Pasternatsky's symptom is
negative on both sides. The stool is loose, regular,
black. Urination is free and regular. The patient has had
mensis since the age of 14, in recent years it has been
irregular, lasting up to 2 weeks, and heavy for 7 days.
Examinations: upon admission: Hb
–
53 g/l,
erythrocytes
–
2.2 million, color index
–
0.6, leukocytes
–
6.0 x 109/l, platelets
–
single. Coagulogram: CCV - 48,
PTI - 67%, plasma heparin tolerance - 19, plasma
fibrinogen - 1.99, fibrinolytic activity - 130, blood clot
retraction - 0.27. Biochemical tests: total protein - 58.5
g/l, total bilirubin - 23.7, direct - abs, indirect - 23.7 mol/l,
ALT - 1.1 mol/l, AST - 0.5 mol/l, HBsAg
–
negative.
Ultrasound
–
fatty hepatosis. ECG
–
sinus tachycardia,
changes in the left atrium, depolating changes in the
myocardium.
Volume 03 Issue 11-2023
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(2023:
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)
OCLC
–
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Publisher:
Oscar Publishing Services
Servi
Based on these data, a diagnosis was made: Werlhof's
disease, a chronic, often relapsing course.
Complications: steroid gastric ulcer, Cushingism,
hyperpolymenorrhea.
Severe
posthemorrhagic
anemia.
Concomitant: chronic hepatitis.
The patient received a general strengthening agent,
hemostatic agents, Riboxin, glandular and potassium
preparations, red blood cell mass, and plasma.
Dexamethasone solution 6.0 mg per day by inhalation
for 3 days and 7 days 4.0 mg per day + 4.0 mg
intravenously. General tests on the 3rd day of
treatment: Hb
–
110 g/l, erythrocytes
–
3.9 million,
platelets
–
36.1 x 109/l, leukocytes
–
6.1 x 109/l,
lymphocytes
–
32%, ESR
–
8 mm/hour. EGDFS (day 3)
–
a stomach ulcer was detected. The pati
ent’s condition
improved, hemodynamics stabilized, stool color
returned to normal. Petechiae on the div
disappeared on days 5-6, the bruises decreased and
some resolved, the color became yellow-brown. On
the 14th day of treatment: Hb - 118 g/l, erythrocytes -
4.0 million, platelets - 80.0 x 109/l, leukocytes - 7.0 x
109/l, segmented - 59%, lymphocytes -37 %, ESR
–
9
mm/hour. Accordingly, positive changes in the
coagulogram. After stabilization of the patient’s
general condition, an operation was performed -
splenectomy according to the clinic’s proposed
method. During the operation, blood loss was more
than 30.0 ml; after the operation, about 10 ml was
released through the drainage tube and removed on
the 2nd day. The postoperative course is smooth.
General blood test after surgery: Hb - 129 g/l,
erythrocytes - 4.2 million, platelets - 175.0 x 109/l,
leukocytes -6.7 x 109/l, segmented - 75, lymphocytes -
14.0 %, ESR - 5 mm/hour. Coagulogram: CCV - 37, PTI -
95%, plasma tolerance to heparin - 10, blood clot
retraction - 0.4. Discharged on the 9th day after
surgery in satisfactory condition, clinical and
hematological remission.
RESULTS AND DISCUSSION
After hormonal treatment, in 2 patients with
thrombocytopenia (33.3%), platelets rose to 60
thousand and on the 4th day the hemorrhagic
syndrome in the form of GI was stopped. Clinical
remission was obtained on average on day 10, and in 4
(66.7%) patients platelets reached from 150,000 to
175,000 on average on day 7. In all 4 patients, the
phenomena of hemorrhagic syndrome in the form of
gastrointestinal tract were stopped on days 2-3 of
treatment and clinical and hematological remission
was obtained. In 1 patient, after splenectomy, clinical
and hematological remission was obtained.
Hemodynamic parameters returned to normal in all
patients. In two patients, hemoglobin rose to normal;
the rest were discharged with mild anemia. Clinical
observations indicate that when taking GCS hormones
Volume 03 Issue 11-2023
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OCLC
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Publisher:
Oscar Publishing Services
Servi
per os in large doses, as well as for a long time in
patients with Werlhof's disease, complications from
the gastrointestinal tract may occur. GCS not only
cause the development of ulcers, but also inhibit the
healing of existing ulcers. Experimental reproduction
of acute insufficiency of the adrenal cortex causes
suppression of secretion, disruption of the mucous
membrane with the development of ulcers. In
conditions of hormonal deficiency, the resistance of
the mucous membrane to the action of ulcerogenic
factors of the stomach undoubtedly decreases. Large
doses of corticosteroid hormones, when administered
repeatedly peros, slow down the healing of affected
areas of the gastrointestinal tract and lead to an
exacerbation of the pathological processes existing in
it. Long-term hormonal therapy leads to insufficiency
of the adrenal cortex, this, in turn, suppresses the
secretion of the gastrointestinal tract, leads to
disruption of the integrity of the mucous membrane
and the development of gastritis, duodenitis or ulcers
in the gastrointestinal tract. In thrombocytopenia, the
vascular endothelium, deprived of the angiotrophic
function of platelets, becomes porous, brittle, and
increased permeability, especially in patients with
severe hemorrhagic syndrome and with hormonal
damage to the gastrointestinal tract, and is often
complicated by bleeding.
CONCLUSION
Taking this into account, hormonal drugs have been
transferred from per os to inhalation or intravenous
administration with increasing doses. Endoscopic
examination is carried out with ongoing gastric
bleeding under enhanced hemostatic therapy. During
endoscopic examination, any additional injury can
become a source of bleeding, including local
endoscopic
hemostasis.
Further
endoscopic
examinations and treatment should be carried out
after normalization of the number of platelets in the
blood and their function. There is a definite
relationship between the platelet count and clinical
manifestations. When the platelet count is above 30-
50x109/l, the course of the disease is often
asymptomatic. When the platelet count is below
30x109/l, hemorrhagic complications appear. You need
to know that determining the cause of bleeding is only
possible using laboratory methods. If conservative
treatment fails and bleeding continues, emergency
splenectomy is recommended.
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SJIF
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FACTOR
(2021:
5.
694
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(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
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