Πρώτη ενότητα: Ενδοσκοπική θεραπεία
The principles of treatment for gastrointestinal hemorrhage are: rapidly stabilize the vital signs of the child; evaluate the severity of hemorrhage; determine the bleeding focus; clarify the cause of hemorrhage, treat according to the cause; formulate special treatment methods; surgical treatment.
1Rapidly stabilize the vital signs of the child
(1General emergency measures:
① Absolute bed rest: Lie on the side with the pillow removed, keeping the respiratory tract unobstructed. Avoid inhaling blood into the trachea during vomiting to cause asphyxia, and maintain tranquility.
② No food: The time of fasting should be until the bleeding stops24h.
③ Oxygen therapy: After massive hemorrhage, blood pressure decreases, hemoglobin levels decrease, and its oxygen-carrying function decreases. Oxygen therapy is provided to ensure oxygen supply to vital organs in the body under anemia conditions.
④ Strictly observe the condition: Observe the patient's pulse, blood pressure, respiration, body temperature, urine output, mental state changes, limb temperature, skin and nail bed color, peripheral venous filling; the amount and color of hematemesis and black stools; if necessary, central venous pressure measurement: the normal value is 0.59～1.18kPa（6～12cmH2O), below normal indicates insufficient blood volume, above normal indicates excessive fluid volume, heart failure; determine blood routine, red blood cell hematocrit, coagulation time, thrombin, and prothrombin time; liver and kidney function, blood electrolyte determination.
(2Actively replenish blood volume: In cases of active massive hemorrhage, blood transfusion or intravenous fluid replacement should be given quickly to maintain blood volume. Generally, according to the estimated amount of hemorrhage, physiological saline or5％glucose saline20ml/kg. Simple crystalloid solutions are quickly transferred to the extracellular space, so it is advisable to use colloidal solutions in moderation. Such as whole blood, plasma, or dextran, commonly used is medium molecular weight dextran, which can increase osmotic pressure, expand blood volume, and have a relatively long-lasting effect, each time15～20ml/kg.
Indications for blood transfusion: ① Heart rate〉110/min; ② Red blood cells〈3×1012/L; ③ Hemoglobin〈70g/L; ④ Systolic blood pressure〈12kPa（90mmHg). Patients with liver cirrhosis should receive fresh blood, as stored blood contains a high nitrogen content, which can induce hepatic encephalopathy. In patients with portal hypertension, prevent excessive and rapid blood transfusion to increase portal vein pressure and trigger rebleeding. The amount of blood transfusion and fluid infusion should not be excessive, and it is best to adjust the infusion rate and amount according to the central venous pressure (CVP). CVP can reflect blood volume and right heart function, CVP〈0.49kPa（〈5cmh2ocvp=""0=""98kpa=""10cmh2o=""〉30ml/h, indicating that the intake of fluid has basically been met.
2, and evaluate the severity of hemorrhage
(1Mild hemorrhage: hemorrhage volume reaches10％～15%, heart rate, blood pressure, hemoglobin, and red blood cell count and hematocrit are normal. It can also be manifested by increased pulse, slightly cool extremities, decreased blood pressure, and decreased pulse pressure.
(2Moderate hemorrhage: hemorrhage volume accounts for20%, expressed as thirst, significantly accelerated pulse, cool extremities, oliguria, decreased blood pressure, and decreased pulse pressure. From lying to sitting, pulse rate increases ≥20/min, blood pressure decreases ≥10mmHg, with urgent indications for blood transfusion.
(3Severe hemorrhage: hemorrhage volume accounts for30% to40%, expressed as thirst, irritability, gray complexion, cold extremities, cyanosis, skin mottling, fine and rapid pulse, marked oliguria, and decreased blood pressure. Hemoglobin is below70g/L, red blood cell count below3×1012/L, red blood cell volume below30%.
3、Determine the bleeding focus
According to the medical history, clinical manifestations, signs, auxiliary examinations can estimate the bleeding site, such as hematemesis with jaundice, spider veins, splenomegaly, abdominal wall varices and ascites, abnormal liver function, electrophoresis showing λ-globulin significantly increased, sodium sulfobromophthalein test and indocyanine green test results are fast, consider esophageal and gastric variceal rupture bleeding, gastroscopy can make an accurate diagnosis.
4、Determine the cause of bleeding, treat the disease according to the cause
Those with clear etiology should receive etiological treatment in a timely manner. If the gastrointestinal mucosal lesions are caused by drugs, the drugs should be discontinued promptly; vitamin K deficiency bleeding should be supplemented with vitamin K; if there are conditions such as portal hypertension, ulcer disease with perforation, etc., early surgical treatment should be performed; hemostatic drugs correcting the hemostatic and coagulation disorders in the blood system should be given, such as batroxil, lyophilized thrombin complex.
5、Develop special treatment methods
Gastrointestinal bleeding is divided into two types: non-variceal bleeding and variceal bleeding. Different treatment methods are adopted according to different types.
(1）Non-vascular source gastrointestinal bleeding (ulcerative bleeding):
①Inhibition of gastric acid secretion: If children only have bleeding without hemodynamic changes and the bleeding can stop spontaneously, it is only necessary to provide acid-suppressing drugs. The hemostatic effect induced by body fluids and platelets only occurs when pH>6.0 at 0 o'clock to be effective, therefore, by neutralizing gastric acid, reducing the inhibitory effect of gastric acid on platelet hemostasis, it can effectively control the bleeding of peptic ulcers. In addition, controlling the acidity of gastric juice can reduce the backdiffusion of hydrogen ions and inhibit the activity of pepsin, reducing the damage to the gastric mucosa. Clinically, H2Receptor antagonists such as cimetidine (Tagamet), daily25～30mg/kg, initially intravenous infusion2times/d,2～3Day, after the condition is stable, change to oral medication, continuous ulcer disease for6Week, erosive gastritis4Week, the ulcer hemostasis rate reaches86％～90%, the effective rate of hemostasis for stress ulcers and gastric mucosal erosion is75%; or ranitidine daily6～7.5mg/kg, famotidine 0.0mg8～1.0mg/kg. Proton pump inhibitors such as omeprazole 0.0mg daily8～1mg/kg, intravenous injection; or 0.6～0.8mg/kg, taken in the morning in one dose, course of treatment4Week.
②Endoscopic treatment: When children have acute, persistent or recurrent bleeding, there are hemodynamic changes, and the cause is unknown, endoscopic treatment should be performed.
A、Indications: Active bleeding in ulcer focus, blood clots adherent or exposed vessels; if the ulcer base is clean and the blood crust flat, there is no need for urgent endoscopic treatment.
B、Method: Local spraying of hemostatic drugs, local injection, electrocoagulation and thermal coagulation for hemostasis. Local spraying of norepinephrine, the mechanism is to cause local vessel wall spasm, vasoconstriction around the bleeding surface, and to promote blood coagulation; injection treatment is through paravenous injection of epinephrine or sclerosing agent, causing tissue edema, compressing bleeding vessels for hemostasis; the principle of thermal coagulation for hemostasis is to utilize the generated heat to coagulate tissue proteins for hemostasis. In addition, there are laser photocoagulation and microwave hemostasis.
③Vascular embolization therapy: after selective angiography is confirmed, catheters can be infused with artificial emboli through arteries to embolize blood vessels to achieve hemostasis, for example, for duodenal ulcer bleeding, embolizing the superior mesenteric artery is often effective in stopping bleeding, with a hemostasis success rate of65％～75％. However, arterial embolization for hemostasis sometimes can cause serious consequences such as infarction and necrosis of the organ supplied, so it should be strictly controlled for indications.
(2）Vasogenic gastrointestinal bleeding:
①Drugs: drugs that reduce portal pressure reduce portal pressure, reduce blood flow to the bleeding site, create good conditions for coagulation and stop bleeding. The main drugs that reduce portal pressure are mainly divided into two categories:
A、Vasopressor drugs:
a、Vasopressin (antidiuretic hormone) and its derivatives: can constrict the pre-capillary sphincters of the small visceral arteries and capillaries, reduce visceral blood flow, thereby reducing the pressure of the portal venous system and the pressure of varicose veins; used for portal hypertension, esophageal and gastric variceal rupture bleeding. The commonly used dose for adults is 0.2U/min, intravenous infusion, if ineffective, increase to 0.4～0.6U/min, the dose exceeds 0.8U/min, the efficacy no longer increases and adverse reactions increase accordingly. Generally, it is not necessary to use a first dose, after hemostasis with 0.1U/min maintenance12h after discontinuation of medication. Adverse reactions include: increased blood pressure, angina, arrhythmias, abdominal pain, vomiting, frequent defecation, even complications of intestinal ischemia and necrosis, aggravating liver and kidney function damage, etc. To reduce adverse reactions, it can be used in combination with nitroglycerin.
b、Somatostatin and its derivatives: have inhibitory effects on the secretion of gastric acid and pepsin, reduce the blood flow of the main portal vein, and protect gastric mucosal cells. For upper gastrointestinal bleeding, especially for esophageal variceal rupture bleeding, it is an effective and safe drug. Commonly used are2types, somatostatin (施他宁)5？g/kg+saline5ml, intravenous slow push3～5min, immediately with5？g/（kg·h）at a continuous intravenous infusion rate (adult3000？g+5％glucose500ml intravenous infusion to maintain12h), after hemostasis should continue treatment24～48h, to prevent rebleeding; adult octreotide, 0.1mg/times, intravenous or subcutaneous injection,3times/d, or 0.1mg initial intravenous push, then 0.3mg intravenous infusion,25？g/h, maintain12h. Dosage per body weight for children. Adverse reactions: mild, occasionally palpitations, dizziness, nausea, increased frequency of bowel movements, etc., symptoms disappear after slowing down or stopping the injection rate.
B、Vasodilators:
a、Nitroglycerin: usually used in combination with posterior pituitary extract, it can dilate arteries and veins, reduce the anterior and posterior load of the heart, reduce portal blood flow, and decrease portal pressure.
b、Phentolamine: an α-adrenergic receptor antagonist, it can directly act on the α-adrenergic receptors of the portal vein vascular system of the liver.1Receptors, causing portal vein vasodilation and a decrease in portal pressure.
②Endoscopic treatment: includes sclerotherapy and endoscopic variceal ligation (EVL).
A、硬化剂治疗：是目前已建立的最好的治疗食管静脉曲张破裂出血治疗方法，该方法的安全性及有效性已被证实，且费用低廉，适用范围广，操作简单。它通过经静脉内或静脉旁注入硬化剂或血管收缩剂，使组织发生水肿、压迫出血血管，导致血管壁增厚，周围组织凝固坏死及曲张静脉栓塞、纤维组织增生而止血。目前常用的硬化剂有：5％鱼肝油酸钠、1％～2％乙氧硬化醇、无水乙醇等。并发症：胸痛、低热、注射部位出血、食管溃疡、食管狭窄等。
B、静脉曲张套扎术：是用于治疗食管静脉曲张的新型内镜治疗方法。这种技术与痔的结扎方法相似。操作时，将曲张静脉吸入内镜前端弹性带装置内，通过活检通道拉紧绊线，将系带拉脱结扎于曲张静脉根部。优点。并发症少、使曲张静脉消失所需的治疗次数少。缺点：操作繁琐且不易掌握。
③三腔双囊管压迫止血：是目前治疗食管、胃底静脉曲张破裂出血最有效的止血方法之一，主要用于内科药物治疗失败或无手术指征者。通常在放置三腔双囊管后48h内行静脉套扎或硬化剂治疗。并发症有吸入性肺炎，甚至食管破裂、窒息。
6、外科手术
消化道出血的患儿。应尽可能采用保守治疗。手术治疗至少需大致确定出血部位。以确定手术途径。紧急手术病死率高，必须慎重。指征为：
(1）经内科药物治疗、内镜治疗24h出血不止者。
(2）呕血或便血较重，同时伴低血压再出血者。
(3）出血量较多达血容量25％以上，内科综合抢救措施无效时。
(4Νεκρωτική του γαστρεντερικού, διάτρηση, σπαστική εμμηχάνωση, επαναλαμβανόμενη ανωμαλία και Meckel's diverticulum.
Δεύτερος τμήμας, πρόγνωση
Η επαναλαμβανόμενη αιμορραγία του γαστρεντερικού επηρεάζει συχνά την ανάπτυξη και την ανάπτυξη των παιδιών, και η πρόγνωση είναι καλή όταν οι αιτίες μπορούν να αφαιρεθούν έγκαιρα; Αν η αιτία είναι η ασθένεια του αίματος (λευχαιμία, κακοήθης αναιμία ή DIC), η πρόγνωση εξαρτάται από την πορεία της αρχικής ασθένειας.
