RU2266752C2 - Method for endoscopic hemostasis in bleeding-complicated chronic gastroduodenal ulcer - Google Patents

Abstract

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

Description

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

The urgency of the problem of treating patients with bleeding complications of chronic gastric ulcers (CJ) and chronic duodenal ulcers (CJ duodenal ulcer) is associated with a high frequency of development of this complication, as well as unsatisfactory results of its treatment. This is primarily due to the high mortality rate, reaching 8-20%. Mortality in a relapse of bleeding, which characterizes the most severe forms of bleeding, reaches 30-40%. Close attention to this problem has led to the creation and implementation of new methods, including endoscopic, for the treatment of bleeding complicated by HLJ and HYa duodenum. Despite the existing large arsenal of endoscopic methods of hemostasis, the number of relapses of bleeding after their use remains high (15-50%) and does not tend to decrease. In this regard, the challenge remains to develop affordable and reliable methods for endoscopic stopping of bleeding and prevention of its relapse.

Known methods of hemostasis by injection using an endoscopic injector of drugs with local vasoconstrictor action (adrenaline, epinephron, etc.) in the periulcerous shaft (around the ulcer defect) 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). Relapse of bleeding after topical application of vasoconstrictors reaches 16.7% (SCS Cluing, JWC Zeung et al. Endoscopic injection of adrenaline for activity bleeding Ulceres: a randomized trial // Be. Med. J. - 1988. - No. 296. - P .1631).

A known method of preventive endoscopic hemostasis by introducing into the bottom of the ulcer defect various sclerosants (alcohol-novocaine mixture, absolute ethanol, hypertonic solution, thrombovar, ethoxysclerol, etc.). The 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).

A known method of endoscopic hemostasis by using various adhesive compositions. However, the use of this technique is fraught with the possibility of developing various complications. This primarily refers to the use of various synthetic adhesives. In particular, cyanoacrylates polymerize very quickly and firmly, which can damage expensive equipment. Cyanacrylate infiltration of biological tissues leads to the formation of infiltrate, which subsequently significantly complicates the implementation of surgical interventions. In addition, the high price of disposable endoscopic needles makes it difficult to widely introduce the method into clinical practice (E. D. Fedorov, A. I. Mikhalev, S. Yu. Orlov et al. Endoscopic diagnosis and stopping of acute gastroduodenal bleeding and predicting the risk of their relapse // RZHGGK. - 2002. - No. 1. - S.9-18).

A known method of endoscopic hemostasis using drugs that cause non-specific coagulation of blood proteins (feracryl, caprofer). The recurrence of bleeding after the use of caprofer reaches 35% (A.A. Kurygin, M.V. Grinev, O. N. Skryabin et al. Use of the hemostatic drug “caprofer” in emergency surgery // Herald of Surgery. - 1995. - No. 1. - S. 91-95).

Closest to the proposed one is a method of combined endoscopic hemostasis by application of fibrin glue (FC) to the ulcer crater, ethanol injection into the area of a bleeding vessel, and starting from day 4 of the hospital period of laser therapy with the Milta apparatus for 7-10 days (Y.Ch. Urakova , T.V. Khorobrykh, O.E. Lutsevich et al. A variant of minimally invasive treatment of ulcerative gastroduodenal bleeding in elderly patients // Materials of the Ninth Russian Gastroenterological Week, October 20-23, 2003, Moscow - v.13. - P.47) . Relapse of bleeding after applying this method, the authors note in 12.0% of cases.

The purpose of the invention is to increase the effectiveness of endoscopic hemostasis, reduce the number of recurrences of bleeding in the early posthemorrhagic period, and simplify the method.

This goal is achieved by the fact that they carry out complex endoscopic treatment, including the introduction into the periulcerous shaft of solutions of adrenaline and dalargin, and then the application on the ulcerous floor of the drug (plate) TahoeKomba (TK).

Comparative analysis with the prototype showed that the proposed solution differs from the known one in that additional solutions of adrenaline and dalargin are introduced into the periulcerous shaft and the TC is applied to the bottom of the ulcer defect.

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

The analysis of patent and specialized 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 methods of hemostasis and prophylaxis of recurrence of bleeding in chronic obstructive pulmonary hypertension using a complex of the proposed drugs in the proposed quantities and including the proposed sequence of manipulations. Namely, the totality of the proposed modes of the method is necessary and sufficient to achieve the goal - to increase the effectiveness of primary hemostasis and reduce the number of relapses of bleeding from OCD.

What is new in achieving this result is that for the first time, TC was used for hemostasis and the prevention of recurrence of bleeding from CGD, as well as the combined use of TK with adrenaline and dalargin, which allows to improve the results of treatment of patients with complicated bleeding of CGD.

Moreover, the proposed method is affordable and easy to use.

The method can be carried out in medical institutions, incorporating an endoscopic office or department.

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

The method is as follows.

Fibrogastroduodenoscopy (FGDS) is introduced into the stomach or duodenum to the location of the ulcer defect. After the detection of a ulcerative defect, an injector is injected through the biopsy channel of the FGDS, with the help of which 10 ml of a 0.01% solution of adrenaline hydrochloride are injected into the submucous layer of the periulcerous shaft. Injection of the drug is carried out from 4-6 points (up to 2.5 ml of solution per point). Then, a dalargin solution (1 mg of dalargin diluted in 2 ml of sterile physiological saline) from 4 points (0.5 ml each) is also introduced into the submucous layer of the periulcerous zone (0.5-1.0 cm from the edge of the ulcer defect) one point). If there is a blood clot in the ulcer crater, it is removed using biopsy forceps or washed with saline through a catheter. Then remove the endoscope. Biopsy forceps are inserted through the biopsy channel of the endoscope, which fix the TK plate. The size of this plate should be sufficient so that it completely covers the bottom of the ulcer. To avoid early fixation of the TC plate, biopsy forceps are preliminarily isolated from the preparation with a plastic film. The distal end of the forceps is 1-2 cm from the edge of the endoscope. After this, the FGDS is reintroduced to the site of the ulcer defect. During the introduction of TC, air is constantly insufflated in small portions to avoid premature wetting of the plate. Biopsy forceps cover the bottom of the ulcer with a TC plate. The TC plate is pressed with biopsy forceps to the ulcerous floor for at least 2 minutes to ensure more reliable bonding to the ulcerous bottom. After this, the branches of the biopsy forceps are freed from the TC plate. FGDS removed. During the first 12-24 hours, a repeated endoscopic examination is performed to assess the condition of the ulcer defect (a source of former bleeding).

Example 1. Patient B., 70 years old, was admitted to the clinic on March 30, 2003. An endoscopic examination revealed a chronic ulcer complicated by bleeding (diameter - 0.7 cm, depth - 0.2 cm) of the duodenal bulb. Endoscopic hemostasis was performed by the proposed method. After the detection of a ulcerative defect, an injector was injected through the FGDS biopsy channel, with the help of which 10 ml of a 0.01% solution of adrenaline hydrochloride were injected into the submucosal layer of the periulcerous shaft. Injection of the drug was carried out from 4 points (2.5 ml of solution per point). Then, a dalargin solution (1 mg of dalargin diluted in 2 ml of sterile physiological saline) from 4 points (0.5 ml per point) was also introduced into the submucosal layer of the periulcerous zone (0.5 cm from the edge of the ulcer defect) . Then the endoscope was removed. Biopsy forceps were inserted through the biopsy channel of the endoscope, which fixed the TK plate. After this, the FGDS was reintroduced to the site of the ulcer defect. Biopsy forceps covered the bottom of the ulcer with a TC plate. The TC plate was pressed with biopsy forceps to the ulcer bottom for 2 minutes. After this, FGDS was removed. After 12 hours, a repeat endoscopic examination was performed. It has been ascertained that the bottom of the ulcer defect is covered with a TC plate, there are no signs of bleeding. During the observation in the hospital, the patient had no recurrence of bleeding. During control endoscopic examinations, complete healing of the ulcer defect was established. The patient was discharged with recovery.

Example 2. Patient G., 71 years old, was admitted to the clinic on April 26, 2003. During an endoscopic examination, a chronic ulcer complicated by bleeding was revealed (diameter - 2.5 cm, depth - 0.6 cm) of the upper third of the stomach body. A thrombosed vessel and a fixed blood clot were determined at the bottom of the ulcer defect. Endoscopic hemostasis was performed by the proposed method. FGDS was introduced into the stomach. An injector was injected through the biopsy channel of the FGDS, with the help of which 10 ml of a 0.01% solution of adrenaline hydrochloride were injected into the submucosal layer of the periulcerous shaft. Injection of the drug is carried out from 6 points (up to 1.6 ml of solution per point). Then, a dalargin solution (1 mg of dalargin diluted in 2 ml of sterile physiological saline) from 4 points (0.5 ml per point) was also introduced into the submucous layer of the periulcerous zone (1.0 cm from the edge of the ulcer defect) . Using an endoscopic catheter, a blood clot of the bottom of the ulcer was washed with saline. Then the endoscope was removed. Biopsy forceps were inserted through the biopsy channel of the endoscope, which fixed the TC plate. After this, the FGDS was reintroduced to the site of the ulcer defect. Biopsy forceps covered the bottom of the ulcer with a TC plate. The TK plate was pressed with biopsy forceps to the ulcer bottom for 3 minutes. After this, the FGDS was removed. After 24 hours, a repeat endoscopic examination was performed. It was found that the bottom of the ulcer defect is covered with a plate of the TC, there are no signs of bleeding. There was no recurrence of bleeding while in the hospital. During control endoscopic examinations, ulcer defect epithelization was established. The patient was discharged with improvement.

The proposed method was used for the treatment of 43 patients with complicated bleeding of OGD (28 patients with HND duodenum and 15 patients with HNG). Relapse of bleeding was observed in 1 patient (2.33%) on the third day of the hospital period.

In control endoscopic examinations after 12 hours, fragments of TC in the ulcer were determined in all patients, which exceeds this indicator when applying an ulcer defect using FC (prototype method). When performing FC application, it must be repeated every 8-12 hours. Thus, the proposed method allows to achieve high efficiency of primary (100%) and final (97.67%) hemostasis, significantly reduce the number of recurrences of bleeding from CGD in the early posthemorrhagic period.

The proposed method allows to reduce the number of relapses of bleeding in comparison with both the prototype method and other methods-analogues, in which this indicator is 16.7-50%. The proposed method of endoscopic hemostasis is more reliable compared to the prototype method, since the number of bleeding relapses after its use is significantly lower (2.33%) than the prototype method (12.0%).

Moreover, the proposed method is simple and accessible for endoscopists performing diagnostic and treatment procedures in emergency endoscopy, does not require additional expensive equipment.

The proposed method for endoscopic hemostasis in complicated bleeding of chronic gastric hypertension is recommended for use in clinical practice.

Claims (1)

A method for endoscopic hemostasis in case of chronic gastroduodenal ulcers complicated by bleeding, including endoscopic injections of drugs into the area of the ulcer defect and application of the bottom of the ulcer defect with a drug, characterized in that a 0.01% solution of adrenaline hydrochloride is used as the injection drug, which is administered in an amount of 10 ml, while the injection of the drug is carried out from 4-6 points of 1.6-2.5 ml per point, and 1 mg of dalargin diluted in 2 ml of physiological saline, p In this case, the injection of the drug is carried out from 4 points of 0.5 ml per point, and the administration of drugs is carried out in the submucosal layer of the periulcerogenic shaft, and TakhoKomb, which is pressed to the bottom of the ulcer defect for at least 2 minutes, is used as an application agent.