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INVENTION
Patent of the Russian Federation RU2201143

METHOD FOR CONTROL OF EFFICIENCY OF ENDOSCOPIC HEMOSTATICS AND PREDICTION OF THE RISK OF GASTROINTESTINAL BLEACHING

The name of the inventor: Pantsirev Yu.M .; Shapovalyants SG; Orlov S.Yu .; Fedorov ED; Mikhalev A.I.
The name of the patent holder: Russian State Medical University
Address for correspondence: 117997 , Moscow, ul. Ostrovityanova, 1, Russian State Medical University, Patent Department, SV Pyzhov
Date of commencement of the patent: 2001.01.11

The method can be used in medicine, namely in gastroenterology. After performing an endoscopic stop and / or preventing bleeding with the help of endoscopic ultrasonography, the presence in the bottom of an ulcer of vascular structures invisible on its surface is revealed. Determine their exact size and depth of occurrence. If close to Ј 1 mm from the bottom of the ulcerative defect is observed, the preserved vascular structures і 1.5 mm in diameter make a conclusion about the continuing threat of repeated bleeding and ineffectiveness of the endoscopic hemostasis. The method allows to increase the accuracy of the control.

DESCRIPTION OF THE INVENTION

The invention relates to medicine, in particular to surgery and endoscopy, and can be used to control the efficacy of endoscopic hemostasis in predicting the risk of recurrence of gastrointestinal bleeding and determining surgical tactics.

A method is known to control the effectiveness of endoscopic treatment and predict the risk of recurrence of gastrointestinal bleeding using the method of endoscopic Doppler ultrasonography, which makes it possible to detect the presence of active blood flow in vessels located in the bottom of a ulcerative defect, but inaccessible to examination in normal endoscopy in visible light (Miller LS, Friedman LS. "The endoscopic Doppler and ulcer rebleeding risk: probing the source." Gastroenterology 1992; 102: 734-736). However, the use of the continuous wave Doppler ultrasound system does not provide significant advantages in predicting the risk of rebleeding in comparison with the traditional endoscopic criteria used for these purposes (Fullarton GM, Murray WR. Prediction of rebleeding in peptic ulcers by visual stigmata and endoscopic Doppler ultrasound Criteria "Endoscopy 1990; 22: 68-71).

More encouraging are the results of the authors who used for this purpose intermittent wave Doppler ultrasonography (Kohler B, Riemann JF. "Does Doppler ultrasound improve the prognosis of acute ulcer bleeding?" Hepato-Gastroenterology 1994: 41: 51-53). An ultrasonic probe with a diameter of 1.8 mm, freely conducted through the biopsy channel of a standard endoscope, firstly allows varying the penetration depth of ultrasound from 0.1 mm to 1.5 mm and, secondly, allows to differentiate the acoustic signals emanating from the arteries with Active blood flow located in the bottom of the ulcer, from arteries located at a distance of more than 1.0 mm from the bottom of the ulcer. The latter, as a rule, are not sources of repeated bleeding (Johnston JH, "The sentinel clot and invisible vessel: pathologic anatomy of bleeding peptic ulcer." Gastrointestinal Endoscopy 1984; 30: 313-315). Comparing the results of intermittent-wave Doppler ultrasonography with endoscopic bleeding stigms classified by Forrest in 140 patients with acute ulcerative gastroduodenal bleeding, the authors showed that only 59% of the patients had a coincidence. In this case, the relapse of bleeding after the injection endoscopic hemostasis by polydocanol was developed in 9% of the total number of patients only in the "Doppler-positive" group and not in any patient from the "doppler-negative" group, which allowed the authors to conclude that the method was more predictive Intermittent-wave Doppler ultrasonography.

However, all these methods are inherently based on the qualitative sign - the presence or absence of blood flow in the vessels of the ulcer crater and are not able to give an idea of ​​such extremely important prognostic parameters as the exact diameter, topography and architectonics of the underlying bleeding vessel, and to determine the exact layer of the organ wall , In which the vessel lies, and to reveal reliable signs of penetration of the ulcer crater into neighboring organs.

We have set a task to develop an effective, based on objective, precisely defined and measured parameters of the source of bleeding, a method for monitoring the effectiveness of endoscopic hemostasis and predicting the recurrence of gastrointestinal bleeding.

The solution of the task is achieved by the fact that after an endoscopic stop and / or prevention of bleeding with the help of ultrasound endosonography, the exact depth of the ulcer (corresponding to the layers of the gastrointestinal wall) is determined, its spread beyond the serous membrane (penetration), the presence of ulcers of the vascular Structures, determine their exact size and depth of occurrence. Preservation in the immediate vicinity of the bottom of the ulcerative defect of vascular structures visible during endosonographic scanning, which can not be detected with traditional endoscopy in visible light, allows an objective conclusion about the inadequacy of endoscopic hemostasis and the high risk of rebleeding. This in turn, in accordance with tactical settings, allows you to determine the indications for urgent surgical intervention or to perform a repeated endoscopic action on the source of bleeding.

The method is carried out as follows. Patients entering the hospital with a clinical picture of acute gastrointestinal bleeding, emergency esophagogastroduodenoscopy is performed, the source, character and intensity of bleeding are established. Then stop and / or prevent bleeding with the help of monoactive hydro-diathermocoagulation, injection of vasoconstrictor or injection of ethanol. Using the radially scanning echo endoscope GF-UM20 or ultrasonic probes MH-2R from Olympus, an endoscopic ultrasonography is performed for detailed study of the wall of the digestive tract in the area of ​​the ulcerative defect. Define: the size of the ulcerative defect, the depth of the ulcer according to the layers of the wall of the gastrointestinal tract, its spread beyond the wall (penetration), the localization of the defect, the presence of ulcers in the bottom of the vascular structures, their size and depth of incidence, EUS is performed either immediately after endoscopic hemostasis, Or within the next 12-24 hours, that is, the time that is released for the decision on the need for an urgent operation. In the immediate vicinity ( Ј 1 mm) from the bottom of the ulcerative defect, the preserved vascular structures in the form of linear arcuate anehogenous formations і 1.5 mm in diameter make a conclusion about the ineffectiveness of endoscopic therapy and the continuing threat of rebleeding. If there is no ulcer in the vascular structures after the endoscopic hemostasis is performed and there is no penetration, ulcers in the surrounding tissues ascertain the adequacy of the endoscopic hemostasis and predict a small risk of rebleeding.

The essence of the invention is illustrated by the following specific examples.

Example 1. Patient K., 73 years old, ib. 16414 (1998) entered the hospital on 5.11.1998 with a clinical picture of acute gastrointestinal hemorrhage of an average severity of 8 hours ago. In the history: a sharp weakness, a single melena. At admission, the condition is of medium severity, the skin is pale, the pulse is 102 beats per minute, the blood pressure is 120/80 mm Hg. Art. When probing the stomach - clots of dark blood, rectal - melena. Hb - 105 g / l, erythrocytes - 3,6, hematocrit - 27%.

According to the data of the urgent EHDS, the source of the erosive bleeding stopped at the time of the examination was an acute ulcer of the posterior wall of the middle third of the body of the stomach, measuring 40 × 30 mm, up to 3 mm deep, with thrombosed vessels in the bottom in the form of dark-cherry-colored tubercles up to 2 mm (Forrest 2a). Prevention of bleeding recurrence was carried out by mono-active diathermocoagulation. Taking into account clinical, laboratory and endoscopic data, the risk of bleeding recurrence was regarded as large. The patient was hospitalized in a specialized surgical department and received intensive therapy, including a transfusion of erythrocyte mass in a volume of 350 ml, antisecretory, antiulcer, haemostatic therapy.

18 hours after the end of the initial endoscopic examination, an urgent endoscopic ultrasonography of the area of ​​the ulcerative defect with an ultrasound mini probe with a scanning frequency of 12 MHz was performed. It is determined that the ulcerative defect reaches the submucosal layer, in which a linear anechoic structure up to 2 mm in transverse dimension can be traced. The edges of the ulcerative defect in the form of hypoechoic edema, the layers of the stomach wall along the edges of the ulcer are clearly traced. In the places of hemostatic influence, the thickening of the stomach wall is determined due to the presence in the submucosal layer of an irregular shape of round hypo-anechogenic inclusions. Thus, the following was ascertained: the inadequacy of the endoscopic hemostasis performed and a conclusion was made about the high threat of its renewal. Immediate remedial action was taken on the source of bleeding through the endoscope, by endoclyping the vascular arc (4 clips of MD-850) and additional mono-active diathermocoagulation of small vessels. When one of the clips was applied to the vascular artery, the arterial bleeding of medium intensity resumed, which stopped when the next clip was applied.

Subsequently, the patient was conservative in the conditions of the surgical department, received a full complex of intensive, hemostatic, antiulcer therapy, but on the 6th day from the last EGDS the patient again developed a bleeding recurrence, stopped by conservative measures.

Example 2. Patient M., 41 years, Ib. 9179 (1999) entered the hospital on 7.06.1999, and with a clinical picture of acute gastrointestinal hemorrhage of moderate severity, 2 days ago. In the anamnesis: multiple melena. At admission: the condition is of medium severity, the skin is pale, the pulse is 102 beats per minute, the blood pressure is 100/60 mm Hg. When probing the stomach - blood clots, rectally - melena. Hb - 60 g / l; Erythrocytes - 2,1; Hematocrit 17%; Deficiency of globular volume - 25%.

According to the data of the urgent EGD, the source of the erosive bleeding stopped at the time of the examination was an acute ulcer of small curvature at the border of the middle and lower third of the body of the stomach, up to 11 mm in diameter, up to 2 mm deep with a fixed clot-clot in the bottom (Forrest 2b). Prevention of bleeding recurrence was carried out by paravasal administration of 96.6% ethanol from 2 points of 0.4 ml and the introduction of ulcers from 2 points into 6 ml of 25% ethanol-novocain solution into the base and edges. Taking into account clinical, laboratory and endoscopic data, the risk of bleeding recurrence was regarded as large. The patient was hospitalized in the intensive care unit and received intensive therapy including transfusion of erythrocyte mass to fresh frozen plasma in a volume of 1.5 liters, antisecretory, antiulcer, haemostatic therapy.

After 7.5 hours after the end of the primary EHDS, the patient underwent a control EGDS and ultrasonography of the ulcer area with a mini-probe with a scanning frequency of 12 MHz. It was determined that the ulcerative defect reaches the submucosa without penetrating it. The edges of the ulcerative defect without hypoechoic edema, the layers of the stomach wall along the edges of the ulcer are clearly traced. In the submucosal layer of linear anehogenic structures with a size of more than 1 mm was not detected. At the injection site of the alcohol-novocaine mixture, the thickening of the stomach wall is determined due to the presence in the submucosal layer of an irregular shape of round hypo-anechogenic inclusions. Thus, the following were ascertained: the adequacy of the endoscopic hemostasis performed, the absence of a relapse of bleeding, and a conclusion was made about the small threat of its renewal due to the small depth of the ulcer and the absence of large vascular structures in its bottom.

Subsequently, the patient was conservative in the conditions of the surgical department, there were no signs of recurrence of bleeding.

Thus, we found that the proposed method for predicting the risk of recurrence of acute gastrointestinal bleeding is informative and effective, it objectifies the process of determining the indications for urgent surgical intervention and provides a differentiated approach to the definition of surgical tactics in this category of patients.

CLAIM

1. A method for monitoring the efficacy of endoscopic hemostasis and predicting the risk of recurrence of gastrointestinal bleeding, characterized in that after performing an endoscopic stop and / or preventing bleeding, the presence in the bottom of the ulcer of vascular structures invisible on its surface is detected with the determination of their exact dimensions and depth of bedding , And when detected in close proximity - 1 mm from the bottom of the ulcerative defect of preserved vascular structures і 1.5 mm in diameter make a conclusion about the continuing threat of repeated bleeding and ineffectiveness of the endoscopic hemostasis.

2. The method according to claim 1, characterized in that the detection in the immediate vicinity is 1 mm from the bottom of the ulcerative defect of preserved vascular structures in the form of linear arcuate anehogenous formations 1.5 mm in diameter invisible on the surface of the ulcerative defect in the traditional endoscopic examination , Is carried out with the help of endoscopic ultrasonography

print version
Date of publication 30.03.2007gg

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