RU2405464C1 - Method of stopping bleeding in case of acute ulcer and after polypectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to surgical gastroenterology and endocrinology. Essence of method is in introduction into biopsy canal of endoscope of flap of collagen sponge "Trombocol", corresponding to ulcer size and shape, bringing endoscope to ulcer, pushing sponge out of biopsy canal, its application on ulcer and holding with endoscope end or biopsy forceps with open cups, as well as in control endoscopic examination. First, into biopsy canal of endoscope placed is mini-tampon, which is pushed out first. On two sides of sponge mucous- muscular sutures are applied. After that endoscope is taken out with intake of mini-tampon, applied sutures being removed at control endoscopic examination after 8 hours.

EFFECT: application of claimed invention ensures formation of stable thrombus in ulcer and bleeding vessels, prevents sponge displacement, reduces number of manipulations in region of ulcer defect.

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Description

The invention relates to medicine, namely to surgical gastroenterology and endoscopy, and can be used in patients with gastric ulcer, a condition after polypectomy complicated by bleeding, in order to stop bleeding and relapse of the disease.

In the development of peptic ulcer, stressful situations, psychoemotional overstresses, leading to the disintegration of those functions of the cerebral cortex that regulate the secretion and motility of the gastroduodenal system, are of primary importance. A morphological substrate of peptic ulcer is a chronic recurrent ulcer. During the formation, it goes through the stages of erosion and acute ulcers, which allows us to consider acute and chronic ulcers as stages of the morphogenesis of peptic ulcer. The microscopic picture of chronic gastric ulcer in different periods of peptic ulcer is different. During remission, scar tissue is found at the edges of the ulcer. The mucous membrane at the edges is thickened, hyperplastic. In the area of the bottom, the destroyed muscle layer and scar tissue replacing it are visualized, and the bottom of the ulcer can be covered with a thin layer of epithelium. Nerve fibers and ganglion cells undergo dystrophic changes and decay. Sometimes in the bottom of the ulcer among the scar tissue there is a proliferation of nerve fibers by the type of amputation neuroma. During an exacerbation of peptic ulcer, a wide area of fibrinoid necrosis appears in the bottom and edges of the ulcer. On the surface of necrotic masses is fibrinous-purulent or purulent exudate. Granulation tissue with a large number of thin-walled vessels and cells delimits the necrosis zone. Following the granulation tissue is a coarse scar tissue. An exacerbation of an ulcer is evidenced not only by exudative-necrotic changes, but also by fibrinoid changes in the walls of blood vessels, often with blood clots in their lumens, as well as mucoid and fibrinoid swelling of scar tissue at the bottom of the ulcer. In connection with these changes, the size of the ulcer increases, it becomes possible to destroy the entire wall of the stomach. This can lead to serious complications. Thus, an exacerbation of peptic ulcer even in cases of a favorable outcome leads to an increase in cicatricial changes in the stomach and aggravates the violation of trophism of its tissues, including newly formed scar tissue, which is easily destroyed after another exacerbation of peptic ulcer (Strukov A.I., Serov VV - Pathological anatomy: Textbook. - 4th edition., - M .: Medicine, 1995. - 688 p.). Many methods are known for hemostasis of a bleeding ulcer, but all the proposed methods ultimately have a temporary effect due to the fact that the formed scar tissue can easily be destroyed due to the effects of nutritional, acid-peptic, stress factors.

A known method, characterized in that hemostasis is carried out by endoscopic injection of adrenaline, and the prevention of recurrence of bleeding by subsequent injection of sclerosants: polydocanol (Balanzo J., Sainz S., Such J., Espinos JC, Guamer C, Cusso Y. et al. Endoscopic haemostasisis by local injection of adrenaline and polidocanol in bleeding ulcer: a prospective randomized trial. Endoscopy 1988; 20: 289-91) and ethanol (Chung SCS, Leong HT, Chan ACW, Lau JYW, Yung MY, Leung JVC et al. Epinephrine or epinephrine plus alcohol for injection of bleeding ulcers: a prospective randomized trial. Gastrointest Endoscopy 1996; 43: 591-5). However, sclerosants (polydocanol, ethanol) increase the size of the ulcer defect, cause complications such as necrosis and perforation of the organ wall, in addition, they do not significantly reduce the frequency of recurrence of bleeding and death.

A known method (Loizou LA, Bown SG Endoscopic treatment for bleeding peptic ulcers: randomized comparison of adrenaline injection and adrenaline injection + Nd: YAG laser photocoagulation. Gut 1991; 39: 1100-3), including stopping bleeding with endoscopic injection of adrenaline followed by laser photocoagulation for the prevention of recurrence of bleeding. The method is expensive, it is not without such negative aspects as an increase in the area of a peptic ulcer, necrosis and perforation of the organ wall, and also relapses and deaths are not uncommon.

The known method [Chung S.S., Lau J.Y., Sung J.J., Chan A.C., Lau C.W., Ng E.K., Chan F.K., Yung M.Y., Li A.K. Randomized comparison between adrenaline injection alone and adrenaline injection plus heat probe treatment for actively bleeding ulcers. BMJ; 1997 May 3; Vol.314 (7090), p.1307-11], including stopping bleeding by endoscopic injection of adrenaline, followed by electrocoagulation of the bleeding source to prevent recurrence of bleeding. However, this method does not exclude necrosis and perforation of the organ wall due to tissue burn during electrocoagulation, moreover, recurrence of bleeding and deaths are not uncommon.

The prototype of the invention is a method for the prevention of recurrence of bleeding from peptic ulcers of the stomach and duodenum (RF Patent No. 2209638, 2007). This method consists in the fact that a flap of the collagen sponge Trombokol was inserted into the distal canal of the biopsy canal of the endoscope in accordance with the size and shape of the ulcer. They applied it to the ulcer and held it for 3-5 minutes. Endoscopic monitoring was performed every 4-6 hours. In the absence of a "thrombocol" in the ulcer, repeated application was performed. In the presence of bleeding, it was previously stopped by endoscopic injection of adrenaline. In the presence of a callous ulcer, the edges of the ulcer were refreshed with biopsy forceps before applying the sponge. In the presence of a blood clot larger than 5 mm, the thrombus was carefully shifted with the end of the endoscope or with closed biopsy forceps. Endoscopic manipulations were performed against antisecretory therapy.

The disadvantage of this method is that the hemostatic sponge, when soaked, becomes weakly fixing and does not attach to the wall of the gastric mucosa, and accordingly flies with a minimal displacement from the ulcer defect, which leads to frequent FGD control. In addition, frequent endoscopic monitoring affects the secretion of the stomach, irritation of the mucosa due to air insufflation occurs.

In addition, the frequency of fibrogastroduodenoscopy leads to skidding and dissemination of the mucous membrane of the ulcer defect by the bacterium Helicobacter pilori, which adversely affects tissue granulation and leads to a recurrence of the disease (S. I. Pimanov, monograph. Esophagitis, gastritis and peptic ulcer disease - 2000 )

The objective of the invention is to develop a more gentle way to stop bleeding with minimal exposure to manipulation of the defect, providing increased efficiency in stopping bleeding and preventing complications associated with bleeding.

The technical result is the formation of a persistent thrombus in an ulcer and bleeding vessels, preventing the displacement of the sponge, reducing the number of manipulations in the area of a peptic ulcer.

The proposed method is as follows. A mini swab is first placed in the biopsy canal of the endoscope. After that, the flap of the collagen sponge “Trombokol” corresponding to the size and shape of the ulcer is twisted into a tube and inserted into the biopsy channel. The endoscope is inserted into the lumen of the organ and brought to the ulcer, then a mini swab is pushed out, while collecting excess mucus along the course of the manipulation and blood near the ulcer defect, then the sponge is pushed out with biopsy forceps to the bottom of the ulcer. After that, the sponge is pressed to the ulcer with the end of the endoscope or with biopsy forceps with the cups open until it is completely adhered and firmly fixed to the ulcer. Then, to prevent the displacement of the sponge from a peptic ulcer on two sides of the sponge, two mucosomuscular (mucus-muscular) sutures are applied with a microfine needle. Next, the endoscope is removed with a mini-swab fence. Application in this way to the ulcer of the Trombokol sponge leads to the formation of a persistent thrombus in the ulcer and bleeding vessels. The use of additional seams leads to a tight installation and fastening of the sponge in the area of a peptic ulcer, which excludes frequent repeated FGDS.

After a checkup with an endoscope after 8 hours, the sponge is in the area of the ulcer, there is no bleeding. After that, minimally traumatic removal of sutures is carried out, while the sponge remains tightly and firmly fixed to a peptic ulcer.

Thus, the additional use of a mini swab allows you to clean the surrounding tissue of mucus and excess blood and technically correctly apply a sponge, and the use of additional seams, in order to strengthen for a longer period and prevent sponge displacement, leads to a reduction in control examinations and to a dense, strong fixing the sponge in the area of the ulcer.

The proposed method allows to reduce the frequency of recurrence of bleeding from peptic ulcers of the stomach and duodenum after endoscopic or spontaneous hemostasis, accelerates the rate of repair of ulcers, which reduces the time of inpatient treatment. In addition, the proposed method is technically simple, reliable, practically safe, and compared with other methods of endoscopic prophylaxis of bleeding recurrence, it is cheap.

The proposed method is illustrated by the following clinical example:

Patient F., 55 years old, was admitted to the resuscitation and intensive care unit of the hospital of the station of Ufa Russian Railways, Department of Surgical Diseases and New Technologies with a diagnosis of duodenal ulcer complicated by bleeding. Examination of FEGDS revealed a chronic bleeding oval ulcer of the anterior wall of the duodenal bulb 0.5-0.7 cm in size. Immediately after stating the fact of gastrointestinal bleeding, 20 mg quamatel (famotidine) was administered intravenously, followed by the same dose every every 12 hours before the manipulation. The bleeding was stopped by injection of 0.1% adrenaline (after preliminary dilution in a 10% hypertonic solution of sodium chloride in a ratio of 1: 10000) around a bleeding vessel and under it from 3 points, 1 ml in each of them. The gastric contents (liquid blood) were aspirated, after which the endoscope was removed.

A mini swab was placed in the biopsy channel of the endoscope. After that, a flap of the collagen sponge “Trombokol”, corresponding to the size and shape of the ulcer, twisted into a tube, was inserted into the biopsy channel. The endoscope was inserted into the lumen of the organ and brought to the ulcer, then a mini-tampon was pushed out, an excess of mucus was collected along with the manipulation and blood near the ulcer defect, then the sponge was pushed out with biopsy forceps to the bottom of the ulcer. Then the sponge was pressed to the ulcer with the end of the endoscope until it completely adhered and firmly fixed to the ulcer. After that, to prevent the displacement of the sponge from a peptic ulcer on two sides of the sponge, two mucosomuscular (muscular-muscular) sutures were applied using a microfine needle. Next, the endoscope was brought out with a mini-swab fence. The application, therefore, to the ulcer of the Trombokol sponge led to the formation of a persistent thrombus in the ulcer and bleeding vessels. The use of additional sutures led to a tight installation and fastening of the sponge in the area of a peptic ulcer, which excluded frequent repeated FGDS.

After a checkup with an endoscope after 8 hours, the sponge was in the area of the ulcer, no bleeding was noted. After that, the stitches were minimally traumatic for the mucosa, while the sponge remained tightly and firmly fixed to the ulcer defect.

The additional use of a mini swab allows you to clean the surrounding tissue of mucus and excess blood and apply a sponge technically, and the use of additional seams, in order to strengthen for a longer period and prevent sponge displacement, leads to a reduction in control examinations and to tight, firm fixation of the sponge in areas of peptic ulcer.

Thus, the proposed method allows to reduce the frequency of recurrence of bleeding from peptic ulcers of the stomach and duodenum after endoscopic or spontaneous hemostasis, accelerates the rate of repair of ulcers, which leads to a reduction in the duration of inpatient treatment. In addition, the proposed method is technically simple, reliable, practically safe, and compared with other methods of endoscopic prophylaxis of bleeding recurrence, it is cheap.

Claims (1)

A method of stopping bleeding, including introducing a thrombocoll collagen sponge flap into the biopsy channel of the endoscope, corresponding to the size and shape of the ulcer, bringing the endoscope to the ulcer, pushing the sponge out of the biopsy channel, applying to the ulcer and holding the endoscope with the endoscope or open-end biopsy forceps, examination, characterized in that a mini-swab is first placed in the endoscope’s biopsy channel, which is pushed out first, mucoso-muscular sutures are placed on both sides of the sponge, then en castrated outputted with fence mini tampon and superimposed stitches removed on the control endoscopic examination after 8 hours.