Medical endoscopy for bleeding

Medical endoscopy for bleeding from the upper parts of the digestive tract has long been used. In 1956, a rigid endoscope was successfully used to stop bleeding. In 1968, Palmer reported on the visualization of the focus of bleeding and the thermal effect on it.

In more than 80% of cases, bleeding from the upper parts of the gastrointestinal tract stops on its own, and therefore patients need only usual symptomatic therapy. Spontaneous stop of bleeding occurs, as a rule, within 12 hours. In most patients, bleeding stops before they enter the hospital. The recurrence of bleeding, after it was stopped by conservative methods, occurs, as a rule, during the first 3 days. In cases of continuing bleeding or its recurrence, endoscopic stopping methods are the methods of choice. Their effectiveness is high enough. Only less than 10% of patients in order to stop bleeding need urgent surgery.

Indications for endoscopic hemorrhage.

1. Bleeding unexpressed intensity.
2. Severe bleeding in patients with unconditional operational risk for stabilizing the condition.

Methods of endoscopic arrest of gastrointestinal bleeding

1. Coagulation of blood proteins with the help of targeting drugs: 96-degree alcohol, tannin, collargol, etc. With the purpose of tightening the hemorrhagic clot.
2. Hypothermic effects on the bleeding vessel: chloroethyl, liquefied carbon dioxide, etc. The applications of these drugs are carried out through teflon or polyethylene catheters. At the catheter, the lumen should be narrowed in the distal end, for this catheter in the region of the distal end is pulled over the flame. When applying a large number of vapors, for their evacuation through the biopsy channel the catheter is made much smaller than its size. After chloroethyl application for electro-or photocoagulation, a two- or three-time exchange of air is produced - an ignition warning. Chlorerate is applied with a syringe, once with no more than 20 ml. Hemostatic effect is short-lived and requires fixation.
3. Hydraulic tamponade of tissues in the bleeding zone. Produced by injection needle. An important condition - the introduction of fluid in the submucosal layer, which leads to the compression of the vessels of this layer. The reliability of hemostasis is enhanced by the addition of vasoconstrictive drugs (ephedrine, mesethon, androxone). Ephedrine is not very desirable because of the short duration of the action. It is inexpedient to use novocaine, which has a pronounced antispasmodic effect. For hydraulic tamponade use saline from 20 to 70 ml. Begin to carry out infiltration from the distal parts, then passing to the proximal ones. Tamponade is made from 3-4 injections, while the ulcer defect decreases in size and stops bleeding. When the ulcer of the bulb of the duodenum does not pass into the bulb, the tamponade can be performed through the submucosal layer of the pylorus, infiltrating all the walls from 4 jabs. Injection of the needle should be performed, deviating from the edge of the ulcer by 0.5-0.6 cm. The action of the tamponade lasts 2-2.5 hours.
4. Mechanical influence on the center of bleeding by application of film-forming applications. The film-forming aerosols and medical glue are used: BF, MK-6, MK-7, MK-8, etc. Can be used as a means of strengthening coagulated tissues after photo and electrocoagulation. They are applied through a catheter using a syringe. Aerosol adhesive compositions can be used to initially stop minor bleeding or to fix a hemorrhagic clot and fibrin covering the mucosal erosion zone. When applying applications, you must follow a number of rules:
   1. The presence of the film on the surface of the mucosal defect should be prolonged. This is achieved by appropriate preparation of the defect: it is cleaned of blood, lumps of food and mucus with a stream of water and dried with ether or alcohol;
   2. Film-forming solutions should be applied "from top to bottom", i.e. In the patient's position on the "sick" side (for example, with a small gastric ulcer in the position on the right side), which contributes to a good filling of the defect and prevents the drug from entering the optics of the endoscope. The drug should be injected into the catheter under moderate pressure, so as not to splash it over a large area;
   3. during the application of solutions, the stomach and duodenum should not be too bloated with air, since when the organs fall, the contact of the film with the bottom of the defect is broken;
   4. immediately after the application to the catheter, 1-2 ml of acetone is introduced to prevent clogging of the resulting film. After extracting the endoscope, the end of the catheter is cleaned with acetone from the glue and the catheter is removed from the endoscope.

In this way, the sealing of the biopsy channel of the endoscope with polymer film is prevented and the device is disabled. Applications are desirable to produce daily, as the polymer film can be fragmented within a day, after which the defect is exposed.

5. Adhesive tissue infiltration. With the help of a flexible needle or a needleless injector, glue is introduced into the submucosal layer. The danger of this method is associated with the possibility of phlegmon.
6. Electrothercoagulation. Mono- and bipolar electrodes are used. To prevent blood from flooding the source of bleeding, it is necessary to rinse the bleeding zone with icy water, and sometimes the position of the patient must be changed. The exposure with a monopolar electrode should not exceed 2-3 seconds, and with a bipolar electrode 4-5 seconds. As the exposure time increases, the danger of perforation increases dramatically, and an excessive amount of smoke is formed, which complicates endoscopy and requires more frequent aspiration. It is necessary to always see the focus of bleeding, in the absence of visibility, coagulation is not permissible. It is advisable to begin coagulation by means of point dehydration of tissues along the periphery of ulcers from 4-7 zones, receding from the edge of the ulcer by 2-4 mm. After this, a ulcerative defect is removed from the liquid blood and directional coagulation is performed. Coagulation of the vessels in the area of the bottom of the ulcer is contraindicated.

When coagulating with a monopolar electrode for 2 seconds, the necrosis region extends to the mucosa, within 4 seconds to the submucosa, within 6-7 seconds to the muscular layer, within 10 seconds to the serosa. When coagulating with a bipolar electrode, the area of necrosis goes along the mucosa, and not deep into - coagulation is less dangerous.

7. Laser photocoagulation. Gives a good hemostatic effect. The bottom of the defect is covered with a film of coagulated blood, and the zone of coagulation necrosis spreads into the submucous layer of the stomach wall. In the muscular and serous layers, inflammatory edema and stasis in small vessels are observed. In addition, when laser radiation is used due to the evaporation of liquid from the tissues, wrinkling and a decrease in the size of damage defects are noted, which leads to compression and thrombosis of the vessels. Laser radiation with a short wavelength is used: neodymium (wavelength 1.06 μm), argon (0.6 μm) and copper (0.58 μm).

Indication for the use of laser radiation is the continued bleeding in acute and chronic ulceration, mucosal damage, varicose veins, disintegrating tumors. An obligatory condition for successful application of laser radiation is a good visibility of the source of bleeding. The presence of blood and its clots dramatically reduces the effectiveness of photocoagulation in connection with the absorption of energy by blood. With continued bleeding, it is necessary to release the source from the blood and its clots. The direction of the laser beam during electrocoagulation should be tangential, while in cutting - perpendicular. The duration of effective treatment depends on the nature of the source of bleeding, the diameter of the vessels, the radiation power and other factors.

8. Sclerosing therapy. It is used for sclerosing varicose veins of the esophagus. Sometimes it is introduced into the tissue around the periphery of the ulcerative defect in the stomach and bulb of the duodenum. The introduction of the sclerosing drug (sodium tetradecyl sulfate, varicicide, thrombovar, etc.) produces endo- and perivascular. The most pronounced effect with combined administration. Enter with a needle, starting with the distal parts, and the second injection is made proximal. During one manipulation, up to 5 ml is administered. Re-introduction can be made in 3-4 days, when the edema drops and the threat of phlegmon disappears.
9. Clipping or ligation of blood vessels and tissues in the bleeding zone.
10. Balloon tamponade of the esophagus, stomach and duodenum with probes of Blakemore type.

[1], [2], [3], [4], [5]