Hepatogenic upper gastrointestinal bleeding is defined as upper gastrointestinal bleeding that occurs on the basis of gastrointestinal lesions including esophago-gastric varices, portal hypertensive gastropathy, hepatogenic ulcers and hepatic gastrointestinal insufficiency on the basis of severe liver disease. Due to the severe liver disease itself, it is often combined with complications such as hepatic encephalopathy, infection, hepatorenal syndrome, and disorders of the internal environment and DIC. Therefore, treatment is difficult and the morbidity and mortality rates are higher than those of non-hepatic hemorrhage.
I. Etiology of hepatogenic upper gastrointestinal bleeding
1. Ruptured esophageal-fundus varices bleeding is the most common cause of hepatogenic upper gastrointestinal bleeding. Emergency gastroscopy found that ruptured esophagus-fundus variceal bleeding accounted for 52.4% and non-variceal bleeding accounted for 47.6%, which often caused hemorrhagic shock or induced hepatic encephalopathy due to the large amount of bleeding.
2, portal hypertensive gastropathy (PHG) incidence accounted for 50%-80% of patients with cirrhosis. PHG is mostly light, no specific clinical symptoms. The main clinical manifestation of severe PHG is upper gastrointestinal bleeding, mostly a small amount of vomiting blood, black stool, a few appear hemorrhage, which can lead to hemorrhagic shock, and can induce hepatic encephalopathy, infection, liver and kidney syndrome, etc. The rate of rebleeding after bleeding is very high.
3. Hepatogenic ulcer is a peptic ulcer secondary to cirrhotic portal hypertension, often accompanied by erosive gastritis. The incidence is about 2-3 times that of the normal population and accounts for 20%-30% of the upper gastrointestinal bleeding in cirrhosis.
4, hepatic gastrointestinal insufficiency patients with severe liver disease (heavy hepatitis and cirrhosis loss of compensation) due to liver insufficiency caused by the gastrointestinal secretion, absorption, movement, barrier and circulation and other aspects of dysfunction, known as hepatic gastrointestinal insufficiency, and in severe cases is called hepatic gastrointestinal failure. In the advanced stage of liver failure in severe liver disease, gastrointestinal bleeding caused by gastrointestinal mucosal erosion and ulceration is often seen due to nutritional disorders, bacterial destruction, mucosal barrier damage, gastric acid erosion, self-digestion, and impaired coagulation mechanisms.
5, esophagus – cardia mucosal tear syndrome severe liver disease patients due to violent vomiting or sudden increase in intra-abdominal pressure, resulting in the cardia, distal esophagus mucosa and submucosa tears and complicated by massive bleeding.
In addition, acute gastric mucosal damage, gastric sinusoidal capillary dilation, and ectopic varices are also the etiology of hepatogenic upper gastrointestinal bleeding.
II. Clinical manifestations of hepatogenic upper gastrointestinal bleeding
The clinical manifestations of upper gastrointestinal bleeding mainly depend on the amount and speed of bleeding. The clinical manifestations are vomiting blood and black stool, as well as a series of changes caused by massive blood loss.
1. Vomiting blood and black stool are the characteristic manifestations of upper gastrointestinal bleeding. Vomiting blood is mostly brown and coffee grounds-like, such as a large amount of bleeding, vomiting without adequate mixing of gastric acid, it is bright red or blood clots. Black stool is tarry, thick and shiny. When the bleeding is large and the blood advances quickly in the intestine, the stool may be dark red or even bright red.
The most prominent manifestation of ruptured esophagogastric varices is often vomiting blood. The vomiting blood is often bright red, large in volume, gushing out, or even spraying, and most patients have a feeling of fullness in the epigastrium before vomiting blood. Generally speaking, ruptured esophagus-fundus varices bleeding is more serious than other bleeding, and patients often go into shock quickly.
2, hemorrhagic peripheral circulation failure generally manifests as dizziness, panic, weakness, sudden bleeding may lead to syncope, thirst, cold limbs, rapid heart rate, low blood pressure, etc.. In severe cases, the patient is in shock, with irritability, confusion, pale face, cold extremities, cyanosis, shortness of breath, and decreased blood pressure, which can lead to death if not handled properly. If the urine volume does not increase after the blood volume is replenished, be alert to acute renal failure.
3, anemia after acute massive bleeding are hemorrhagic anemia, after bleeding tissue fluid infiltration into the blood vessels to replenish blood volume, so that blood dilution, generally must be more than 3-4 hours before the hemoglobin drop, 24-72 hours after bleeding blood dilution to the maximum. If the patient is not anemic before bleeding, and the hemoglobin drops to below 70g/L in a short time, it means that the bleeding volume is large, mostly above 1200ml.
4.Fever may appear within 24 hours after massive upper gastrointestinal bleeding with a low fever, usually not exceeding 38.5℃, lasting 3-5 days.
5.Azotemia generally increases in blood urea nitrogen a few hours after bleeding, reaching a peak in about 24-48 hours, mostly not more than 14.3 mmol/L, and decreases to normal after 3-4 days. If the blood volume decreases, the renal blood flow decreases and the glomerular filtration rate decreases, not only the urea nitrogen increases, but also the creatinine increases. If creatinine is more than 133μmol/L and urea nitrogen is more than 14.28mmol/L, it indicates that the bleeding is more than 1000ml.
Estimation of blood loss and shock
The estimation of blood loss is extremely important for further management. Generally, the daily bleeding volume is above 5ml, the color of stool remains unchanged but the occult blood test is positive; black stool appears above 50-100ml. The estimation of blood loss by the amount of vomited blood and fecal blood is often not very accurate, because vomited blood and fecal blood are often mixed with stomach contents and feces respectively, and some blood is still stored in the gastrointestinal tract and not excreted. Therefore, it can be judged according to the change of peripheral circulation due to the decrease of blood volume.
1.The general condition of blood loss is less than 400ml, blood volume is mildly reduced, which can be compensated by tissue fluid and spleen blood storage, and circulating blood volume can be improved within 1 hour, and there can be no conscious symptoms. When symptoms such as dizziness, panic, cold sweat, weakness and dry mouth appear, it means that the blood loss is above 400ml; if there is syncope, wet and cold limbs, little urination and irritability, the blood loss is at least above 1200ml; if bleeding continues, in addition to syncope, there is shortness of breath and no urination, the acute blood loss has reached above 2000ml.
2.Pulse is an important indicator to judge the degree of blood loss. Once the blood loss is too large, the compensatory function of the body is not enough to maintain the effective blood volume, it can enter the state of shock. Therefore, when there is a lot of bleeding, the pulse is fast and weak, and the pulse rate is above 100-120bpm, the blood loss is estimated to be 800-1600ml; when the pulse is fine or even unclear, the blood loss has reached more than 1600ml.
3.Blood pressure The change of blood pressure, like pulse, is a reliable indicator to estimate the amount of blood loss. When the acute blood loss is 800ml or more, the systolic blood pressure can be normal or slightly increased, and the pulse pressure difference is reduced. Although the blood pressure is still normal at this time, but has entered the early stage of shock, should closely observe the dynamic changes in blood pressure. In acute blood loss of 800-1600ml, systolic blood pressure can be reduced to 70-80mmHg; in acute blood loss of 1600ml or more, systolic blood pressure can be reduced to 50-70mmHg. In more severe bleeding, blood pressure can not be measured.
Shock index can also be used to estimate the amount of blood loss, shock index = pulse rate / systolic blood pressure, the normal value of 0.5, indicating normal blood volume. Index = 1 for mild shock, about blood loss 800-1200ml; index > 1 for severe shock, blood loss 1200-2000ml; index > 2 for severe shock, blood loss more than 2000ml.
Fourth, determine whether to continue active bleeding
Clinically, you cannot judge whether bleeding is continuing by hemoglobin drop or tarry stool alone, because there is a certain process of hemoglobin drop after one bleeding. If the bleeding is 1000ml, the tarry stool can last 1-3 days and the occult blood in the stool can last up to 1 week; if the bleeding is 2000ml, the tarry stool can last 4-5 days and the occult blood in the stool can last up to 2 weeks.
The following manifestations should be considered as continuing active bleeding: ① repeated vomiting of blood, increased frequency and volume of black stool, or discharge of dark red or bright red blood stool; ② more fresh blood in the drainage of the gastric tube; ③ within 24 hours after active rehydration and blood transfusion still can not stabilize blood pressure and pulse, the general condition has not improved; or after rapid rehydration and blood transfusion, the central venous pressure is still falling; ④ hemoglobin, red blood cell count and hematocrit (4) Hemoglobin, red blood cell count and hematocrit continue to decrease, and reticulocyte count continues to increase; (5) Bowel sounds are active. This indication is for reference only, as the bowel sounds may also be active when there is blood in the intestine.
If the patient feels better, can sleep peacefully without cold sweat and restlessness, and the pulse and blood pressure return to normal and do not drop any more, the bleeding can be considered to have been reduced, slowed down or even stopped.
V. Emergency treatment of hepatogenic upper gastrointestinal bleeding
The clinical management of hepatogenic upper gastrointestinal bleeding varies according to the speed and amount of bleeding. In the case of chronic or small bleeding, emphasis is placed on etiological treatment, while in the case of acute massive bleeding, the main contradiction is blood loss and insufficient blood volume, the condition is urgent and changes quickly, and serious cases can be life-threatening, so active measures are needed to rescue the patient.
(A) replenish blood volume
1.Immediate establishment of intravenous infusion channel When upper gastrointestinal hemorrhage, blood transfusion and rehydration therapy are crucial, and effective intravenous infusion channel should be established as soon as possible, and it is recommended that all patients with hemorrhage must maintain two large-caliber peripheral or central venous channels.
2.Rehydration principles In case of upper gastrointestinal hemorrhage, blood should be dispensed immediately. In the process of blood distribution, in order to replenish the effective blood volume and maintain the effective peripheral circulation, balanced fluid or isotonic saline can be transfused first. If the blood pressure recovers and can be maintained normally, it indicates that the blood loss is small and no further bleeding has occurred. When there is a lack of blood source, dextrose or other plasma substitutes can be used as a temporary substitute for blood transfusion, but low-molecular dextrose should not exceed 1000ml/d. The amount of rehydration is 1/4-1/3 of the blood volume in moderate shock, and 1/2 of the blood volume in severe shock. when the blood pressure and heart rate are stable, it can be changed to maintenance intravenous rehydration.
3.Transfusion of fresh blood rich in clotting factors is recommended for patients with severe liver disease because clotting factors and platelets can be reduced. Indications for blood transfusion: ① Hemorrhagic shock due to heavy bleeding is an absolute indication for blood transfusion, but generally blood transfusion is not necessary for small bleeding. ②Pulse greater than 120bpm, blood pressure less than 90/60mmHg, hemoglobin <80g/L are the objective indications for transfusion. (③) Those who appear in shock mostly have massive and rapid bleeding, and blood loss of more than 1000ml within a few hours or blood loss of more than 20% of circulating blood volume is an indication for emergency transfusion. A rapid increase in blood pressure may induce rebleeding, because the blood volume in portal hypertension is already about 30% higher than the normal blood volume. Therefore, it is important to avoid excessive transfusion and rehydration, and 2/3-3/4 of the blood loss should be enough to maintain the systolic blood pressure at 100 mmHg.
Whether the blood volume is replenished or not, the following indicators can be referred to: ① pulse rate turns from fast and weak to normal and strong; ② extremities become warm and red; ③ systolic blood pressure is normal or close to normal; ④ pulse pressure difference is more than 30mmHg; ⑤ urine volume is above 25ml/h; ⑤ central venous pressure returns to normal.
(II) Maintain the stability of internal environment
In patients with massive upper gastrointestinal bleeding, while replenishing blood volume, special attention should be paid to maintaining electrolyte and acid-base balance. Patients with massive bleeding and shock often have different degrees of acidosis due to insufficient tissue perfusion and cellular hypoxia. Mild acidosis is often corrected by itself after replenishment of blood volume and improvement of microcirculation, and there is no need to apply alkaline drugs; if alkaline drugs are applied prematurely, it may cause metabolic alkalosis. However, when acidosis is severe, sodium bicarbonate solution should be given according to the degree of acidosis to correct it as appropriate. The dosage of sodium bicarbonate solution can be calculated according to the formula: HCO3- requirement (mmol) = [HCO3-normal value (mmol/L) – HCO3-measurement value (mmol/L)] × body weight (kg) × 0.2. Generally Half of the calculated value will be entered within 2~4 hours, and the arterial blood gas and serum electrolyte concentration will be rechecked after 2~4 hours, and the need for further supplementation will be decided according to the test results
(C) Hemostasis should be taken for different etiologies.
1.Treatment of non-esophageal-fundopalatine variceal rupture bleeding
(1) Histamine H2 receptor antagonist and proton pump inhibitor gastric acid plays an important role in the pathogenesis of upper gastrointestinal bleeding, so inhibiting gastric acid secretion and neutralizing gastric acid can achieve the effect of hemostasis.
(2) Growth inhibitor growth inhibitor can not only inhibit gastric acid secretion, but also inhibit the effect of gastrin and pepsin, and can protect the gastric mucosa with prostaglandin, so it has good effect on hepatogenic upper gastrointestinal bleeding.
(3) norepinephrine gastric bleeding can be used norepinephrine 8mg plus cold saline 100-200ml, perfused through the gastric tube or orally, once every half hour to one hour, if necessary, can be repeated 3-4 times, hemostatic efficiency 80%.
(4) Endoscopic hemostasis
(1) Endoscopic spraying of hemostatic drugs such as Monsell’s solution or norepinephrine directly on the bleeding foci can generally receive immediate hemostatic effect. Monsell’s solution is a kind of alkaline iron sulfate, with strong astringent effect, commonly used concentration is 5%-10%, 50-100ml each time, the hemostatic efficiency is 85%-90%.
② High-frequency electrocoagulation hemostasis: electrocoagulation hemostasis must determine the bleeding vessels before proceeding, and must not be operated blindly. In case of gastric bleeding, the rate of hemostasis is 88% for the first time and 94% for the second application when the stomach is washed with ice water before electrocoagulation. For bleeding fierce esophageal-fundus variceal bleeding, electrocoagulation is not suitable.
③Laser hemostasis: two kinds of laser available for hemostasis are argon laser and garnet laser, the success rate of hemostasis is 80%-90%, the efficacy of which is still controversial for the treatment of esophageal-fundopalatine variceal bleeding.
④Local injection of vasoconstrictor or sclerosing agent: Endoscopically injected with 1/10,000 epinephrine in the submucosa around the bleeding foci to make local vasoconstriction and swelling of surrounding tissues to compress the blood vessels, which plays a temporary hemostatic role. This is followed by local injection of sclerosing agent such as 1% sodium tetradecyl sulfate to occlude the blood vessels. This method can be used for patients who cannot tolerate surgery or for the elderly and frail.
⑤ Placement of suture clips: Suture clips are placed under direct endoscopic view to stop bleeding vessels by suture clips. This method is safe, easy and effective, and can be used for peptic ulcer or stress ulcer bleeding, especially for small arterial bleeding with more satisfactory results.
(6) Intra-arterial infusion of vasoconstrictors or artificial embolus: via selective angiographic catheter, intra-arterial infusion of pituitary pressor 0.1-0.2 U/min for 20 min, and if bleeding still continues, the concentration is increased to 0.4 U/min, and the amount is reduced 8-24 h after hemostasis. Injecting artificial bolus is usually done with gelatin sponge, so that the bleeding blood vessel is blocked and the bleeding is stopped.
2.The treatment of ruptured esophagus-fundus variceal bleeding includes drugs and balloon filling to stop bleeding, and the drugs mainly include vasopressin and its derivatives, growth inhibitor and its analogues, etc.
(1) Vasopressin and its derivatives are effective for medium and small bleeding, and balloon tamponade is needed for large bleeding. The combination of nitroglycerin and vasopressin can improve the efficacy and reduce the occurrence of vascular side effects. Terlipressin is a synthetic vasopressin analogue with fewer side effects and a longer half-life than vasopressin, so it can be administered intermittently.
(2) Growth inhibitor and its analogues can stop varicose vein bleeding in 80% of patients, and growth inhibitor and its analogues oxytocin are administered intravenously. The method of administration: growth inhibitor is given as a loading dose of 250μg intravenously and then immediately administered intravenously at a rate of 250μg/h for 18-72h; octreotide is given as 100μg intravenously for the first time and then 25μg/h intravenously for 72h.
(3) Balloon tamponade is generally used to stop bleeding in the fundus of the stomach and the middle and lower esophagus with a three-lumen two-bladder tube or a four-lumen two-bladder tube. Among them, the four-lumen two-bladder tube has a proprietary lumen for aspiration of secretions above the esophageal bursa to reduce the occurrence of aspiration pneumonia. The pressure of the esophageal sac and gastric sac after gas injection is required to be 35-40 mmHg, and the initial pressure can be maintained for 12-24 hours, after which the air is deflated every 4-6 hours, depending on the degree of bleeding activity for 5-30 minutes each time, and then re-injected to prevent ischemic necrosis of the mucosa from being pressurized for too long. In addition, the gastric lumen tube should be flushed with water every 1-2 hours to avoid blockage of the hole by blood clots, which may affect the use of the gastric lumen tube. After 24 hours of hemostasis, the tube should be deflated and observed for 1-2 days before extraction. The effect of balloon tamponade is better for medium and small amount of esophagogastric-fundus variceal bleeding, and the efficiency of hemostasis for large bleeding varies from 40% to 90%.
(iv) Surgical treatment
In upper gastrointestinal hemorrhage, emergency surgery often has higher complication and death rate than elective surgery, so internal hemostasis treatment is taken first as far as possible, and only when internal hemostasis treatment is ineffective and the bleeding site is clear, surgical treatment is considered to stop the bleeding. At present, non-shunt peripancreatic vascular dissection is mostly used clinically, while shunt decompression of the portal system has been used less clinically due to the higher incidence of postoperative portal-body shunt encephalopathy.
(V) Interventional treatment
For some severe upper gastrointestinal hemorrhage, when medical treatment fails and surgery is not tolerated, selective angiography can be considered to find the bleeding lesion and perform vascular embolization at the same time.