Professor Tang Shoujiang: Gastrointestinal bleeding hot 13 questions

At the Bethune Digestive Disorder Cloud Summit Forum - Sino-US Gastrointestinal Bleeding Seminar held in November 2021, Professor Tang Shoujiang from the University of Mississippi Medical Center shared the clinical and endoscopic treatment of non-variceal gastrointestinal bleeding and the clinical and endoscopic treatment of varicose vein rupture and bleeding in the United States, and answered related questions.

Q1: Is esophageal variceal > 2cm contraindicated?

Esophageal varices greater than 2 cm are not contraindicated. Based on past experience, peri-circumferential varices can also be ligation, and the ligation should not damage the mucous membranes, and there should be no bleeding after ligation. When repairing, the surrounding tissues of the ulcer will gradually anastomose, so 2 cm or 3 cm, and even peri-ring varicose veins are not contraindicated and can be performed.

Q2: What should I do if I have a major bleeding after returning home from esophageal variceal outpatient treatment?

There has been almost no major bleeding at home after the ligation, but there have been cases of heavy bleeding after a few days and ulcers caused by not taking medicine, but the probability is also relatively low, 0.5% to 2%.

If there is really a major bleeding situation, you should first confirm whether it is gastric variceal bleeding or esophageal variceal bleeding, be sure to do a careful examination, and then confirm the bleeding in other locations after the stomach is excluded.

For example, bleeding from varicose veins in the esophagus, see if the varicose vein bleeding occurs in a treated or untreated location. If there is varicose bleeding in an untreated location, just bandage it again. If there is bleeding in the treated location, it can be ligated again with a titanium clip, and if there is a heavy bleeding, it can be re-ligated again.

Q3: Chinese lax patients generally stay in the hospital for observation, while patients in the United States can go home after outpatient ligation, so what is the medical advice for patients after returning home?

In the United States, if the patient is active bleeding, it is necessary to be hospitalized; if it is inactive bleeding, after ligation observation of 0.5 to 1h, the patient can go home, life returns to normal, but to emphasize that the day can not eat hard food, the first two days are also best to eat soft food, and emphasize the importance of taking antacids.

Q4: How long do I need to take antacids?

According to U.S. guidelines, antacids need to be taken for 8 weeks, but in clinical practice, there are also those that recover after taking 2 weeks. The guideline in the United States is to recommend re-examination every 2 to 3 weeks, and our hospital stipulates that it is reviewed every 4 weeks, and basically no ulcers appear during the re-examination. The same is true of taking antacids, and the first 3 to 4 weeks are critical periods.

Q5: What is the influence of the rubber material of different lashing devices on the ligation treatment?

Whether it is imported or domestic, or recommended to use natural rubber products, natural rubber lashing device and elastomer are different, elasticity and shedding difficulty coefficient are not the same, which has been done in a very early years of control experiments.

Q6: What experiences can I share about endoscopic hemostasis of Duchenne disease bleeding?

Dieulafoy disease generally refers to the absence of ulcers, but bleeding from 1 mm to 3 to 4 mm in the arteries. Traditional treatment is to inject next to it, followed by heat condensation. Now all use titanium clips, I will generally put 2 clips, let it form an angle, I personally prefer to use large clips, usually with 16mm, so that after treatment, although it will bleed, but it is relatively small, basically very satisfied.

Other treatments have been reported in the literature, some using argon ion coagulation (APC), but this method is not currently mainstream. There are also people who use the method of multi-ring lassipator, in the large intestine, small intestine is OK, but in the stomach, because the stomach wall is very thick, the ligator has the possibility of early loss.

Therefore, if you use a lashing device, it is recommended to put a titanium clip underneath to prevent the trap from falling off early.

Q7: For patients with peptic ulcer bleeding, the APC method is used to stop the bleeding, and the accompanying risk is not high, such as perforation?

In Europe and the United States, if it is superficial telangiectasia, the APC method is preferred. Although APC has been reported to treat arterial bleeding, peptic ulcers, etc., it is basically not used. Because APC is hot, there is also the possibility of perforation, so it is not recommended to use APC, but it is more appropriate to use a titanium clip.

Q8: Whether patients can receive endoscopic biopsies, EMRs, etc. during aspirin use, the current views of the United States, China, and Japan are not the same, so what is actually the case in the United States?

In the past 5 to 10 years, european and American guidelines have stipulated that it is necessary to stop the drug for 5 to 7 days, and it has been later confirmed that it is safe to take aspirin alone and unsafe to take it with other drugs. Earlier, I published an article on a survey with a doctor in South Korea, which mainly compared the differences in the concept of anticoagulants used by doctors in Europe, the United States, Japan, and South Korea before and after surgery. Doctors in Europe and the United States are more concerned about the possibility of myocardial infarction, vein coagulation, stroke, and thrombosis, while doctors in the East are more concerned about surgical complications such as bleeding.

Q9: 49% of patients with colonic diverticulum can spontaneously stop bleeding, but clinically they may still choose to let patients observe and carry out endoscopic hemostasis as soon as possible, so how should we grasp the timing clinically?

This question is not addressed in U.S. guidelines, nor has there been a controlled experiment. My personal experience is that if it is polyp bleeding, in Europe and the United States, it is generally bleeding tonight, surgery tomorrow, if it is active bleeding, there is a blood clot, then use a titanium clip.

However, there are also cases of not doing it, generally the patient is older or less bleeding, the risk of doing it is greater than not doing it, and it is chosen not to do it under the premise of obtaining the patient's consent. It mainly depends on what is best for the patient and the patient's willingness.

Secondly, regarding the prevention of polyp bleeding, use titanium clips to prevent preventive sealing to reduce bleeding. 5% to 10% of cases in the United States are large polyps, the general treatment method, if it is 1cm or more, inject the mucosa for endoscopic mucosal resection (EMR), and then seal it with a titanium clip. In my experience over the past decade, there have been almost no cases of large polyps bleeding after such treatment, but after small polyps are treated with heat, there are one or two cases of bleeding every year.

Studies have confirmed that polyps of more than 2 cm (in the position of the large intestine and small intestine) must be sealed with titanium clips, which can reduce the bleeding rate by about 70%.

Q10: I heard that many internal hemorrhoids in the United States are simply performed by community doctors and family doctors. Are there clear guidelines for ligation and hardening of internal hemorrhoids?

Internal hemorrhoids are a common problem, with occasional bleeding usually untreated, with frequent bleeding or when the patient does not want to bleed. Anoscopy can be done by either a general practitioner or an internal physician, and when a general practitioner does not want to do analoscopy, it is referred to a doctor in the department of gastroenterology. In the United States, 60% to 70% of gastroenterologists are private doctors, such doctors prefer to do internal hemorrhoid treatment, mainly simple, short time, can be completed in the outpatient clinic, and the cost of internal hemorrhoid treatment in the United States is similar to that of colonoscopy.

The treatment of internal hemorrhoids is mainly based on the method of ligation. The advantage of ligation treatment is that it is effective, it can quickly not bleed, and there is no need for follow-up, and the disadvantage is that it will be painful after surgery. Generally, 2 to 3 ligs are good to use, not too much.

Q11: What experience do you share about diverticular bleeding?

For bleeding in the diverticulum of the colon, it is recommended to use a titanium clip, which is highly safe, does not need to worry about perforation, and the effect is good. Some Japanese literature also recommends the use of the method of ligation, ligation does not need to be cut, more effective, and the bleeding rate is also very small, but it needs to use a mirror, and it is also necessary to pull out the mirror after doing it.

Q12: Peptic ulcer bleeding, domestic hospitals like to use soft electrocoagulation to stop bleeding, professor Tang on soft coagulation to stop bleeding how to see?

Previously, soft electrocoagulation was also used to stop bleeding, but in the past decade, titanium clips have basically been used, and titanium clips are faster, safer and more effective.

Q13: Is the risk of perforation high after gastrointestinal bleeding rubber ring ligation?

The perforation of the esophagus has not yet been seen, and it is safe to operate in the stomach. Japan and the United States have carried out animal and human specimen experiments, in the small intestine, colon operation, mucosal base layer 30% to 40% of the sleeve, it is recommended not to cut after the set, otherwise the probability of perforation will be very high. After using the titanium clip, the small intestine and large intestine can also be processed.

All in all, esophageal and gastric ligations are safe, and duodenum and colon are recommended not to be covered, and if you are covered, remember not to cut.

Source: EndoNews Endoscopic New Knowledge