Endoscopic sclerotherapy and ligation of varicose veins of the esophagus and cardia

Results of endoscopic treatment of 39 patients with acute bleeding from varicose veins of the esophagus and cardia and of 46 patients as prophylaxis of bleeding recurrence are presented. Rate of primary hemostasis in acute bleeding was 92.3%. In 3 patients with bleeding from varicose veins of cardia endoscopic treatment was not effective. In prophylactic treatment rate of bleeding recurrence during 1 year was 15.2%. A 6 month--survival was 93.3%, it depended on functional group by Child. Endoscopic methods (sclerotherapy, ligation) are effective for arrest and prophylaxis of portal bleedings.     

Gastroduodenoscopy at diagnosis and treatment of ulcerous gastroduodenal bleedings

Results of treatment of 458 patients with ulcerous gastroduodenal bleedings are analyzed. It is demonstrated that argon-plasma coagulation (APC) is the most effective at primary endoscopic hemostasis and amounts to 92.5% compared with 87.5% at radio-wave coagulation and 79.7% at injection method. Treatment and diagnostic algorithm based on patients state severity assessment (by SAPS scale) and risk of bleeding (by Forrest) was developed. Use of this algorithm led to decrease of lethality due to acute blood less from 6.1 to 2.7% (including at conservative treatment from 4.5 to 2.2%) and postoperative lethality from 14.5 to 5.6%.     

Endoscopy of bleeding gastroduodenal ulcers

A new device -- "low-temperature washer" has been developed for better endoscopic visualization of bleeding gastroduodenal ulcers. Endoscopic classification of gastroduodenal bleedings by Forrest has been modified, a new classification of endoscopic hemostasis methods is proposed. Results of diagnosis and treatment of 246 patients are analyzed. Application of the new device increased diagnostic and treatment efficacy of urgent endoscopy, decreased the number of surgeries performed on the peak of the bleeding.     

Diagnostic and therapeutic treatment policy in ulcerous gastroduodenal bleedings

Results of treatment of 796 patients with ulcerous gastroduodenal bleedings (UGDB) are analyzed. The study group consisted of 676 patients who have undergone endoscopic hemostasis. The control group consisted of 120 patients treated with traditional therapy. Endoscopic hemostasis in the study group was effective in 628 (92.8%) patients, recurrence of bleeding was seen in 21 (3.3%) patients. Effective hemostasis in the control group was achieved in 92 (76.6%) patients, recurrence of bleeding occurred in 13 (14.1%) patients. Positive result of Helicobacter pylori detection was in 600 (88.7%) patients. It is concluded that local treatment of ulcer with glue applications reduces 3 times number of bleeding recurrences.     

Endoscopic methods of prevention and treatment of hemorrhage of portal genesis

Results of endoscopic interventions on 72 patients with portal hypertension of different etiology are presented. In patients with acute bleedings the frequency of primary hemostasis was 94%. In 2 patients with hemorrhages from the cardial veins of the stomach the endoscopic interventions proved to be ineffective. Prophylactic treatment gave 20% recurrent bleedings during a year. Survival of the patients during 6 months was 88.5% and considerably depended on the functional group according to Child. The endoscopic interventions (sclerotherapy, ligation) should be considered effective methods to arrest bleeding and to prevent bleedings of portal genesis.     

Treatment of gastroduodenal ulcer bleedings in a general hospital of emergency care

Treatment of patients with gastroduodenal ulcer bleedings in a general hospital of emergency care is a complex of measures including of endoscopic diagnosis and stopping of bleeding, use of effective antisecretory drugs with obligatory laboratory control of acid-producing function of the stomach, surgical treatment and eradication of H. pylori. Up-to-date methods of endoscopic hemostasis - spirituous infiltration, argon-plasma coagulation, clipping of vessels in ulcer and also their combination in difficult cases - provide reliable hemostasis and allow to avoid urgent surgery. Recently we succeeded in reducing the rate of urgent surgeries performed at the height of bleedings from 70 to 40%. These methods can be recommended for clinical practice because they reduce significantly lethality rates in patients with severe conditions.     

Endoscopy in the diagnosis and treatment of gastroduodenal hemorrhage]

An experience of work of the department of general surgery with the course of endoscopy is presented. The endoscopic diagnosis and treatment of 2931 patients for 6 years were performed for bleedings from the upper parts of the gastrointestinal tract. Errors in endoscopic diagnosis made 5%. The authors divided them into three groups: methodical (preparing the patients, methods of examination), diagnostic (assessment of the substrate and type of bleeding, probability of recurrences), tactical (medical policy, dynamics of observations). Hemostasis in endoscopic arrest may be complete or temporary (stable or unstable). The most effective methods are thought to be coagulation, clipping and a combination of the methods. Medicamentous means are less effective. The authors recommend to be aware of the endoscopic possibilities and not to try to stop bleeding by any means thereby wasting time.     

Principles of medical care of patients with gastrointestinal ulcer hemorrhage]

A new protocol of treatment policy is proposed based on the results of treatment of 518 patients with gastrointestinal ulcer bleedings. All the patients are divided into 3 groups: with continued bleeding, with unstable spontaneous hemostasis, and with stable spontaneous hemostasis. Corresponding policy of treatment was used: surgery, endoscopic hemostasis, conservative treatment. In endoscopic hemostasis we preferred to clamp vessel or ulcer leading to hemostasis in all 36 cases. Hemostasis was not achieved in 6% patients, recurrence of bleeding was in 4.2% patients, 24.6% patients underwent emergency operations. The majority of operated patients underwent stomach resection (51.6%). The proposed principles of treatment permitted to decrease overall lethality from 5.2 to 2.6%, postoperative lethality--from 15.7 to 7.5%.     

Endoscopic hemostasis of erosive-ulcerous gastroduodenal bleeding with fibrin glue at critically ill patients

Experience of endoscopic hemostasis of acute erosive-ulcerous gastroduodenal bleeding with fibrin glue at critically ill patients is described. This glue is adhesive substance based on high-concentrated solution of fibrinogen (concentration of protein not less 60 g/l). Application of adhesive permitted to stop the bleeding at 84 of 87 extremely seriously ill patients (mean point according to APACHE--II scale was 19.5+/-0.9). Prolonged endoscopic control with repeated application of adhesive permitted to avoid bleeding clinical recurrences, to stop repeatedly with endoscopy 4 of 6 recurrent bleedings, to avoid forced surgery at 80 of these patients. Adhesive accelerated significantly the healing of ulcers despite of hypoxic injury of mucosa. Endoscopic hemostasis permitted to avoid forced surgical aggression, to improve treatment results and to decrease lethality at critically ill patients.     

Acute gastroduodenal bleedings against the background of diabetes mellitus

The authors have analyzed results of treatment of 60 patients with acute gastroduodenal bleedings against the background of diabetes mellitus. The main methods of diagnosis are the endoscopic and laboratory methods. In 60% of the patients the source of bleeding was acute erosion-ulcerous lesions, in 40% -chronic ulcers. Choice of the method of treatment depended on the source of bleeding, the degree of carbohydrate metabolism, the spectrum of concomitant pathology. Endoscopic hemostasis is the method of choice in treatment of acute and chronic ulcers of high risk of relapses in somatically burdend patients.     

Peptic ulcer hemorrhage: Local injection of fibrin sealant—Experimental and clinical data

This study was undertaken to assess the role of fibrin sealant in achieving early hemostasis and wound healing following endoscopic injection in peptic ulcer hemorrhage. In an experimental study in Wistar-rats we looked at the healing rate and histological changes of laser-induced acute gastric ulcers and acetic acid-induced chronic gastric ulcers following injection of standard sclerosants as well as fibrin sealant. A statistically favourable result was observed in the fibrin treated group. We also treated 127 patients suffering from bleeding peptic ulcers with local injection of fibrin sealant (33 Forrest stage la, 40 Forrest lb, 54 Forrest Ila) in a prospective clinical trial during the period of 1. February 1988 to 31. January 1991. A primary recurrence was noticed in 19 (14.9%) patients. With a 2. injection the hemostasis was definite in 116 of 127 patients (91.3%). Only 11 patients (8.6%) needed surgery for hemostasis. The mortality was 6.3% (8 patients).     

Endoscopic diagnostics and management of postoperative gastrointestinal bleedings

The features of clinical course, the frequency and the pattern of gastrointestinal bleedings after diverse abdominal operations were studied over a period of time from 1993 to 2006. Postoperative gastrointestinal bleedings were observed at 503 patients. The frequency of postoperative gastrointestinal bleedings amounted 0.5% after operations on account of purulent diseases with different localization, 0.6% after abdominal and cardiovascular operations, 0.8% after lung operations, 1.5% after operations on the account of burn disease, 6.1% after hepatopancreatobiliary operations. In accordance with the stages of postoperative period, distinctions in endoscopic picture and the tactics of treatment early and late bleedings were distinguished during the investigation. It has been established, that blood supply disturbance in portal vein, manifested by transient portal hypertension is, one of the most important pathogenetic factors of development of bleeding after hepatopancreatobiliary operations along with acute erosive (ulcerous) affection, caused by stress or trauma, and multiple organ failure. The features of clinical course of postoperative bleedings were studied in different groups of surgical patients. The comparative evaluation of efficacy of endoscopic methods of hemostasis (injection,various endoclips, hydrothermocoagulation, argon-plasma coagulation) was carried out. It was shown that the application of new methods of endoscopic sanation and investigation of the upper gastrointestinal tract had resulted in increase of frequency of exposure of gastrointestinal bleeding source from 69.8% to 88.4% at primary urgent esophagogastroscopy. The efficacy of hemostasis at postoperative gastrointestinal bleeding raised from 70.3% to 92.4%.     

不同内镜止血方法治疗老年消化性溃疡出血的效果比较

目的：评价不同内镜止血方法治疗老年消化性溃疡出血的效果。方法回顾性分析2008年1月～2013年12月在北京大学首钢医院住院并接受内镜治疗的80例老年消化性溃疡出血患者的临床及内镜检查资料,病变出血征象采用Forrest分级。内镜止血治疗方法包括内镜下肾上腺素注射（54例）和金属钛夹治疗（26例）。结果进行内镜治疗的病变均为Forrest Ⅰa～Ⅱb级。与内镜下肾上腺素注射组相比,金属钛夹治疗组的内镜治疗成功率更高（96.2％与87.0％）,再出血发生率更低（7.7％与14.8％）,临床症状消失时间更短[（2.3±0.6）d与（3.4±1.1）d],住院天数更短[（7.8±0.9）d与（11.5±2.4）d],差异均有统计学意义。结论内镜下金属钛夹止血治疗老年消化性溃疡出血的有效性和安全性均优于肾上腺素注射治疗。     

Treatment of gastroduodenal bleedings: from surgery to therapy?

Results of treatment of 2352 patients with gastroduodenal ulcer bleedings were analyzed. Surgical treatment was performed at 495 (21%) of them. Emergency life-saving operation was performed at 78 (15%) patients, urgent operation after primary hemostasis - at 114 (23%), elective operations - at 303 (62%). Various resections were carried out at 78% cases, organ-saving surgeries - at 22%. The main problem in the treatment program of these patients is the prophylaxis of bleeding recurrence. Rational pathogenetic out-patient treatment of ulcer disease, prophylaxis of recurrences and complications are the key points which need close collaboration between surgeons and gastroenterologists.     

高危溃疡致胃肠道出血血管造影表现及栓塞治疗效果

目的观察高危溃疡致胃肠道出血血管造影表现及动脉栓塞治疗效果。方法对49例经胃镜证实高危溃疡致胃肠道出血患者行血管造影及栓塞治疗,观察造影表现、栓塞前后溃疡变化,评价栓塞疗效。结果造影总阳性率51.02%(25/49),栓塞成功率100%,止血总有效率83.67%(41/49),再出血率10.20%(5/49),无严重并发症发生。术后复查胃镜提示溃疡Forrest分级均下降,无活动性出血表现,高危溃疡由急性期向愈合期转变。结论高危溃疡致急性胃肠道出血动脉造影总阳性率高,栓塞治疗安全有效。     

The role of endoscopy in diagnosis and treatment of gastroduodenal bleedings

The experience in diagnosis and treatment of 469 patients with gastroduodenal ulcer bleedings is presented. Sensitivity of endoscopy in detection of bleeding source was 98.8%, in detection of ulcer size -- 93.4%, specificity -- 80.6%. It is demonstrated that the most frequently recurrence of bleeding occurs when ulcer size is more than 1 cm. Location of ulcer on posterior, posterior-superior and posterior-inferior walls of the duodenal bulb is an unfavorable prognostic symptom (rebleeding occurs in 17.1, 30.0 and 12.5% cases, respectively). Types Forrest-Ia and Forrest-IIa are especially dangerous for recurrence (21.4 and 15.6%, respectively). In types Forrest-Ib and Forrest-IIb rebleeding occurs less frequently (4 and 6%, respectively). In types Forrest-Ia and Forrest-Ib rebleeding occurs mainly on the first day, rebleeding in types Forrest-IIa occurs more often on the first-second day, however it is possible up to day 7. Rebleeding in types Forrest-IIb occurs also mainly during the first two days. Endoscopic hemostasis (electrocoagulation and injection therapy) was performed in 40 patients. In 6 (15%) cases hemostasis was not achieved. In 8 (20%) cases endoscopic hemostasis led to a temporary effect, i.e. rebleeding was seen within 24-72 hours after endoscopic procedure. Stable hemostasis with endoscopy was achieved in 26 (65%) patients.     

The endoscopic ligation and sclerotherapy in a complex prevention program of variceal bleedings in extrahepatic portal hypertension

The results of prophylactic endoscopic treatment of 22 patients with extrahepatic portal hypertension (main group--EPH) and 76 patients with cirrhosis of the liver (a comparison group--CL) who had had variceal bleedings were analyzed. In the EPH group permanent eradication was obtained in 14 patients (63.6%), in the CL group--in 46 patients (50.5%). With the average duration of achieving the eradication the number of sessions before achieving it proved to be greater than that for CL. Recurrent bleeding during the first month of observations was noted in 7 out of 22 patients. In most cases the sources of bleedings were postligational and postinjectional ulcers of the cardial part of the stomach. Long-term results (1-5 years) were followed-up in 14 patients. In 9 patients there was no recurrent bleeding during 2-5 years of observation. Thus, it is expedient to use endoscopic interventions as the methods of the "first line" in the complex program of secondary prophylactics of variceal bleedings in extrahepatic portal hypertension.     

Laser photocoagulation of bleeding gastric and duodenal ulcer

Laser photocoagulation of bleeding ulcer is one of the effective methods of endoscopic hemostasis. Experimental studies were carried out on resected stomach preparation. The preparations were studied histologically. Clinical trial was conducted in 43 patients with gastric and duodenal ulcer for hemostasis and prophylaxis of recurrent bleeding. Initial endoscopic hemostasis was successful in all the patients. Relapse of bleeding was seen in 4 patients. Overall efficacy of laser hemostasis was 90.7%. It is concluded that laser photocoagulation is one of effective and convenient methods of endoscopic hemostasis.     

Endoscopic clipping versus band ligation in the management of bleeding esophageal varices

BACKGROUND: The effectiveness of endoscopic clipping in the hemostasis of bleeding esophageal varices and the eventual variceal eradication was compared with that of band ligation. METHODS: Forty patients were enrolled in the study in a prospective manner, 19 of whom received endoscopic clipping (group I) and the remaining (n = 21 patients) received endoscopic band ligation (group II). All patients in this study presented with bleeding from esophageal varices. The patient characteristics (age, sex, Child-Pugh score, variceal grade) were comparable in the two groups. After initial hemostasis, the patients were assigned one of the two forms of endoscopic therapy which was continued in the follow-up sessions until varices were eradicated. Early and late results were compared. RESULTS: Initial hemostasis was achieved in all patients in group I but two patients in group II required clip ligation for initial hemostasis because of the failure in band ligation. Those two were treated with band ligation in the follow-up sessions. A total of 224 clips in 53 treatment sessions and 296 bands in 82 treatment sessions were placed in group I and group II, respectively. The rates of complete variceal eradication were 89% and 76% in group I and group II, respectively (p > 0.05). The median number of required treatment sessions for complete eradication of the varices was significantly lower in group I than group II (3 versus 4, p = 0.013). Three patients from group I (15%) and seven patients from group II (33%) were readmitted for variceal bleeding during the follow-up period (p > 0.05). CONCLUSIONS: With the advantages of high initial hemostasis rate, decreased risk of rebleeding, and fewer treatment sessions needed for variceal eradication, endoscopic clipping is as effective as band ligation, or perhaps more effective in the treatment of bleeding esophageal varices.     

The recurrent bleeding risk of a Forrest IIc lesion at the second-look endoscopy can be indicated by high Rockall scores ≥ 6

Surgical Endoscopy - The Forrest classification is widely applied to guide endoscopic hemostasis for peptic ulcer bleeding. Accordingly, practice guidelines suggest medical treatment only for ulcer...