How to choose medicine for acute upper gastrointestinal bleeding?

Only for medical professionals to read for reference acid inhibitor + somatostatin or vasopressin + blood volume supplement
.

Acute upper gastrointestinal bleeding refers to bleeding caused by lesions of the digestive tract above the ligament of flexion, including the esophagus, stomach, duodenum, bile duct, and pancreatic duct
.

According to the cause of bleeding, it can be divided into non-varices bleeding and varicose bleeding.
Most of the acute upper gastrointestinal bleeding is non-varices bleeding
.

Acute non-varices upper gastrointestinal bleeding is mostly caused by upper gastrointestinal lesions, and a few are caused by biliary and pancreatic diseases, including peptic ulcer, acute and chronic gastric mucosal injury, esophageal and cardia mucosal tear syndrome, upper gastrointestinal malignant tumors Etc.
common
.

Bleeding from esophagus and gastric fundus varices is a common complication in patients with decompensated liver cirrhosis
.

So, how to treat patients with acute upper gastrointestinal bleeding? Drug therapy is still the first choice for the treatment of acute upper gastrointestinal bleeding
.

The drug treatment of acute upper gastrointestinal bleeding includes acid inhibitors, somatostatin, vasopressin and blood volume supplementation
.

Antibiotics should be used prophylactically for patients with liver cirrhosis and portal hypertension with rupture of esophagus and gastric varices
.

1.
Drug treatment methods ▎Acid inhibitors commonly used drugs: acid inhibitors include proton pump inhibitors (PPI, such as esomeprazole, omeprazole, pantoprazole, lansoprazole, rabeprazole, Ilaprazole, etc.
), H2 receptor antagonists (H2RA, such as ranitidine, famotidine, etc.
)
.

Among them, the effect of PPI on acid suppression and hemostasis is better than that of H2RA.
PPI has a faster onset and can significantly reduce the incidence of rebleeding.
Therefore, it is recommended that critically ill patients use PPI for acid suppression treatment as soon as possible
.

Mechanism of action: The acid suppressor increases the pH value in the stomach by inhibiting the secretion of gastric acid to make the pH value>6.
At the same time, it can inhibit the activation of pepsin, promote platelet aggregation and the formation of fibrin clots, and avoid premature dissolution of blood clots.
It is beneficial to stop bleeding and prevent rebleeding, and can be used to treat peptic ulcers
.

Adverse reactions: The general adverse reactions of PPI are nausea, gastrointestinal flatulence, diarrhea, abdominal pain, constipation, dry mouth, headache, dizziness, blurred vision, liver dysfunction, etc.
, usually mild and self-limiting
.

▎ somatostatin and the like commonly used drugs: somatostatin and its analogues, such as somatostatin, octreotide
.

Clinically, it can be used for acute esophageal and gastric fundus varices bleeding, acute non-varices bleeding, acute upper gastrointestinal bleeding and so on in liver cirrhosis
.

The combination regimen for severe acute upper gastrointestinal bleeding is intravenous somatostatin + PPI
.

This program can quickly control the upper gastrointestinal bleeding caused by most different causes, and minimize the incidence of serious complications and mortality
.

After the first intravenous bolus of 50μg of octapeptide somatostatin, it was followed by continuous intravenous infusion of 50μg/hour; after the first intravenous bolus of 250μg of myristin somatostatin, followed by continuous intravenous infusion of 250μg/hour, it could be increased to 500μg/hour intravenous drip
.

Somatostatin and its analogs can be used continuously for 5 days or more
.

Mechanism of action: Somatostatin and its analogs can reduce visceral blood flow, reduce portal pressure, inhibit angiogenesis and secretion of gastric acid and pepsin, and inhibit the secretion of gastrointestinal and pancreatic peptide hormones, which can significantly reduce peptic ulcer bleeding The surgical rate of patients, prevent the occurrence of early rebleeding, and effectively prevent the increase of hepatic vein pressure gradient after endoscopic treatment
.

Adverse reactions: The main adverse reactions of somatostatin and its analogues are nausea, dizziness, and facial flushing, especially when the injection speed is fast, the patient may have nausea and vomiting
.

▎ Vasopressin and similar drugs commonly used: such as pituitrin, vasopressin, terlipressin, etc.
, which can reduce portal pressure, and are used to treat liver cirrhosis, portal hypertension, esophagus and gastric variceal bleeding
.

Continuous intravenous infusion of vasopressin 0.
2 to 0.
4 U/min, the maximum dose can be increased to 0.
8 U/min
.

N-α-Triglycyl-8-lysine-vasopressin (terlipressin) method of use: the first dose of 2 mg intravenous bolus, and then 2 mg once every 4 hours
.

If bleeding is controlled, the dose can be gradually reduced to 1 mg once every 4 hours to maintain
.

Mechanism of action: Vasopressin is a visceral vasoconstrictor, which can reduce the blood flow of internal organs, resulting in a decrease in portal blood flow into the liver and lower portal pressure.
Because of the higher incidence of cardiac and cerebrovascular complications, it is recommended to combine with nitric acid The combination of ester drugs such as nitroglycerin can further reduce portal blood flow and portal pressure, and at the same time reduce the adverse effects of vasopressin, and the continuous high-dose vasopressin intravenous use should not exceed 24 hours
.

Terlipressin is a synthetic vasopressin analogue, which can effectively reduce hepatic vein pressure gradient and portal vein blood flow for a long time, and has little effect on systemic hemodynamics
.

Adverse reactions: The main adverse reactions of vasopressin and its analogs include ischemia of the heart and peripheral organs, arrhythmia, hypertension, and intestinal ischemia
.

▎Replenish blood volume Hemodynamically unstable acute upper gastrointestinal hemorrhage should be resuscitated in time to restore and maintain vital organ perfusion
.

Patients with massive blood loss need appropriate infusion of blood products to ensure tissue oxygen supply and maintain normal coagulation function
.

Blood transfusion should be considered in the following situations: systolic blood pressure <90mmHg; heart rate>110 beats/min; Hb<70g/L; hematocrit (Hct)<25% or hemorrhagic shock
.

After active volume resuscitation, persistent hypotension still exists.
In order to ensure the minimum effective perfusion of vital organs, vasoactive drugs can be used
.

▎Prophylactic use of antibiotics for patients with cirrhosis, portal hypertension and rupture of esophagus and gastric varices.
Preventive application of antibiotics can significantly improve the prognosis.
Therefore, for patients with cirrhosis and portal hypertension and rupture of esophagus and gastric varices, antibiotics should be used preventively
.

The risk of infection in patients with liver cirrhosis, portal hypertension, rupture of esophagus and gastric varices and bleeding can be assessed by Child-Pugh classification
.

The higher the Child-Pugh classification, the higher the risk of infection
.

Child-Pugh A patients who abuse or drink alcohol are also at high risk of infection after bleeding from esophageal and gastric varices
.

For patients with cirrhosis and portal hypertension, rupture of esophagus and gastric varices, prophylactic administration of antibiotics can help stop bleeding, reduce the occurrence of rebleeding and infection, and the 30-day mortality rate is also lower
.

Antibiotics should be selected reasonably according to the resistance of local bacteria
.

The results of a randomized controlled trial showed that intravenous ceftriaxone is more effective in preventing bacterial infections than oral norfloxacin in patients with esophageal and gastric varices bleeding from cirrhosis and portal hypertension.
A controlled study found that there was no significant difference in the effect of ceftriaxone between 3 days and 7 days
.

2.
Classical prescription analysis ■ Prescription 1 octreotide acetate 0.
1mg for injection, 500ml 5% glucose injection for intravenous injection, 0.
6mg octreotide acetate for injection, usage: 0.
025mg/hour intravenous pump injection of 0.
9% sodium chloride injection 100ml, for injection Pantoprazole 40mg, usage: intravenous drip once every 12 hours Indications: patients with peptic ulcer and acute upper gastrointestinal bleeding
.

Medication analysis: Peptic ulcer bleeding is the most important cause of acute non-varices upper gastrointestinal bleeding in China, and its mechanism is caused by the invasion and rupture of the ulcer base or marginal blood vessels
.

Octreotide is a derivative of somatostatin.
After octreotide injection, it can inhibit the release of gastrointestinal hormones and neurotransmitters, reduce the secretion of gastric acid and gastrin, thereby improving the pH of the upper digestive bleeding site, and is beneficial to the intestinal wall mucosal injury site The secretion of vasoactive peptides reduces the visceral arterial blood flow and exerts the hemostasis effect of the upper gastrointestinal tract
.

Pantoprazole is a proton pump inhibitor.
It has a strong inhibitory effect on acid.
It can not only inhibit the secretion of gastric acid caused by choline, histamine, and gastrin, but also inhibit the basic secretion of gastric acid, and it has the ability to keep the pH at a lower level.
The effect of increasing to above 6 in a short period of time maintains the pH level of gastric juice at a level conducive to blood clotting
.

Pantoprazole can inactivate gastric protein after increasing the pH value of gastric juice, enhance the protective effect of gastric mucosa, enhance the healing speed of peptic ulcer, and can inhibit the activity of Helicobacter pylori and accelerate peptic ulcer Healing
.

The combination of octreotide and pantoprazole can play a synergistic effect, and has a significant effect on the treatment of peptic ulcer and acute upper gastrointestinal bleeding
.

■ Prescription 20.
9% sodium chloride injection 15ml, thrombin freeze-dried powder 2000IU, usage: gastric tube perfusion or oral administration once every 4 hours 0.
9% sodium chloride injection 100ml, injection 30mg lansoprazole, usage: intravenous Infusion every 12 hours.
Indications: patients with acute gastric mucosal disease and acute upper gastrointestinal bleeding
.

Medication analysis: Patients with major surgery, severe shock, burns, brain injury or other serious systemic diseases are prone to acute gastric mucosal lesions, with edema, hemorrhagic, congestive superficial erosions and ulcers as the main clinical manifestations.
Also known as stress ulcer
.

Lansoprazole is a proton pump inhibitor.
It is the drug of choice for the treatment of acute gastric mucosal lesions.
It has the characteristics of continuous administration, long-lasting efficacy, and strong specificity.
It can produce pH in the stomach within 3 to 5 hours of administration.
Effective control
.

It also stimulates gastric antrum G cells, releases a large amount of gastrin, improves gastric mucosal blood circulation, provides nutrition for gastrointestinal cells, improves gastric mucosal points, stabilizes gastric mucosal cells, and makes gastric mucosal better Repair and heal
.

Thrombin is a serine protease with good anticoagulant and procoagulant properties.
It can promote the conversion of fibrinogen to fibrin and quickly form a stable clot on the surface of the lesion.
It can also promote the rapid aggregation of platelets and further exert local hemostatic effects.

.

There are few adverse reactions of thrombin.
Currently, only allergic reactions have been reported, and allergic reactions can be avoided through allergy tests.
Therefore, thrombin has high safety
.

Lansoprazole combined with thrombin can play a synergistic effect, and has a significant effect on the treatment of acute gastric mucosal lesions and acute upper gastrointestinal bleeding
.

■ Prescription 3 0.
1mg of octreotide acetate for injection, 500ml of 5% glucose injection for intravenous injection, 0.
6mg of octreotide acetate for injection, usage: 0.
025mg/hour intravenous pump injection of 0.
9% sodium chloride injection 15ml, thrombin freeze-dried powder 2000IU, Usage: gastric tube perfusion or oral administration once every 4 hours.
Indications: patients with liver cirrhosis and portal hypertension, esophagus and gastric varices rupture and bleeding
.

Drug analysis: Octreotide is a synthetic octapeptide cyclic compound, which has a similar effect to natural endogenous somatostatin, but it has a strong and long-lasting effect.
Its half-life is 30 times longer than that of natural somatostatin, and it is well tolerated.

.

Octreotide can selectively reduce the blood flow and pressure of the portal vein and collateral circulation, and reduce the pressure of the esophageal and gastric varices; it can inhibit the secretion of gastric acid and pepsin, protect the gastric mucosa, and promote the repair of the gastric mucosa, thereby effectively treating the upper digestive tract Bleeding
.

Octreotide is administered by intravenous injection, which has the characteristics of long-lasting efficacy, quick effect, and complete absorption.
It has fewer adverse reactions, such as nausea, vomiting and other adverse digestive reactions.
It usually does not affect the treatment and has high safety
.

Octreotide combined with thrombin can exert a synergistic effect of drugs.
Octreotide can reduce portal pressure, inhibit the secretion of gastric acid and pepsin, while thrombin can exert coagulation function, induce platelet aggregation, etc.
, thereby further improving the hemostatic effect
.

Octreotide combined with thrombin in the treatment of hemorrhage from esophageal and gastric varices of cirrhosis and portal hypertension can effectively stop bleeding, reduce blood transfusion, shorten bleeding and hospital stay, and have high safety
.

Reference materials: [1] The Emergency Physician Branch of the Chinese Medical Doctor Association, the Emergency Medicine Branch of the Chinese Medical Association, the Military Emergency Medicine Professional Committee, etc.
Expert consensus on the emergency diagnosis and treatment process of acute upper gastrointestinal bleeding (2020 edition) [J].
Chinese Emergency Medicine Journal, 2021, 30(1): 15-24.
[2] "Chinese Journal of Internal Medicine" editorial board, "Chinese Medical Journal" editorial board, "Chinese Journal of Digestion" editorial board, etc.
.
Acute non-varices upper gastrointestinal tract Guidelines for Diagnosis and Treatment of Bleeding (2018, Hangzhou)[J].
Chinese Journal of Internal Medicine, 2019, 58(3): 173-180.
[3] "Chinese Journal of Digestive Surgery" Editorial Board, "Chinese Journal of Digestive Surgery" Editorial Board.
Acute Expert consensus on multidisciplinary prevention and treatment of varicose upper gastrointestinal bleeding (2019 edition)[J].
Chinese Journal of Digestive Surgery, 2019, 18(12): 1094-1100.
[4] Chinese Medical Association Hepatology Branch.
Guidelines for Diagnosis and Treatment of Liver Cirrhosis [J].
Chinese Journal of Liver Diseases, 2019, 27(11): 846-865.
[5] Spleen and Portal Hypertension Surgery Group, Chinese Medical Association Surgery Branch.
Hemorrhage from esophageal and gastric varices in cirrhosis and portal hypertension Expert consensus on diagnosis and treatment (2019 edition)[J].
Chinese Journal of Surgery, 2019, 57(12): 885-892.
[6] National Health Commission of the People’s Republic of China.
Guidelines for the clinical application of proton pump inhibitors (2020 edition)[ J].
Chinese Journal of Practical Rural Doctors, 2021, 28(1): 1-9.
[7] Chinese Pharmaceutical Association Hospital Pharmacy Professional Committee, Chinese Medical Association Clinical Pharmacy Branch, Expert Consensus of Proton Pump Inhibitor Optimization Application Writing Group.
Expert consensus on the optimal application of proton pump inhibitors[J].
Chinese Journal of Hospital Pharmacy, 2020, 40(21): 2195-2213.
[8] Chen Yong, Xie Xiaoyu.
Lansoprazole in the treatment of neurosurgery critically ill patients with acute gastric mucosa Observation of the clinical effect of disease (AGML)[J].
Modern Diagnosis and Treatment, 2020, 31(15): 2393-2395.
[9] Zhang Qiong, Zhang Yongli.
Octreotide combined with pantoprazole in the treatment of peptic ulcer combined with upper gastrointestinal tract Bleeding[J].
Thrombosis and Hemostasis, 2020, 26(4): 646-648.
[10] Zou Rong.
Therapeutic effect and clinical value of octreotide combined with thrombin in the treatment of liver cirrhosis with upper gastrointestinal bleeding[J].
Capital Food and Medicine, 2021, 28(2): 63-64.
[11] Li Qianjun, Pan Feng, Feng Yanling, etc.
Evaluation of the efficacy of octreotide combined with thrombin in the treatment of patients with liver cirrhosis and upper gastrointestinal bleeding[J].
China Practical Medicine, 2020, 15(30): 136-138.