Preparation for endoscopy for gastrointestinal bleeding

Preparation for fibroendoscopy with gastrointestinal bleeding is performed at the time of resuscitation. Anesthesia should be performed depending on the patient's condition. Local anesthesia is more often used, but anesthesia is also used (endotracheal and intravenous). In patients with a tendency to indomitable vomiting, it is advisable to carry out a study under endotracheal anesthesia - preventing regurgitation. In patients with pathological fear before the study and epileptics, psychiatric patients underwent an IV / anesthesia study.

Research should be carried out on a functional table. The patient is on the left side of the study. Disagreeable is the issue of gastric lavage before endoscopy. Gastric lavage is not always necessary: firstly, a small curvature and antral department can be looked at and with a sufficient amount of blood; Secondly, approximately 10% of patients with a bleeding duodenal ulcer in the stomach are not found, tk. In the absence of episodes of fresh bleeding, the blood from the stomach passes into the gut fairly quickly; thirdly, gastric lavage is not always effective, because large blood clots are difficult to disintegrate, they do not pass through the probe and clog it. Moreover, when rinsing, the stomach may accumulate water, which makes it difficult to inspect, and the washing probe can injure the mucous membrane, making it difficult to find the main source of bleeding. The need for gastric lavage should be determined during endoscopy and there is:

1. if it is impossible to perform a revision of the stomach due to a large amount of liquid blood and its clots;
2. in the event that the examination was unsuccessful due to the presence of a large number of small clots and scarlet blood on the walls of the organ;
3. if one surface bleeding spot (acute ulcer or erosion) is detected and a large amount of blood is present in the organ, which makes it impossible to examine in detail the walls of the stomach and duodenum and exclude the presence of other sources of bleeding;
4. at the slightest doubt as a primary examination.

With the localization of the source of bleeding in the esophagus, blood drains into the stomach and prevents the examination of the esophagus. If in an air-diluted stomach half of its volume occupies blood or liquid, then it is difficult to make a qualitative examination of the entire mucosa. In these cases, it is necessary to empty the stomach.

If liquid blood and large blood clots occupy less than half the volume of the expanded stomach, a detailed examination can be made by changing the position of the patient. With the rise of the foot end of the table, the contents accumulated in the bottom and large curvature do not interfere with the revision of other parts of the stomach, and when the head end of the table is raised, the proximal parts of the stomach are released for examination. Small blood clots on the surface of the mucous membrane can easily be washed off with a stream of water from the catheter.

Blood clots make it difficult to examine the duodenum because of its small size. If the blood clot has moved to the intestine from the stomach, it can be easily rinsed off the mucous membrane with a water jet or moved with biopsy forceps. If you find at least the edge of a ulcer defect, covered with a clot, the diagnosis is clear, and there is no need to move the clot.

Gastric lavage is best done with ice water (+ 4-6 degrees). In winter, tap water is added by 1/3 of crushed ice, in summer - 2/3 or 3/4 of crushed ice. The water will be ready in 10 minutes. This gives a hypothermic effect on the bleeding vessels. It is advisable to add substances that enhance hemostasis.

Once it should be injected 250-300 ml. Enter slowly with a syringe. Evacuation should be carried out necessarily by gravity in 1-1,5 minutes after water retention in a gleam of a stomach. Active evacuation without water retention in the lumen of the stomach promotes increased bleeding and insufficient hypothermic effects. Only a thick gastric tube is used, through which small clots can escape. The time for gastric lavage should be consistent with the change in the activity of washing water staining. If within 10-15 minutes there is no tendency to lightening - washing stops - more radical help is needed. With a tendency to clarification, washing continues to 30-40 minutes. The amount of water is up to 10 liters. Any rinsing with continued bleeding should be combined with general haemostatic therapy.

It should be borne in mind that the endoscopic picture of the mucous membrane of the organs changes with bleeding . This is due, on the one hand, the presence of a thin layer of blood and fibrin on the walls, absorbing a significant amount of light rays, on the other - pallor of the mucosa due to the development of posthemorrhagic anemia. In the absence of anemia at the height of the bleeding, a thin layer of blood covering the mucous membrane of the stomach and duodenum gives it a pink color and masks the defects. With an average and severe degree of anemia, the mucous membrane, on the contrary, becomes pale, matte, lifeless, and inflammatory hyperemia around the source of bleeding decreases and disappears altogether. Reduction and disappearance of the contrast between the "sick" and "healthy" tissues cause a uniform coloration of the mucous membrane, which makes it difficult to search for a source of bleeding and distorts the endoscopic picture. This can lead to diagnostic errors: either the source of bleeding can not be detected (more often with superficial ulceration-erosions, acute ulcers), or it is misinterpreted (for benign and malignant ulcers).

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

Varicose veins of the esophagus

In most cases, patients with varicose veins of the esophagus do not bleed from them. However, when bleeding from them does occur, it usually happens to be more severe than bleeding from any other source of the upper gastrointestinal tract.

Endoscopically, the diagnosis is unquestionable if the study reveals bleeding varicose veins of the esophagus. A presumptive diagnosis of bleeding from such veins can be made in cases when varicose veins are revealed in the esophagus and there are no other possible sources of bleeding in either the stomach or the duodenum. Traces from fresh ruptures (pigment spots on the surface of varicose dilated veins) are additional evidence of recent bleeding from varicose veins of the esophagus.

With continued bleeding during endoscopy, a lot of liquid blood is detected in the esophagus. To avoid injury to the mucosa, the inspection is performed with minimal air insufflation, and a catheter conducted through a biopsy channel or using a syringe flushing is used for flushing. With esophagoscopy, a jet or dropping of blood from the surface of the varicose stem is seen, which makes it difficult to study. Defect in the mucosa is usually not visible. The varicose stem can be in the form of a single longitudinal trunk, extending from the middle of the thoracic to the cardia, or in the form of 2, 3 or 4 trunks. Separate varicose nodules to profuse bleeding, as a rule, do not lead. With stopped bleeding, veins can subside and become poorly differentiated (discharge of blood).

When there are no defects on the esophagus mucosa and there is no pathology on examination of the stomach and duodenum and there is a suspicion of varicose veins of the esophagus, a test can be performed to fill the esophagus veins: the endoscope is drawn into the stomach, the end is folded onto the cardia and delayed by 1.5 -2.0 min, then straighten the end, remove the endoscope to the lower part of the thoracic esophagus and esophagus veins, observe the filling of the esophagus veins (only in the absence of defects on the mucosa of the esophagus). The magnitude of bleeding can be judged by the imposition of fibrin on tops of venous trunks, in the area of the defect to the periphery may be intralucent hematomas.

Bleeding from varicose veins of the esophagus is best stopped by endoscopic sclerosing therapy or endoscopic bandaging of bleeding varicose veins. For sclerosing therapy, 5% varicocidal solution, 1% or 3% thrombovar solution or 1% sodium tetradecyl sulfate solution is used. The veins under the vision control are punctured below the source of bleeding and 2-3 ml of the sclerosing drug are injected into it. Then the vein is punctured above the bleeding site and injected into it with the same amount of the drug.

After that, the site of the vein between the points of the puncture is pressed for some time by the distal end of the endoscope, thus preventing the spread of the drug along the vascular anastomoses to the superior vena cava. During the endoscopic examination, no more than two or three varicose veins should be thrombosed, as a complete cessation of outflow through the veins of the esophagus contributes to a significant increase in venous pressure in the region of the cardiac part of the stomach, which can lead to profuse bleeding from the varicose veins of this region. Repeated sclerotherapy of the remaining varicose veins of the esophagus is performed after 2-3 days, and the course of treatment includes 3-4 sessions. Control over the effectiveness of the treatment is carried out 10-12 days later using radiological and endoscopic studies.

When performing sclerosing therapy in about 20% of cases, there are various complications, such as ulceration, development of stricture, motor disorders of the esophagus and mediastinitis.

Endoscopic ligation of bleeding varicose veins of the esophagus is also quite effective, and the incidence of complications during its implementation is much less. Both manipulations, if repeated 5 times or more within 1-2 weeks, lead to obliteration of varicose veins and reduce the likelihood of a recurrence of bleeding.

To stop bleeding, a balloon tamponade of bleeding varicose veins of the esophagus is also used. To do this, use Sengstaken-Blake-more esophageal-gastric probes or Minnesota-Linton gastric. Correctly installed probes allow in most cases to stop bleeding. However, when the cuffs are opened, it often recurs. Due to the high frequency of possible complications, these probes should only be used by those doctors who have sufficient experience in their installation.

Mallory-Weiss Syndrome

Mallory-Weiss syndrome most often occurs in people who abuse alcohol in vomiting as a result of uncoordinated abdominal wall reductions. Bleeding develops from cracks in the mucous membrane located deep in the furrows between the longitudinal folds. They are always located on the back wall of the esophagus and cardioesophageal junction. They are caused by the relationship between the mucosa and the submucosa. Mucosal ruptures have the form of longitudinal ragged wounds up to 2-3 and even 4-5 cm long and up to 1-5 mm wide, of a reddish color, of a linear shape. Most breaks are single, but they can be multiple. The bottom of the ruptures is filled with blood clots from which fresh blood flows. The mucous membrane at the edges of the wound is impregnated with blood.

Aiming washing leads to the removal of blood and exposure of the mucosal defect. Gaps can seize the mucous membrane, submucosal and muscle layers, and sometimes complete wall ruptures are observed. The lamination of the edges of the rupture is easy to determine with a moderate constant introduction of air into the stomach, although the application of this technique is fraught with the threat of intensification or resumption of bleeding.

The edges of the wound diverge and its walls are exposed. In the depth of the wound, it is possible to see individual muscle fibers with broken and preserved structures that are thrown in the form of narrow strips between the walls.

Bleeding is rarely intense. In the process of endoscopy, as a rule, it is possible to reliably stop it with sclerotherapy, electro- or photocoagulation. If, after the bleeding has passed quite a lot of time (4-7 days), then during the endoscopy, longitudinal bands of yellowish white color are found - mucosal wounds covered with fibrin. They have the form of grooves with low edges. When the air is injected, their surface does not increase. Deep ruptures of the stomach wall heal within 10-14 days, often with the formation of a longitudinal yellowish rumen, and superficial - for 7-10 days, leaving no traces.

Disruptions of the mucosa can be not only in the Mallory-Weiss syndrome, but also in traumatic origin.

[6], [7], [8], [9], [10], [11], [12],

Bleeding from a tumor

Bleeding from the tumor can be massive, but rarely is prolonged, because in the tumor there are no main vessels. Appearance of tumors is not difficult, but sometimes they can be completely covered with blood clots and not visible due to their large curvature. Above benign tumors the mucosa is mobile. It is not always advisable to take a biopsy, but if you take it, then from those areas where there is no decay.

[13], [14], [15], [16], [17]

Bleeding from an ulcer

The effectiveness of endoscopic diagnosis of acute ulceration is higher the less time has passed since the onset of bleeding and the less pronounced posthemorrhagic anemia. The decrease in the diagnostic value of endoscopy over time is explained by the rapid healing of superficial ulceration, the disappearance of inflammatory hyperemia around the defect and the absence of signs of bleeding at the time of examination. Acute erosion can be epithelialized within 2-5 days. Diagnosis of chronic ulcers as the cause of gastroduodenal bleeding in most cases is simple in view of the typical endoscopic features for them. Particular attention should be given to the detection of thrombosed vessels on the bottom of defects, which allows to determine the threat of recurrence of bleeding. The peculiarity of the endoscopic picture of chronic ulcers with bleeding from them lies in the fact that the depth of ulcers and the height of the edges diminish, the scars are poorly visible. These changes are the cause of diagnostic errors: chronic ulcers are regarded as acute. Bleeding ulcers can be covered with a loose bloody clot or hemolyzed blood, which makes it difficult to recognize it. When you see at least the edge of the ulcer - the diagnosis is beyond doubt. When bleeding from the ulcer of the bulb of the duodenum, the flow of blood from the bulb through the gatekeeper into the stomach is noted, which is not the case with bleeding from a stomach ulcer. With profuse bleeding, ulcers are not visible.

To determine the tactics of treatment for a bleeding chronic ulcer endoscopic stomach ulcer. The manifestations of bleeding are divided into types according to Forrest:

• IA - jet arterial bleeding from an ulcer,
• IВ - blood suction from a ulcerative defect,
• IC - blood comes from under a tightly fixed clot,
• IIА - an ulcer with a thrombosed vessel in the bottom,
• IIB - presence of a fixed blood clot,
• IIC - in the ulcer small thrombosed vessels,
• III - signs of bleeding are absent (defect under fibrin).

An endoscopic picture of the type Forrest IA shows an emergency operation. At IB, attempts are made to endoscopically stop bleeding (electrocoagulation, chipping), but with unsuccessful attempts, the endoscopist must in time give way to a surgeon for an operative stop of bleeding.

It should be noted that this approach is somewhat simplistic, because the possible development of bleeding recurrence and the choice of appropriate treatment tactics can be judged by the kind of chronic ulcer in endoscopic examination. If there is an ulcer with a clean whitish base, the probability of rebleeding is less than 5%, and if the ulcer has flat pigmented edges - about 10%. In the presence of a fixed blood clot that can not be washed from the ulcer base, the risk of rebleeding is 20%, and if a large blood clot is seen over a well-visible vessel, the probability of re-bleeding rises to 40%.

If an ongoing arterial bleeding is detected during endoscopy and the patient's general condition remains stable, then in cases where endoscopic hemostasis is not performed, the probability of continuation or occurrence of a bleeding recurrence is 80%. At the same time, the risk of developing subsequent bleeding relapses in the presence of each of the above endoscopic signs increases approximately 2-fold. Thus, the described endoscopic characteristics of a chronic ulcer are very convenient morphological features for assessing the likelihood of developing a bleeding recurrence.

Patients with peptic ulcer, who have a chronic ulcer of the stomach or duodenum with a clean whitish base or with flat pigmented edges of the crater, do not need any special treatment measures. Many studies have shown the high efficacy of endoscopic treatments for patients with a vessel visible in the bottom of the ulcer or ongoing bleeding. Most often, endoscopic treatment methods use injections of adrenaline ulcers at the edges at a dilution of 1:10 000 followed by electrothermocoagulation with a mono- or bipolar electrode. In this case, coagulate should be the tissue (the bottom and edge of the ulcer), located next to the vessel. In this case, the zone of thermal necrosis spreads to the vessel, causes a blood clot in it and stops the bleeding. Coagulate directly the vessel can not be. The formed scab "is welded" to the electrothermoprobe and, together with it, detaches from the vessel, leading to bleeding. After such treatment, relapse of bleeding occurs in approximately 20% of patients. It is also possible to apply electrothermocoagulation if a thrombosed vessel is detected to increase the length of the thrombus and reduce the risk of bleeding recurrence. In this case, it is also necessary to coagulate the tissue near the vessel.

With a relapse of bleeding in patients at high risk of surgical treatment, a second attempt of endoscopic hemostasis can be undertaken. The remaining patients are shown surgical treatment.

[18], [19], [20], [21], [22], [23]

Bleeding from erosion

It can be massive if the erosion is located above the large vessels. Erosions look like superficial defects of mucous round or oval. Infiltration of the mucosa as in ulcers is not observed.

[24], [25], [26], [27], [28], [29], [30], [31]

Hemorrhagic gastritis

It often develops in the proximal parts of the stomach. Mucous is covered with blood, which is easily washed off with water, but immediately there are "dewdrops" of blood, which completely cover the mucous membrane. Defects on the mucosa are not noted. After the former bleeding, there are point-like intramucosal hemorrhages, which sometimes, merging into fields, form intralucent hematomas, but on their background, dotted hemorrhagic inclusions are visible.

Bleeding in mesenteric thrombosis

Unlike ulcers with mesenteric thrombosis, there are no blood clots in the stomach, although there is blood supply. It has the appearance of "meat slops" and is freely sucked off. Defects on the duodenal mucosa usually does not happen. The endoscope must be taken into the descending part of the duodenum, aspirated blood and observe where it comes from: if from the distal sections - bleeding as a result of mesenteric thrombosis.

[32], [33], [34], [35], [36], [37]

Rundu-Weber-Osler disease

In the period of stopped bleeding, intralesive bruises of the most bizarre form or hemorrhagic rays from the periphery to the main zone are visible. Dimensions from 2-3 to 5-6 mm. Intraluclease hematomas are localized not only on the stomach mucosa, but also on the mucous membrane of the duodenum, esophagus, and oral cavity.

Bleeding from the liver

In the form of hemobiology, it is rarely accompanied by a drop of blood into the stomach, usually in the duodenum. Clinical manifestations in the form of melena. In the absence of visible causes of bleeding, especially in patients with trauma, it is advisable to carefully examine the mucosa of the OBD and try to provoke a release of blood from it (ask the patient to actively cough - the intra-abdominal pressure rises). Inspected with an endoscope with side optics. With hemobiology, blood and hemorrhagic clots appear at the level of OBD.

[38], [39], [40], [41], [42], [43], [44]