Method for endoscopic hemostasis in bleeding-complicated chronic gastroduodenal ulcer

FIELD: medicine, gastroenterology, surgery, endoscopy.

SUBSTANCE: method involves injection of adrenaline hydrochloride 0.01% solution that is administrated in the amount 10 ml and injection is carried out from 4-6 points in the dose 1.6-2.5 ml per a point, and dalargin in the dose 1 mg diluted in 2 ml of physiological solution, and the preparation is injected from 4 points in the dose 0.5 ml per a point. These medicinal agents are administrated into submucosa periulcerogenic zone wherein the preparation "TakhoKomb" is used for application that is pressed to the bottom of ulcer defect for 2 min, not less. Invention promotes to diminish the amount of bleeding relapses in early post-hemorrhagic period due to the combined effect of "TakhoKomb", adrenaline and dalargin. Invention can be used in carrying out the endoscopic hemostasis in bleeding-complicated chronic gastroduodenal ulcers.

EFFECT: improved method for hemostasis.

2 ex

 

The present invention relates to medicine, namely to surgery and endoscopy, and can be used to stop bleeding and prevent its recurrence of chronic gastroduodenal ulcers (HHDA).

The relevance of the treatment of patients with complicated chronic bleeding ulcers of the stomach (HAI) and chronic ulcers of the duodenum (ha WPC) is associated with a high incidence of this complication, as well as unsatisfactory results of his treatment. This is due, primarily, with a high mortality rate, reaching 8-20%. Mortality in bleeding recurrence describing the most severe bleeding, reaches 30-40%. Attention to this issue has led to the creation and implementation of new methods, including endoscopic, treatment complicated by bleeding HAS and HIA duodenum. Despite the large existing stock of endoscopic methods of hemostasis, the number of recurrent bleeding after their use remains high (15-50%) and has no tendency to decrease. In this regard, the challenge remained to develop affordable and reliable methods of endoscopic stop bleeding and prevent its recurrence.

Known methods of hemostasis by injecting using endoscopic injector medicines, which have a local with sudatorium action (adrenaline, epinetron etc) in periultseroznoy shaft (around the ulcer and ulcer crater (M. Hirao, T. Kobayashi, Masudak et al. Endoscopic local injection of hypertronic saline epinephrine solution to arrest hemorrhage from the uppr diges five tract: Clinical application and hemostatic effect // Japan Gastroenterrol. Endosc. - 1990. No. 29. - P.234-242). Recurrence of bleeding after local application of vasoconstrictor means reaches of 16.7% (SCS Cluing, J.W.C. Zeung et al. Endoscopic injection of adrenaline activity for bleeding Ulceres: a randomized trial // Be. Med. J. - 1988. No. 296. - P.1631).

There is a method of preventive endoscopic hemostasis introduction into the bottom of the ulcer different sclerosants (spirit-procaine mixture of absolute ethanol, hypertonic solution, trumbower, atoxicity etc). Recurrence of bleeding after the use of sclerosants reaches 24,1% (N.Soehendra, J.Kempeners Endoscopic control of gastrointestinal bleeding by sclerosing injection // New Press Med. - 1980. No. 9. - P.1955-1956).

There is a method of endoscopic hemostasis by using different adhesive compositions. However, the use of this technique is fraught with the possibility of development of various complications. This primarily refers to the use of various synthetic adhesives. In particular, cyanacrylate polymerize very rapidly and firmly that could damage expensive equipment. Infiltration by cyanacrylate biological tissues leads to the formation of infiltration, which subsequently makes it difficult in the execution of surgical interventions. In addition, the high price of disposable endoscopic needle hinders the widespread introduction of the method in clinical practice (Adeduro, Aigiali, Swellow et al. Endoscopic diagnostics and stop acute gastroduodenal bleeding and prediction of risk of recurrence // RZHGGK. - 2002. No. 1. - P.9-18).

There is a method of endoscopic hemostasis with the use of drugs that cause nonspecific coagulation of blood proteins (paracril, cuprofen). Recurrence of bleeding after the use of Capriana reaches 35% (Ary, Muvrini, Onescreen et al. The use of hemostatic drug "cuprofen in emergency surgery // journal of surgery. - 1995. No. 1. - S-95).

Closest to the proposed method is combined endoscopic hemostasis method of application to the ulcer crater fibrin glue (FC), ethanol injection in the region of a bleeding vessel and starting with 4 days in-hospital period therapy apparatus "MILTA" within 7-10 days (Achurch, Twiropa, Obelezivac et al. Option for minimally invasive treatment of gastroduodenal ulcer bleeding in elderly patients // proceedings of the ninth Russian gastroenterological week, 20-23 October 2003, Moscow - v.13. - P.47). Recurrence of bleeding after applying this method, the authors note 12.0% of cases.

The purpose of ISO is retene - improving the efficiency of endoscopic hemostasis, reducing the number of recurrent bleeding in early posthemorrhagic period, the simplification method.

This objective is achieved in that conduct a comprehensive endoscopic treatment, including the introduction in periultseroznoy shaft adrenaline solutions and dalargin, and then the application for ulcerative bottom of the drug (plate) Efficiency (TC).

Comparative analysis of the prototype showed that the proposed solution differs from the known fact that impose additional adrenaline solutions and dalargin in periultseroznoy shaft and perform the application of the LC at the bottom of the ulcer.

Thus, this method meets the criteria of the invention of "novelty."

The analysis of patent literature showed that the proposed method differs not only from the prototype, but also from other solutions in this and related fields. So, the authors have not found ways of hemostasis and prevention of rebleeding when HDGE with the help of the suggested remedies in the proposed amounts and including the proposed sequence of manipulations. Namely, the aggregate of the proposed modes of way is necessary and sufficient to achieve the goal of increasing the effectiveness of primary hemostasis and juice is Amenia number of recurrent bleeding from HGDA.

New in achieving their intended result is that for the first time used TC for hemostasis and prevention of recurrent bleeding from HGDA, as well as the concomitant use of TC with adrenaline and dalargin, which allows to improve the results of treatment of patients with complicated bleeding, HGDA.

Thus the proposed method is affordable and easy to use.

The method can be carried out in medical institutions, having in its composition endoscopy room or office.

Thus, the proposed solution meets the criteria of "inventive step" and "industrial applicability".

The method is as follows.

Fibrogastroduodenoscopy (EGD) is introduced into the stomach or the duodenum to the location of the ulcer. After the discovery of the ulcer through the biopsy channel of FGDs enter the injector, which perform the injection of 10 ml of 0.01% solution of epinephrine hydrochloride into the submucosal layer periultseroznoy shaft. The injection is carried out 4-6 points (up to 2.5 ml of a solution at one point). Then the submucosa periultseroznoy zone (0.5-1.0 cm from the edge of the ulcer) also through the endoscopic injector injected dalargin solution (1 mg of dalargin, diluted in 2 ml of sterile saline) from 4 points (0.5 ml on the bottom point). If the ulcer crater of the blood clot to be removed with biopsy forceps or washed with a saline solution through the catheter. Then remove the endoscope. Through the biopsy channel of the endoscope to inject biopsy forceps, which secure the plate TC. The size of this plate should be sufficient to completely cover the bottom of the ulcer. To avoid early fixation plate TC biopsy forceps previously isolated from drug polyethylene film. The distal end of the forceps have a distance of 1-2 cm from the edge of the endoscope. Then re-enter fibrogastroduodenoscopy to the place of the ulcer. During the introduction of the LC constantly Inspirat the air in small portions to avoid premature wetting of the plate. Using biopsy forceps cover the bottom of the ulcer plate TC. Plate TC press biopsy forceps to ulcerative bottom for at least 2 minutes to ensure a more reliable bonding it with ulcerative bottom. After that, the branches of the biopsy forceps is released from the plate of the LC. Fibrogastroduodenoscopy extract. During the first 12-24 hours perform repeated endoscopic examination to assess the condition of the ulcer (former source of bleeding).

Example 1. Patient B. 70 years, was admitted to the hospital 30.03.03, During endoscopic examination revealed a complicated krovat the rising chronic ulcer (diameter - 0.7 cm, depth - 0.2 cm) duodenal ulcer. Was made endoscopic hemostasis proposed method. After the discovery of the ulcer through the biopsy channel of FGDs introduced the injector, which was carried out by injection of 10 ml of 0.01% solution of epinephrine hydrochloride into the submucosal layer periultseroznoy shaft. The injection was carried out from 4 points (2.5 ml of a solution at one point). Then the submucosa periultseroznoy zone (0.5 cm from the edge of the ulcer) also through the endoscopic injector introduced dalargin solution (1 mg of dalargin, diluted in 2 ml of sterile saline) from 4 points (0.5 ml at one point). Then extracted the endoscope. Through a biopsy channel of an endoscope introduced biopsy forceps, which recorded a plate TC. After re-introduced fibrogastroduodenoscopy to the place of the ulcer. Using biopsy forceps covered the bottom of the ulcer plate TC. Plate TC pressed biopsy forceps to ulcerative bottom for 2 minutes. After that, fibrogastroduodenoscopy learned. After 12 hours conducted repeated endoscopic examination. It is found that the bottom of the ulcer is covered with a plate TC, no blood evidence. During the observation in the hospital, the patient bleeding recurrence was not. When the control endoscopic studies have established full SAG the pressure ulcer. The patient was discharged with recovery.

Example 2. Patient, 71 years, was admitted to the hospital, 26.04.03 During endoscopic examination revealed complicated by bleeding chronic ulcer (diameter 2.5 cm, depth - 0.6 cm) of the upper third of the body of the stomach. In the bottom of the ulcer was determined thrombosed vessel and fixed blood clot. Was made endoscopic hemostasis proposed method. Fibrogastroduodenoscopy introduced into the stomach. Through a biopsy channel of FGDs introduced injector, which complied with the injection of 10 ml of 0.01% solution of epinephrine hydrochloride into the submucosal layer periultseroznoy shaft. The injection is carried out 6 points (up to 1.6 ml of a solution at one point). Then the submucosa periultseroznoy zone (1.0 cm from the edge of the ulcer) also through the endoscopic injector introduced dalargin solution (1 mg of dalargin, diluted in 2 ml of sterile saline) from 4 points (0.5 ml at one point). Using endoscopic catheter with saline washed blood clot bottom of the ulcer. Then removed the endoscope. Through a biopsy channel of an endoscope introduced biopsy forceps, which were fixed plate TC. After re-introduced fibrogastroduodenoscopy to the place of the ulcer. Using biopsy forceps covered the bottom of the ulcer plate TC. Plate TC pressed biopsy is ipname to ulcerative bottom for 3 minutes. After that, fibrogastroduodenoscopy learned. After 24 hours fulfilled repeated endoscopic examination. It is found that the bottom of the ulcer is covered with a plate TC, no blood evidence. During the time spent in the hospital bleeding recurrence was not. When the control endoscopic studies have shown epithelialization of the ulcer. The patient was discharged with improvement.

The proposed method was used for the treatment of 43 patients with complicated by bleeding HGDA (28 patients with ha KDP and 15 patients with HAI). Recurrence of bleeding was observed in 1 patient (2,33%) on the third day in-hospital period.

When the control endoscopic studies 12 hours fragments TC in ulcerative bottom was determined in all patients that exceeds that of the indicator when carrying out the application of the ulcer using FC (method-prototype). When you run the application FC, it must be repeated every 8-12 hours. Thus, the proposed method can achieve high performance primary (100%) and final (97,67%) hemostasis, significantly reduce the number of recurrent bleeding from HGDA in early posthemorrhagic period.

The proposed method allows to reduce the number of recurrent bleeding compared with the method of the prototype, and in other ways-analogues, in which this show is eh is 16.7-50%. The proposed method of endoscopic hemostasis more reliable in comparison with the method of the prototype, as the number of recurrent bleeding after treatment was significantly lower (2,33%)than the prototype method (12,0%).

Thus the proposed method is simple and accessible for medical endoscopists performing therapeutic and diagnostic procedures in emergency endoscopy does not require additional expensive equipment.

The proposed method of endoscopic hemostasis with abnormal bleeding, HGDA recommended for use in clinical practice.

A method of endoscopic hemostasis when complicated by bleeding gastroduodenal ulcers, including endoscopic injection of drugs in the area of the ulcer and the application of the bottom of the ulcer drug, characterized in that the quality of drugs for injection using a 0.01%solution of epinephrine hydrochloride, which is injected in an amount of 10 ml, and the injection is carried out 4-6 points 1.6-2.5 ml per pixel, and 1 mg of dalargin, dissolved in 2 ml of physiological solution, the injection is carried out 4 points 0.5 ml at one point, and drug delivery carry out the submucosa perilaryngeal shaft, and as the means for applying drug use efficiency, which are pressed to the bottom of the ulcer for at least 2 minutes



 

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