Complex endoscopic treatment of acute gastrointestinal bleeding of ulcer origin

Abstract

Gastrointestinal bleeding (GIB) is determined in 20-30% of patients with peptic ulcer disease. Acute gastrointestinal bleeding is on the first place as the main cause of deaths from peptic ulcer ahead of the other complications. Rebleeding occurs in 30-38% of patients.

Materials and Methods

For getting of the objective endoscopic picture in patients with bleeding gastroduodenal ulcers we used the classification of J.A. Forrest in our study:

Type I - active bleeding:

• I a - pulsating jet;

• I b - stream.

Type II - signs of recent bleeding:

• II a - visible (non-bleeding visible) vessel;

• II b - fixed thrombus - a clot;

• II c - flat black spot (black bottom ulcers).

Type III - ulcer with a clean (white) down.

Integrated endoscopic hemostasis included:

irrigation of ulcer defect and area around it with 3% hydrogen peroxide solution in a volume of 10 - 30ml; Injection of 2-4 mL of diluted epinephrine (1:10000) for hemostasis; use of Argon plasma coagulation.

Results and Discussion

Integrated endoscopic stop of bleeding was performed in 57 patients who were examined and treated at the Department of Surgery from 2006 to 2012. In 16 patients bleeding was caused by gastric ulcer. Gastric ulcer type I localization according to classification (HD Johnson, 1965) was determined in 9 patients, type II - in 2 patients, type III – in 5 patients. In 31 patients bleeding was caused by duodenal peptic ulcer, in 4 patients - erosive gastritis, 1 - erosive esophagitis, and in 5 patients - gastroenteroanastomosis area peptic ulcer. Final hemostasis was achieved in 55 (96.5%) patients. In 50 (87.7%) patients it was sufficient to conduct a single session of complex endoscopic treatment. In 5 (8.8%) patients – it was done two times. In 2 (3.5%) cases operation was performed due to the recurrent bleeding. The source of major bleeding in these patients was: chronic, duodenal ulcer penetrating into the head of the pancreas in one case complicated by subcompensated pyloric stenosis, in the second case - by severe duodenal bulb deformity and acute duodenitis of II-III degree.

Conclusions:

1. An integrated endoscopic treatment of erosive and ulcerative lesions of the upper gastrointestinal tract it was effective to avoid emergency surgery in 36.9% of patients with the risk of recurrent gastrointestinal bleeding;

2. Complex endoscopic techniques are effectively applied in all parts of the esophago-gastroduodenal zone, allowing to perform the final hemostasis in 96.5% of patients;

3. The failures of the complex method were observed in 3.5% of patients and were associated most likely with erosion of large, intramural vessels;

4. Modern endoscopic techniques allow to provide not only temporary, but the final hemostasis, to prevent rebleeding, which in turn helps to avoid emergency surgery.

Key words: argon and plazma endoscopic coagulation (APEC), hydrogen peroxide, injection hemostasis.