Therapeutic endoscopy for hemorrhage

Therapeutic endoscopy for bleeding from the upper gastrointestinal tract has been used for a long time. In 1956, a rigid endoscope was successfully used to stop bleeding. In 1968, Palmer reported on the visualization of the bleeding site and thermal action on it.

In more than 80% of cases, bleeding from the upper gastrointestinal tract stops on its own, and therefore patients only need conventional symptomatic therapy. Spontaneous bleeding usually stops within 12 hours. In most patients, bleeding stops before they are admitted to hospital. Relapse of bleeding, after it has been stopped by conservative methods, usually occurs within the first 3 days. In cases of ongoing bleeding or its relapse, endoscopic methods of stopping are the methods of choice. Their effectiveness is quite high. Only less than 10% of patients require emergency surgery to stop bleeding.

Indications for endoscopic bleeding control.

1. Bleeding of mild intensity.
2. Severe bleeding in patients with an absolute surgical risk for stabilization of the condition.

Methods of endoscopic stopping of gastrointestinal bleeding

1. Coagulation of blood proteins using targeted administration of drugs: 96-degree alcohol, tannin, collargol, etc., with the aim of compacting the hemorrhagic clot.
2. Hypothermic effect on a bleeding vessel: ethyl chloride, liquefied carbon dioxide, etc. These preparations are applied through Teflon or polyethylene catheters. The catheter should have a narrowed lumen in the area of the distal end; for this, the catheter in the area of the distal end is pulled over a flame. During application, a large amount of vapor is formed; to evacuate it through the biopsy channel, the catheter is made significantly smaller than its size. After application of ethyl chloride, a two- or three-fold air exchange is performed to prevent combustion for electro- or photocoagulation. Ethyl chloride is applied using a syringe, no more than 20 ml at a time. The hemostatic effect is short-lived and requires consolidation.
3. Hydraulic tamponade of tissues in the bleeding area. It is performed using an injection needle. An important condition is the introduction of fluid into the submucosal layer, which leads to compression of the vessels of this layer. The reliability of hemostasis is increased by adding vasoconstrictors (ephedrine, mezaton, androxon) to the fluid. Ephedrine is not very desirable due to its short action time. It is inappropriate to use novocaine, which has a pronounced antispasmodic effect. For hydraulic tamponade, saline solution from 20 to 70 ml is used. Infiltration begins with the distal sections, then moves to the proximal ones. Tamponade is performed from 3-4 injections, while the ulcerative defect decreases in size and bleeding stops. When it is impossible to penetrate the bulb of the duodenum in case of an ulcer of the bulb, tamponade can be performed through the submucosal layer of the pylorus, infiltrating all the walls from 4 punctures. The needle should be inserted, retreating from the edge of the ulcer by 0.5-0.6 cm. The effect of the tamponade lasts 2-2.5 hours.
4. Mechanical action on the bleeding site by applying film-forming applications. Film-forming aerosols and medical glue are used: BF, MK-6, MK-7, MK-8, etc. They 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 for the primary stopping of minor bleeding or for fixing a hemorrhagic clot and fibrin covering the area of mucosal erosion. When applying applications, it is necessary to follow a number of rules:
   1. the film must remain on the surface of the mucous membrane defect for a long time. This is achieved by appropriate preparation of the defect: it is cleaned of blood, food lumps and mucus with a stream of water and dried with ether or alcohol;
   2. film-forming solutions are best applied "from top to bottom", i.e. with the patient on the "sick" side (for example, in case of an ulcer of the lesser curvature of the stomach - on the right side), which promotes good filling of the defect and prevents the drug from getting on the optics of the endoscope. The drug should be introduced 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 inflated with air, since when the organs collapse, the contact of the film with the bottom of the defect is disrupted;
   4. Immediately after application, 1-2 ml of acetone is injected into the catheter to prevent clogging by the film that has formed. After removing the endoscope, the end of the catheter is cleaned of glue with acetone and the catheter is removed from the endoscope.

This method prevents the endoscope biopsy channel from being sealed with a polymer film and the device from being put out of order. It is advisable to apply it daily, since the polymer film can fragment within 24 hours, after which the defect is exposed.

5. Glue tissue infiltration. Glue is injected into the submucosal layer using a flexible needle or a needle-free injector. The danger of this method is associated with the possibility of phlegmon.
6. Electrothermocoagulation. Mono- and bipolar electrodes are used. To prevent blood from flooding the bleeding source, it is necessary to wash the bleeding area with ice water, and sometimes it is necessary to change the patient's position. The exposure with a monopolar electrode should not exceed 2-3 seconds, and with a bipolar electrode 4-5 seconds. With an increase in exposure time, the risk of perforation increases sharply, and an excessive amount of smoke is formed, which complicates endoscopy and requires more frequent aspiration. It is necessary to always see the bleeding site; coagulation is not allowed if it is not visible. It is advisable to begin coagulation by point dehydration of tissues along the ulcer periphery from 4-7 zones, retreating from the ulcer edge by 2-4 mm. After this, the ulcer defect is washed from liquid blood and targeted coagulation is performed. Coagulation of vessels in the area of the ulcer bottom is contraindicated.

During coagulation with a monopolar electrode, the necrotic area extends to the mucous membrane within 2 seconds, to the submucous layer within 4 seconds, to the muscular layer within 6-7 seconds, and to the serous membrane within 10 seconds. During coagulation with a bipolar electrode, the necrotic area extends along the mucous membrane rather than deep into it - coagulation is less dangerous.

7. Laser photocoagulation. Provides a good hemostatic effect. The defect bottom is covered with a film of coagulated blood, and the zone of coagulation necrosis extends into the submucosal layer of the stomach wall. Inflammatory edema and stasis in small vessels are observed in the muscular and serous layers. In addition, when using laser radiation, due to the evaporation of fluid from the tissues, wrinkling and a decrease in the size of the defects of damage 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).

An indication for the use of laser radiation is ongoing bleeding in acute and chronic ulcers, mucous membrane damage, varicose veins, and disintegrating tumors. A prerequisite for the successful use of laser radiation is good visibility of the bleeding source. The presence of blood and its clots sharply reduces the effectiveness of photocoagulation due to the absorption of energy by the blood. In case of ongoing bleeding, it is necessary to free the source from blood and its clots. The direction of the laser beam during electrocoagulation should be tangential, while during cutting it should be perpendicular. The duration of effective exposure depends on the nature of the bleeding source, 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 injected into the tissue along the periphery of the ulcerative defect in the stomach and duodenal bulb. The sclerosing agent (sodium tetradecyl sulfate, varicocide, thrombovar, etc.) is administered endo- and perivascularly. The most pronounced effect is achieved with combined administration. It is administered using a needle, starting from the distal sections, and the second injection is made more proximally. Up to 5 ml is administered during one manipulation. Repeated administration can be performed after 3-4 days, when the swelling subsides and the threat of phlegmon disappears.
9. Clipping or ligation of vessels and tissues in the bleeding area.
10. Balloon tamponade of the esophagus, stomach and duodenum with Blakemore-type probes.

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