Preparation for endoscopy for gastrointestinal bleeding

Preparation for fibroendoscopy in case of gastrointestinal bleeding is carried out during resuscitation. Anesthesia should be carried out depending on the patient's condition. Local anesthesia is most often used, but general anesthesia (endotracheal and intravenous) is also used. In patients with a tendency to uncontrollable vomiting, it is advisable to conduct the examination under endotracheal anesthesia - to prevent regurgitation. In patients with pathological fear of the examination and epileptics, mental patients, the examination is carried out under intravenous anesthesia.

The examination should be performed on a functional table. The patient is on his left side during the examination. The issue of gastric lavage before endoscopy is debatable. Gastric lavage is not always necessary: firstly, the lesser curvature and antral section can be examined even with a sufficient amount of blood; secondly, approximately 10% of patients with a bleeding duodenal ulcer do not have blood in the stomach, since in the absence of episodes of fresh bleeding, blood passes from the stomach into the intestine quite quickly; thirdly, gastric lavage is not always effective, since large blood clots are difficult to crush, they do not pass through the probe and clog it. Moreover, during lavage, water may accumulate in the stomach, making it difficult to examine, and the lavage probe may injure the mucous membrane, which makes it difficult to find the main source of bleeding. The need for gastric lavage should be determined during endoscopy and occurs:

1. if it is impossible to perform a revision of the stomach due to a large amount of liquid blood and its clots;
2. if the examination was inconclusive due to the presence of a large number of small clots and scarlet blood on the walls of the organ;
3. when one superficial source of bleeding is detected (acute ulcer or erosion) and a large amount of blood in the organ does not allow a detailed examination of the walls of the stomach and duodenum and exclude the presence of other sources of bleeding;
4. at the slightest doubt about the quality of the initial examination.

When the source of bleeding is localized in the esophagus, the blood flows into the stomach and does little to prevent the esophagus from being examined. If half of the stomach's volume is filled with blood or liquid, it is difficult to perform a high-quality examination of the entire mucous membrane. In these cases, the stomach must be emptied.

If liquid blood and large blood clots occupy less than half the volume of the straightened stomach, a detailed examination can be performed by changing the patient's position. When the foot end of the table is raised, the contents accumulated in the area of the fundus and greater curvature do not interfere with the inspection of other sections of the stomach, and when the head end of the table is raised, the proximal sections of the stomach are freed for examination. Small blood clots on the surface of the mucous membrane are easily washed away with a stream of water from the catheter.

Blood clots make the examination of the duodenum particularly difficult due to its small size. If a blood clot has moved into the duodenum from the stomach, it can easily be washed off the mucous membrane with a stream of water or moved with biopsy forceps. If at least the edge of the ulcer defect is found covered by a clot, the diagnosis is clear and there is no need to move the clot.

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

250-300 ml should be administered once. It should be administered slowly using a Janet syringe. Evacuation should be carried out by gravity 1-1.5 minutes after water retention in the lumen of the stomach. Active evacuation without water retention in the lumen of the stomach promotes increased bleeding and insufficient hypothermic effect. Only a thick gastric tube is used, through which small clots can be discharged. The time of gastric lavage should be consistent with the change in the color activity of the lavage water. If there is no tendency to lighten within 10-15 minutes, lavage is stopped - more radical assistance is needed. If there is a tendency to lighten, lavage continues for up to 30-40 minutes. The amount of water is up to 10 liters. Any lavage with ongoing bleeding should be combined with general hemostatic therapy.

It is necessary to take into account that during bleeding the endoscopic picture of the mucous membrane of the organs changes. This is due, on the one hand, to the presence of a thin layer of blood and fibrin on the walls, absorbing a significant amount of light rays, and on the other hand, to the pallor of the mucous membrane due to the developed posthemorrhagic anemia. In the absence of anemia at the height of bleeding, a thin layer of blood, covering the mucous membrane of the stomach and duodenum, gives it a pink color and masks defects. With moderate and severe anemia, the mucous membrane, on the contrary, becomes pale, matte, lifeless, inflammatory hyperemia around the source of bleeding decreases and completely disappears. The decrease and disappearance of contrast between the "sick" and "healthy" tissues cause a uniform color of the mucous membrane, which complicates the search for the source of bleeding and distorts the endoscopic picture. This can lead to diagnostic errors: either the source of bleeding cannot be detected (more often with superficial ulcerations - erosions, acute ulcers), or it is incorrectly interpreted (with benign and malignant ulcerations).

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Varicose veins of the esophagus

In most cases, patients with esophageal varices never bleed from them. However, when they do bleed, it is usually more severe than bleeding from other upper gastrointestinal sources.

Endoscopically, the diagnosis is not in doubt if bleeding varicose veins of the esophagus are detected during the examination. A presumptive diagnosis of bleeding from such veins can be made in cases where varicose veins are detected in the esophagus and no other possible sources of bleeding are found in either the stomach or the duodenum. Traces of fresh ruptures (pigment spots on the surface of varicose veins) are additional evidence of recent bleeding from varicose veins of the esophagus.

With ongoing bleeding, a large amount of liquid blood is found in the esophagus during an endoscopic examination. In order not to contribute to trauma to the mucous membrane, the examination is performed with minimal air insufflation, and a catheter is inserted through the biopsy channel or a syringe wash is used for flushing. Esophagoscopy shows a jet or drop flow of blood from the surface of the varicose trunk, which complicates the examination. The defect in the mucosa is usually not visible. The varicose trunk can be in the form of a single longitudinal trunk running from the middle of the thoracic region to the cardia, or in the form of 2, 3 or 4 trunks. Individual varicose nodes, as a rule, do not lead to profuse bleeding. When bleeding has stopped, the veins can collapse and be poorly differentiated (blood discharge).

When there are no defects on the esophageal mucosa, and examination of the stomach and duodenum reveals no pathology and there is a suspicion of varicose veins of the esophagus, a test for filling the veins of the esophagus can be performed: an endoscope is inserted into the stomach, its end is bent to the cardia and held for 1.5-2.0 minutes, then the end is straightened, the endoscope is brought out to the lower part of the thoracic esophagus and the veins of the esophagus, filling of the veins of the esophagus is observed (only if there are no defects on the esophageal mucosa). The amount of bleeding can be judged by the imposition of fibrin on the tops of the venous trunks; in the defect zone to the periphery, there may be intramucosal hematomas.

Bleeding from esophageal varices is best stopped by endoscopic sclerotherapy or endoscopic ligation of bleeding varices. For sclerotherapy, 5% varicocid solution, 1% or 3% thrombovar solutions, or 1% sodium tetradecyl sulfate solution are used. The vein is punctured under visual control below the bleeding source and 2-3 ml of the sclerosing agent is injected into it. Then the vein is punctured above the bleeding site and the same amount of the agent is injected into it.

After this, the vein section between the puncture points is pressed for some time with the distal end of the endoscope, thereby preventing the spread of the drug along the vascular anastomoses into the superior vena cava. During the endoscopic examination, no more than two or three varicose veins should be thrombosed, since complete cessation of outflow through the veins of the esophagus contributes to a significant increase in venous pressure in the cardiac region of the stomach, which can lead to profuse bleeding from varicose veins in this area. 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. Monitoring the effectiveness of the treatment is carried out after 10-12 days using X-ray and endoscopic examinations.

When performing sclerotherapy, various complications arise in approximately 20% of cases, such as ulceration, development of stricture, motor disorders of the esophagus and mediastinitis.

Endoscopic ligation of bleeding esophageal varices is also quite effective, and the incidence of complications is significantly lower. Both manipulations, if repeated 5 times or more over 1-2 weeks, lead to obliteration of varicose veins and reduce the likelihood of recurrent bleeding.

Balloon tamponade of bleeding esophageal varices is also used to stop bleeding. Sengstaken-Blakemore esophagogastric tubes or Minnesota-Linton gastric tubes are used for this purpose. Correctly installed tubes allow stopping bleeding in most cases. However, when the cuffs are released, it often recurs. Due to the high frequency of possible complications, these tubes should only be used by doctors who have sufficient experience in their installation.

Mallory-Weiss syndrome

Mallory-Weiss syndrome most often occurs in people who abuse alcohol with vomiting movements as a result of uncoordinated contractions of the stomach walls. Bleeding develops from cracks in the mucous membrane located deep in the grooves between the longitudinal folds. They are always located along the back wall of the esophagus and cardioesophageal junction, since they are caused by the relationship of the mucous membrane with the submucosal layer. Ruptures of the mucous membrane look like longitudinal lacerated wounds up to 2-3 and even 4-5 cm long and up to 1-5 mm wide, reddish in color, linear in shape. Most often, the ruptures are single, but can be multiple. The bottom of the ruptures is filled with blood clots, from under which fresh blood leaks. The mucous membrane at the edges of the wounds is saturated with blood.

Targeted lavage removes blood and exposes the mucosal defect. Ruptures may involve the mucosa, submucosal and muscular layers, sometimes complete ruptures of the wall are observed. The layering of the rupture edges is easily determined by moderate constant introduction of air into the stomach, although the use of this technique carries the risk of increasing or resuming bleeding.

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

Bleeding is rarely intense. During an endoscopic examination, it is usually possible to reliably stop it using sclerotherapy, electro- or photocoagulation. If a sufficiently long time has passed since the bleeding (4-7 days), then during endoscopy, longitudinal yellowish-white stripes are found - wounds of the mucous membrane covered with fibrin. They look like grooves with low edges. When air is pumped in, their surface does not increase. Deep ruptures of the stomach wall heal within 10-14 days, often with the formation of a longitudinal yellowish scar, and superficial ones - within 7-10 days, leaving no traces.

Mucosal ruptures can occur not only in Mallory-Weiss syndrome, but also of traumatic origin.

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Bleeding from a tumor

Bleeding from a tumor can be massive, but is rarely prolonged, because there are no main vessels in the tumor. The appearance of tumors is not difficult, but sometimes they can be completely covered with blood clots along the large curvature and are not visible. The mucous membrane is mobile above benign tumors. It is not always advisable to take a biopsy, but if you take one, then from those areas where there is no decay.

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Bleeding from an ulcer

The efficiency of endoscopic diagnostics of acute ulcers 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 ulcers, the disappearance of inflammatory hyperemia around the defect and the absence of signs of bleeding at the time of examination. Acute erosions can epithelialize within 2-5 days. Diagnostics of chronic ulcers as causes of gastroduodenal bleeding in most cases is not difficult due to their typical endoscopic signs. Particular attention should be paid to the detection of thrombosed vessels at the bottom of the defects, which allows us to determine the risk of recurrent bleeding. The peculiarity of the endoscopic picture of chronic ulcers with bleeding from them is that the depth of the ulcers and the height of the edges decrease, scars are poorly visible. These changes are the cause of diagnostic errors: chronic ulcers are assessed as acute. A bleeding ulcer may be covered with a loose bloody clot or hemolyzed blood, which makes it difficult to recognize. When at least the edge of the ulcer is visible, the diagnosis is beyond doubt. When bleeding from an ulcer of the duodenal bulb, blood flows from the bulb through the pylorus into the stomach, which does not happen with bleeding from a gastric ulcer. With profuse bleeding, the ulcer is not visible.

To determine the treatment tactics for bleeding chronic ulcers, endoscopic gastric ulcers. manifestations of bleeding are divided into types according to Forrest:

• IA - jet arterial bleeding from an ulcer,
• IB - blood seepage from the ulcer defect,
• IC - blood comes from under a tightly fixed clot,
• IIA - ulcer with a thrombosed vessel at the bottom,
• IIB - presence of a fixed blood clot,
• IIC - small thrombosed vessels in the ulcer,
• III - no signs of bleeding (defect under fibrin).

In case of Forrest IA endoscopic picture, emergency surgery is indicated. In case of IB, attempts at endoscopic bleeding control (electrocoagulation, injection) are possible, however, if attempts are unsuccessful, the endoscopist should give way to the surgeon in time for surgical bleeding control.

It should be noted that this approach is somewhat simplified, since the possible development of recurrent bleeding and the choice of appropriate treatment tactics can be judged by the appearance of the chronic ulcer itself during endoscopic examination. In the presence of an ulcer with a clean whitish base, the probability of recurrent bleeding is less than 5%, and if the ulcer crater has flat pigmented edges - approximately 10%. In the presence of a fixed blood clot that cannot be washed off from the base of the ulcer, the risk of recurrent bleeding is 20%, and if a large blood clot is detected over a clearly visible vessel, the probability of recurrent bleeding increases to 40%.

If 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 recurrence of bleeding is 80%. In this case, the risk of subsequent recurrences of bleeding 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 signs for assessing the likelihood of recurrence of bleeding.

Patients with peptic ulcer disease who have a chronic gastric or duodenal ulcer with a clear whitish base or with flat pigmented crater edges do not require any special treatment. Many studies have shown the high efficiency of endoscopic treatment methods for patients with a vessel visible in the ulcer bottom or ongoing bleeding. The most common endoscopic treatment methods are injections of adrenaline diluted 1:10,000 into the ulcer edges, followed by electrothermocoagulation with a mono- or bipolar electrode. In this case, the tissue (ulcer bottom and edge) located near the vessel should be coagulated. In this case, the zone of thermal necrosis spreads to the vessel, causing thrombus formation in it and stopping the bleeding. It is impossible to coagulate the vessel directly, since the resulting scab is “welded” to the electrothermoprobe and, together with it, is torn off from the vessel, leading to bleeding. After such treatment, recurrent bleeding occurs in approximately 20% of patients. Electrothermocoagulation can also be used when a thrombosed vessel is detected to increase the length of the thrombus and reduce the risk of recurrent bleeding. In this case, it is also necessary to coagulate the tissue around the vessel.

In case of recurrent bleeding in patients with a high risk of surgical treatment, a second attempt at endoscopic hemostasis can be made. The remaining patients are indicated for surgical treatment.

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Bleeding from erosions

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

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Hemorrhagic gastritis

It most often develops in the proximal parts of the stomach. The mucosa is covered with blood, which is easily washed off with water, but immediately "dewdrops" of blood appear, which completely cover the mucosa. There are no defects on the mucosa. After the previous bleeding, pinpoint intramucosal hemorrhages are visible, which sometimes, merging into fields, form intramucosal hematomas, but against their background, pinpoint hemorrhagic inclusions are visible.

Bleeding in mesenteric thrombosis

Unlike an ulcer, with mesenteric thrombosis there are no blood clots in the stomach, although there is blood flow. It looks like "meat slops" and is easily aspirated. There are usually no defects in the mucous membrane of the duodenum. The endoscope should be inserted into the descending part of the duodenum, the blood should be aspirated and observed from where it comes: if from the distal parts - bleeding as a result of mesenteric thrombosis.

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Rendu-Weber-Osler disease

During the period of stopped bleeding, intramucosal hematomas of the most bizarre shape or hemorrhagic rays extending from the periphery to the main zone are visible. Sizes from 2-3 to 5-6 mm. Intramucosal hematomas are localized not only on the gastric mucosa, but also on the mucosa of the duodenum, esophagus, and oral cavity.

Bleeding from the liver

In the form of hemobilia, rarely accompanied by blood reflux 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 mucous membrane of the duodenum and try to provoke the release of blood from it (ask the patient to cough actively - intra-abdominal pressure increases). Examine with an endoscope with lateral optics. With hemobilia, blood and hemorrhagic clots are observed at the level of the duodenum.

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