CC BY
4ENDOSCOPIC METHODS OF HEMOSTASIS AND SURGICAL TACTICS FOR ULCERATIVE GASTRODUODENAL BLEEDING IN THE ELDERLY (LITERATURE REVIEW)
1Abdullajanov B.R., 2Botirov A.K., 3Akhmadbekov B.O., 4Bozorov N.E., 5Khamidov F.Sh.
1,2,3,4,5Andijan State Medical Institute https://doi org/10.5281/zenodo. 12730943
Abstract. The authors report that currently the choice of treatment methodfor patients with Ulcerative gastroduodenal bleeding, incl. in old age is one of the most difficult issues in emergency surgery. However, despite significant advances, methods of endoscopic hemostasis are marred by recurrent bleeding, which forces a "desperate" operation, accompanied by high mortality.
The authors conclude that further improvement of the algorithm of actions, taking into account the characteristics of the typology of ulcers ("old" or "senile"), as well as surgical techniques, can optimize surgical tactics and improve the results of surgical treatment.
Keywords: ulcerative gastroduodenal bleeding, recurrent bleeding, endoscopic hemostasis, old age.
Endoscopic methods of hemostasis. Today, there are many methods of endoscopic and pharmacological influence both on the source of bleeding and on the reparative processes of the affected areas of the gastrointestinal mucosa [20;35;37;49;60].
The most commonly used methods of endoscopic hemostasis are: 1) thermal: electrocoagulation, thermocautery, laser photocoagulation, argon plasma coagulation (due to thrombosis of the vessel in the bleeding area); 2) injection: adrenaline; alcohol, sclerosants; cyanoacrylates, thrombin, fibrin glue; 3) mechanical: clipping, ligation. Therapeutic endoscopy for DU allows temporary or final hemostasis, as well as monitoring and repeated hemostasis in case of recurrent bleeding [20;35;37]. Of the physical methods, diathermocoagulation is most often used [35;37]. Laser photocoagulation has given way to similar in efficiency, but significantly less expensive and cumbersome methods of endoscopic hemostasis [49]. One of the competitive advantages of laser photocoagulation is the use of argon plasma coagulation [38]. As an addition or as an independent method of stopping bleeding, the so-called injection method has not lost its position [66]. Today, more and more clinicians adhere to the tactics of combined use of hemostasis methods.
The use of EndoClot in combination with traditional methods of endoscopic hemostasis can increase the success rate of primary hemostasis in 97.1% of patients [51;65]. Quite a large number of publications refer to the use of cyanoacrylate spray [68]. The combined use of hemostatic agents and granular sorbent in the treatment of ulcerative dysplasia is the subject of the work of M.N. Romantsova (2018). Summarizing all of the above methods, we can say that additional research is needed to determine the optimal treatment method for patients with severe bleeding [8;59]. It should be noted that in recent years, on the basis of the experimental department of the Republican Specialized Center for Surgery named after Academician V. Vakhidov, the domestic drug "Geprocel" has been introduced into the clinical practice of this center and the Andijan State Medical Institute [1;15;28;42].
Endoscopic hemostasis methods, despite their pronounced effect, are not able to reliably and over a long period of time prevent the development of recurrent bleeding. In this regard, the latter should be considered as temporary and used to fully prepare the patient for the upcoming surgical intervention [16].
The goals of early endoscopy are to determine the source of bleeding, prognosis, and provide endoscopic treatment when indicated. Treatment recommendations concern primarily the first 72 hours after admission [29]. Hemostatic therapy for DU includes local use of aminocaproic or tranexamic acid inhibitors and parenteral administration of the thromboplastin activator ethamsylate [4]. Eradication of Helicobacter pylori is a key point in preventing recurrence of gastroduodenal ulcer bleeding [12]. There are also studies in which long-term intravenous H2-blockers were associated with an increase in rebleeding [55]. Post-endoscopic management of patients with gastroduodenal ulcer bleeding also depends on the result of endoscopy [69]. If stable hemostasis is not obtained during endoscopy, emergency surgery is required.
There are clinical and endoscopic criteria for threatening recurrent bleeding. Clinical criteria include: 1) severe blood loss; 2) age over 65 years; 3) result on the APACHE III scale > 85 points, on the APACHE II scale > 11 points. Endoscopic criteria include: bleeding according to Forrest Ia, Ib, IIa; callous and penetrating ulcers; ulcer of the posterior wall of the duodenum. There is evidence that recurrent bleeding in 97% of cases develops within 72 hours after its first episode. In patients with a clean bottom of the ulcer after bleeding, recurrence of the latter is possible in 5-7% of cases, and postoperative mortality does not exceed 2%. When an ulcer is filled with blood clots, recurrent bleeding can be expected in 20% of patients, and mortality after emergency surgery reaches 5-7%. In the case of a large thrombosed vessel at the bottom of the ulcer, rebleeding occurs in 40% of patients, and postoperative mortality exceeds 10%. With ongoing jet bleeding or leakage of blood from under a clot, which can be stopped during gastroduodenoscopy, recurrent bleeding develops in 50% of patients, and postoperative mortality exceeds 15%. If there is an effect from conservative and endoscopic methods of hemostasis, but there is a high risk of recurrent bleeding, urgent surgery is performed within 12-24 hours from admission. For elderly patients with a high degree of surgical risk, as well as for bleeding from acute ulcers, excision and suturing of the bleeding ulcer are used. After stitching a chronic ulcer, in half of the cases recurrent bleeding occurs with a probability of death of 60-70%. In other cases, radical organ-preserving or respective interventions are indicated [24].
When diagnosing signs of unstable hemostasis in 70% of patients, early relapse of bleeding occurs within the next 12-48 hours [32]. The main risk factors are age over 60 years, hemorrhagic shock upon admission, severe concomitant pathology, location of the ulcer in the lesser curvature of the stomach or the posterior wall of the duodenum [48;52].
The main drawback of the proposed attempts at prognosis is the lack of clear standardization of data, taking into account, as a rule, only clinical, or only endoscopic, or laboratory data. In determining surgical tactics in the treatment of a patient with ulcerative hyperplasia, the leading place is occupied by a mathematical model for predicting recurrent bleeding [45;62].
After emergency endoscopy, patients, depending on the general condition and stability of endoscopic hemostasis in accordance with endoscopic signs of bleeding activity, as well as taking into account factors predicting recurrent bleeding, can be divided into three groups.
The first group consists of patients with ongoing bleeding (stigmata FIa, FIb), who undergo EG, correct homeostasis, prescribe hemostatic and antiulcer therapy, and undergo endoscopic monitoring with repeated local exposure to the ulcerative defect. If EG is ineffective, indications are given for emergency surgery at the height of bleeding [40]. In patients with effective EG, continued conservative therapy is recommended. If other complications of ulcer are detected, surgery according to indications is performed in a delayed period.
The second group, patients with endoscopic signs of spontaneously stopped bleeding, but unstable hemostasis (FIIa, FIIb, FIIc) with a risk of recurrent bleeding. Endoscopic methods of hemostasis are necessary to prevent relapse and carry out treatment described for patients of group I.
The third group, patients with spontaneously stopped bleeding (FIII) and no signs of DU, have a low risk of recurrent bleeding. Indications for endoscopic interventions to prevent relapse are determined individually. If necrobiotic processes predominate, delayed surgery is performed, and if reparative processes predominate, conservative treatment is indicated [5;50;58].
The temporary nature of hemostasis achieved during endoscopic interventions leads to the development of relapse in 12-46% [27]. "Operations of desperation" undertaken in conditions of recurrent bleeding are accompanied by the highest mortality rate. From these positions, an approach associated with an attempt to predict the risk of recurrent bleeding is becoming increasingly relevant [6;18]. The second important criterion that determines the prognosis of the disease and the choice of adequate treatment tactics is the rational determination of the degree of risk of the upcoming surgical intervention and the main factors influencing its severity [14].
The choice of treatment method for patients with DU is one of the most difficult issues in emergency surgery [3;49]. Of the EG methods for ulcerative hyperplasia, the most common are medicinal, mechanical, physical, and combined. Exposure to hemostatic and vasoconstrictor drugs through targeted irrigation of the ulcer remains the simplest and most widely available method of therapeutic intervention. However, such hemostasis is possible only with minor capillary bleeding. Film-forming aerosol preparations and biological glue nanopowders are widely used to stop DU [64]. The use of adhesive filling methods for the source of bleeding is hampered to some extent by its high cost. Primary EG can be achieved in 94.7% of cases, final - in 95.2% [3]. Konstantinides A. et al. [57], comparing the effectiveness of injection hemostasis in DU with adrenaline and a combination of adrenaline and ethanol, noted a decrease in the frequency of recurrent bleeding from 16.4 to 8.7% [67]. The mechanical method involves clipping the vessel with hemostatic clips, ligation with elastic rings, and endoloops. For bleeding from chronic and callous urinary tracts, its use is not as effective [40]. Physical methods include: thermal exposure (cryotherapy); electrocoagulation; laser coagulation; radiofrequency ablation. Diathermocoagulation (mono- and bipolar) is the most effective method of endohemo stasis and prevention of recurrent bleeding [53]. To influence the source of bleeding with cold agents, chloroethyl is often used; sometimes liquid carbon dioxide is used [3;5]. However, the lack of effect in case of hemorrhage from a large erosive vessel turned out to be the reasons for the unpopularity of this method [5;22]. In 2003, for the first time, radio wave coagulation, which is based on non-contact radio wave exposure to tissue, was used to stop ulcerative hyperplasia. It is possible to reliably stop bleeding in 97.3% of patients [43]. The combined EG method is diverse and depends on the experience and equipment of endoscopists and can combine from 2 to 4 EG methods, depending on the type of source and intensity of bleeding [34;53]. Prevention of recurrent
bleeding consists of dynamic therapeutic endoscopy after 8-12 hours with the introduction of vasoconstrictors in combination with diathermocoagulation [53]. Different types of EG have their own advantages and disadvantages [66].
Clinical signs of a high risk of recurrent bleeding include: a history of ulcer bleeding; repeated vomiting of slightly changed blood; melena in combination with collapse; pain syndrome radiating to the back; persistent disturbances in the hemostatic system (hypocoagulation and hyperfibrinolysis) [30].
Endoscopic signs of unstable hemostasis include: the presence of fresh or slightly changed blood in the stomach or duodenum; the presence of a visible vessel in the ulcer crater, in the lumen of which there is a red or yellow-brown thrombus; the presence of a loose clot of red or cherry color [54]. Additional endoscopic criteria are: localization of ulcers on the lesser curvature of the stomach and the posterior wall of the duodenal bulb, peptic ulcers of the anastomosis; combination of gastric and duodenal ulcers; ulcer size >2 cm; an increase in the size of the defect, the appearance of new thrombosed vessels on its surface [53]. Time intervals for monitoring bleeding vary depending on investigator preference and range from 2 to 24 hours [56]. Repeated endoscopic examination should be carried out every 4-6 hours [43], and according to other data, at intervals of 12 hours on the 1st day and 24 hours on subsequent days. The period of 12-24 hours is the time that is optimal and necessary to prepare the patient for surgery [3;5;49]. Preventive EG is used when there is no visible bleeding, but there are endoscopic signs of a high probability of recurrent bleeding [17].
An active search for methods of combined hemostasis is one of the ways to improve immediate and long-term treatment results. However, the question remains which method is more effective in patients with different severity of the condition, different bleeding patterns, localization of ulcers and concomitant pathologies. There is no consensus yet on the time interval between EG and the effectiveness of various methods.
The treatment tactics for ulcerative gastroduodenal bleeding have changed in parallel with the advances in instrumental diagnostic methods, the possibilities of endoscopic hemostasis, and ideas about the pathogenesis of ulcerative disease and its pharmacotherapy [36]. Active wait-and-see treatment tactics, used before the widespread introduction of endoscopic equipment into clinical practice, gave way to an active surgical approach, when it became possible to visualize the ulcerative defect and determine the degree of stability of hemostasis in it or the ongoing nature of bleeding. Most operations were performed urgently to stop bleeding or prevent its recurrence. However, this approach favorably distinguished the results of treatment from active expectant management, when surgery was usually performed in case of ongoing bleeding or its recurrence, which was accompanied by high postoperative and overall mortality, reaching 45% and 29%, respectively [7].
Many surgeons are proponents of active surgical tactics for ulcerative gastroduodenal bleeding: S.S. Yudin, T.S. Rozanov, M.S. Grigoriev, A.I. Gorbashko, P.M. Postolov and others. S.S. Yudin wrote: "Operations in the early stages of the onset of bleeding can save 95 -96% of patients," and H. Finsterer suggested "operating on the first day of the onset of bleeding." B.S. Rozanov wrote that it is necessary "... to operate before the catastrophe comes close; surgeons should not wait for rebleeding, but must stop it in time." However, this does not mean that they operate on all patients with ulcerative gastroduodenal bleeding [33]. Yudin S.S. (1955) performed
conservative treatment in elderly patients with a short history of ulcers with a high surgical risk [44].
The high risk of emergency surgery in patients over 60 years of age is confirmed by the frequency of deaths, which is 4-7 times higher than that in young and middle-aged patients [11;33]. The objections of many authors to active tactics were dictated by the fact that most ulcer bleeding can be stopped conservatively, and the mortality rate after emergency operations is much higher than after operations in the "cold period", reaching 32% [33].
Active and active expectant treatment tactics for elderly patients with ulcerative gastroduodenal bleeding leads to high postoperative mortality and is therefore not acceptable for this category of patients [21]. All this dictates the need to further improve surgical treatment tactics for Ulcerative gastroduodenal bleeding in elderly patients [3;45]. For patients with signs of unstable hemostasis, the risk of early recurrent bleeding in 70% of patients occurs within the next 12-48 hours. All this should be taken into account when determining the timing of operations [32].
The need to improve the results of treatment of patients with Ulcerative gastroduodenal bleeding led to actively individualized tactics based on the prognosis of recurrent bleeding, which reduced surgical activity to 40% and overall mortality to 10-12%. Taking into account the clinical and endoscopic factors of recurrent bleeding made it possible to take a more individualized approach to the timing of surgical intervention. The development of endoscopic hemostasis methods and their synergistic effect with antisecretory drugs made it possible to avoid recurrent bleeding in most patients and reduce overall mortality to 7-10% [13].
There are various morphological criteria that make it possible to separate mucosal erosions and acute ulcers. In acute ulcers, there are deeper lesions, sometimes involving all layers of the organ wall [26]. Therefore, the incidence of bleeding of varying degrees from acute ulcers reaches 75%. The incidence of acute ulcerative lesions in old age reaches 74.6% [31].
At the present stage, the debate continues in determining surgical tactics, which remain controversial and unresolved to this day [33].
Improving results is possible through the introduction of timely EG, the effectiveness of which is 88-95.8% [66]. If there is no effect from such exposure, indications for surgery are justified.
Active and active expectant treatment tactics for elderly patients with ulcerative gastroduodenal bleeding leads to high postoperative mortality and is therefore not acceptable for this category of patients [21]. Thus, in these conditions, further improvement of surgical tactics for ulcerative gastrointestinal bleeding in this category of patients is necessary to improve treatment results.
Peptic ulcer in elderly and senile patients is currently considered in three variants [23]: I -long-term, occurring in young and middle age and retaining the characteristic periodicity of the course; II - which began in old and senile age ("late" PU) and has its own clinical features and course; III - "senile" ulcer, which, due to the characteristics of ulcerogenesis, should be considered as symptomatic. In old age, ulcers, as a rule, are large in size and have callous edges, and at the bottom of the ulcer the muscular wall of the vessels is replaced by connective tissue, which prevents the collapse and contraction of the vessels, promoting prolonged bleeding [41]. The caliber of the vessel, the elasticity of its walls and the size of the vessel defect directly affect the duration of bleeding [9]. Therefore, the main feature of bleeding in this age group is its massiveness and extreme tendency to recur [39]. The lysis of the formed thrombus by hydrochloric
acid of gastric juice, pepsin and proteolytic enzymes of the pancreas plays an important role in the occurrence of its relapse, which often leads to the failure of conservative therapy and the development of life-threatening severe recurrent bleeding [14]. Therefore, many authors recommend the so-called general, or systemic, hemostatic therapy, which includes calcium preparations, dicinone, s-aminocaproic acid, and vikasol. However, the use of systemic procoagulants in old age is unsafe: when studying the hemostasis system in Ulcerative gastroduodenal bleeding, most patients over 60 years of age revealed an increase in viscosity, increased aggregation of erythrocytes and platelets, which can sometimes lead to the development of disseminated intravascular coagulation syndrome [46].
The goal of efforts aimed at correcting blood loss is to maintain the level of oxygen consumption by tissues to maintain metabolism in them. To improve the results of treatment of ulcerative hyperplasia, it is necessary to improve methods of influencing hemorheology and the microcirculation system [10]. Even slight blood loss against the background of concomitant pathology leads to severe disturbances of homeostasis.
Inconsistency of clinical manifestations, rapidly progressing microcirculatory disorders and sudden decompensation of central hemodynamics are the main features of the course of Ulcerative gastroduodenal bleeding in patients over 60 years of age, who tolerate blood loss worse due to a decrease in the body's compensatory capabilities [61].
Currently, to predict the development of recurrent bleeding of Ulcerative gastroduodenal bleeding, many methods have been proposed, based on individual prognostic signs, a combination of several criteria, and multifactor analysis that takes into account prognostically significant information indicators.
However, as a rule, these techniques are labor-intensive, which complicates their use in practical surgery [19;47;63].
The palliative effect of therapeutic endoscopy allows us to consider it not as an absolute alternative to surgical tactics, but as a preventive method before delayed surgery [25].
According to the Maastricht VI consensus, triple therapy (PPI + clarithromycin + amoxicillin) and bismuth-containing quadruple therapy (PPI + bismuth + tetracycline) are considered and can be empirically prescribed as first-line regimens in regions with low levels of clarithromycin resistance (<15%). + metronidazole). Second-line empiric regimens include fluoroquinolone-containing quadruple therapy (PPI + levofloxacin + amoxicillin + bismuth) or fluoroquinolone-containing triple therapy (PPI + levofloxacin + amoxicillin), as well as bismuth-containing quadruple therapy. As a "rescue" therapy when the above-mentioned ET regimens are ineffective and it is not possible to conduct a microorganism sensitivity test, the Maastricht VI consensus regulates the use of triple therapy with rifabutin (PPI + amoxicillin + rifabutin) [2].
Conclusion. Thus, the choice of treatment method for patients with Ulcerative gastroduodenal bleeding, including in old age, is one of the most difficult issues in emergency surgery.
However, despite significant advances, methods of endoscopic hemostasis are marred by recurrent bleeding, which forces a "desperate" operation, accompanied by high mortality. Therefore, further improvement of the algorithm of actions, taking into account the characteristics of the typology of ulcers ("old" or "senile"), as well as surgical techniques, can optimize surgical tactics and improve the results of surgical treatment.
REFERENCES
1. Alimov M.M., Ismailov B.A., Makhmudov K.O. The effectiveness of using the hemostatic coating "Geprocel" for liver damage in an experiment // Journal Vestnik TMA. -Tashkent. -2016. -No. 3. -p. 17-20.
2. Andreev D.N., Bordin D.S., Nikolskaya K.A., Jafarova A.R., Cherenkova V.V. Current trends in eradication therapy for Helicobacter pylori infection. Medical advice. 2023;17(8):18-27.
3. Antonov O. Possibilities of endoscopic treatment of ulcerative gastroduodenal bleeding // Doctor. -2013. -No. 1. - P. 6-8.
4. Babkin O.V. Active conservative tactics for the treatment of gastroduodenal bleeding in the elderly // Medical assistance. -2001. -No. 4. p. 25-28.
5. Bagnenko S.F., Musinov I.M., Kurygin A.A. [and etc.]. Recurrent ulcerative gastrointestinal bleeding // St. Petersburg: Nevsky Dialect; M.: BINOM. Laboratory knowledge. -2009. -p 256.
6. Belik B.M., Tenchurin R.Sh., Podina M.V. and others. Optimization of methods of endoscopic and pharmacological hemostasis in the treatment of patients with acute gastroduodenal ulcerative bleeding // Materials of the X (anniversary) All-Russian conference of general surgeons with international participation and a conference of young scientific surgeons. -Ryazan. -2018. -May 17-18. -P.29.
7. Briskin B.S., Kornienko A.A., Malamud A.Z. Principles and rationale for therapeutic tactics for ulcer bleeding // Surgery. -1991. -No. 5. P.41-45.
8. Budarev V.N., Fedoseev A.V. Factors determining the effectiveness of endoscopic identification of sources of bleeding // Materials of the X (anniversary) All-Russian Conference of General Surgeons with international participation and a conference of young scientific surgeons. -Ryazan. -2018. -May 17-18. -P.34.
9. Vakhidov V.V., Kalish Yu.I., Khachiev G.L. Features of the course of gastric and duodenal ulcers and its surgical treatment in the elderly // Surgery. -1990. -No. 7. -P.8-13.
10. Vlasov A.P., Al-Kubaisi Sh-A.S., Vlasova T.I., Chigakova I.A. Evaluation of the effects of remaxol on the hemostatic system in acute gastrointestinal bleeding // Materials of the X (anniversary) All-Russian Conference of General Surgeons with international participation and a conference of young scientific surgeons. -Ryazan. -2018. -May 17-18. -P.39.
11. Gostishchev V.K., Evseev M.A., G. Ivakhov Assessment of the severity of the patient's condition during emergency operations due to the high risk of recurrence of gastroduodenal ulcer bleeding // Doctor. - 2007. No. 1. -P.62-64.
12. Gostishchev V.K., Evseev M.A. Acute gastroduodenal ulcerative bleeding: from strategic concepts to therapeutic tactics // Sechenovsky Bulletin. -2010. -No. 1. P.29-35.
13. Evseev M.A. Nonsteroidal anti-inflammatory drugs and the digestive tract. - M.: Borges 2008. - p. 194.
14. Zatevakhin I.I., Shchegolev A.A., Titkov B.E. New technologies in the treatment of ulcerative gastroduodenal bleeding. -M.: Kursiv LLC, 2002. -p. 166.
15. Ismailov B.A., Sadykov R.A., Palymbetova D.N. Delivery device for the use of Geprocel hemostatic coating in minimally invasive surgery // Problems of biology and medicine. -Samarkand - 2018. - No. 4 (104) - P. 160 - 163.
16. Yuldashev G.Y., Khudaibergenov Z.Yu., Yakubova F.U. and others. Diagnostic capabilities of fibroendoscopy for gastroduodenal bleeding of ulcerative etiology //Chir. Uzbek No. 3, 2003 -p. 42.
17. Klochneva E.A. Combined endoscopic and drug hemostasis in the treatment of ulcerative gastroduodenal bleeding. Abstract of the dissertation of a candidate of medical sciences. M., 2012; p. 27.
18. Koraboev B.B. Improving the technology of endoscopic hemostasis for gastroduodenal bleeding // Abstract. Dissertation of the candidate of Medical Sciences. -Andijan. 2021. p. 40.
19. Korovin A.Ya., Maskin S.S., Turkin D.V., et al. Gastroduodenal ulcerative bleeding: assessment of the choice of hemostasis methods and prediction of the risk of recurrent bleeding // Bulletin of surgical gastroenterology. -2017. -No. 1. - p. 41-45.
20. Kubachev K. G., Kachesov E. Yu., Petropavlovskaya O. A., Minimally invasive technologies for the treatment of non-varicose esophageal-gastrointestinal bleeding // Bulletin of surgery. -2018. T.177. No. 2. -p. 25-29.
21. Kubyshkin V.A., Petrov D.Yu., Smirnov A.B. Methods of endoscopic hemostasis in the treatment of ulcerative gastroduodenal bleeding // Surgery named after. N.I. Pirogov. - 2013. - No. 9. - P. 67-72.
22. Mashurova E.V., Vafin A.Z., Aidemirov A.N., Abalyan A.K. Hemostasis in patients with ulcerative gastrointestinal bleeding // Materials of the X (anniversary) All-Russian Conference of General Surgeons with international participation and a conference of young scientific surgeons. -Ryazan. -2018. -May 17-18. -P.68.
23. Myshkin K.I., Duboshina E.A., Grekov I.I. Peptic ulcer of the stomach and duodenum in elderly patients // Surgery. - 1988. - No. 5. - P.17-19.
24. Osipov B.B., Lyzikov A.A., Prizentsov A.A., Skuratov A.G., Kurek M.F. Gastrointestinal bleeding: textbook. -method. manual for 6th year students of the Faculty of Medicine and the Faculty of Training of Specialists for Foreign Medical Universities //Gomel: GomSMU. -2016. - p. 26.
25. Perekhodov S.N., Karpun N.A., Snitsar A.V., Zelenin D.A., Varfalomeev S.I., Martyntsov A.A., Matkov I.V., Pankratov A.A. Experience in the use of endovascular embolization for the prevention of recurrent bleeding from the upper gastrointestinal tract. Surgery. Journal named after N.I. Pirogov. 2023;(1):30 38.
26. Pimanov S.I. Esophagitis, gastritis and peptic ulcer. Guide for doctors. M.: Medical book, 2000. p. 378.
27. Prokubovsky V.I., Cherkasov V.A., Kapranov S.A. Endovascular catheter hemostasis for bleeding in the digestive tract // Surgery. -1988. -No. 2. P.24-28.
28. Sadykov R.A., Ismailov B.A., Sarymsakov A.A. and others. Biological properties of hemostatic coating based on cellulose derivatives // Medical Journal of Uzbekistan. -Tashkent -2018. -No. 3. -p. 92-95.
29. Sazhin V.P., Gryzhenko S.V., Sazhin I.V. The effectiveness of combined hemostasis for ulcerative gastroduodenal bleeding // Russian Medical Journal. - 2012. -No. 2. p.48-51.
30. Seidov V.D., Alekperzade A.V., Nagiyev E.D. The significance of some apudocytes in predicting complications of gastric ulcer with acute bleeding // Surgery. - 2002; 3:36-7.
31. Siluyanov S.V., Smirnova G.O., Luchinkin I.G. Bleeding from acute ulcers of the stomach and duodenum in clinical practice. RMJ. 2009; 5:347.
32. Siraziev I. Sh., Farrakhov A. Z., Zainullin I. V. Indications for early surgery for acute gastroduodenal bleeding // Materials of the All-Russian Conference of Surgeons. -Saratov, 2003. p. 148.
33. Starkov Yu.G., Kurbonov Kh.Kh., Solodinina E.H., Shoshin K.V. Endoscopic diagnosis and treatment of postoperative gastrointestinal bleeding. // Surgery named after. Pirogov. - 2008. - No. 4. - P. 4-10.
34. Stepnov M.V. Combined treatment of patients with ulcerative gastroduodenal bleeding with a high risk of relapse: abstract of the dissertation of a candidate of medical sciences: 01/14/17 //M., 2012. -p. 26.
35. Strukova E.Yu. [and others] Ulcerative gastroduodenal bleeding, aspects of endoscopic hemostasis // Collection of materials of the VII All-Russian scientific and practical conference "Current issues of endoscopy 2016". - Saint Petersburg. -2016. -P. 128-129.
36. Stupin V.A., Baglaenko M.V., Kan V.I., et al. Mortality structure in ulcerative gastroduodenal bleeding // Surgery. Journal named after N.I. Pirogov. -2013. -No. 5. -p. 31-35.
37. Timen L.Ya. Possibilities of endoscopic hemostasis and the importance of endoscopy in the choice of tactics in the treatment of gastroduodenal bleeding // Current issues of endoscopy. -Saint Petersburg. -2016. - p. 216-218.
38. Timerbulatov V.M., Sagitov R.B., Timerbulatov Sh.V. and others. Therapeutic tactics for recurrent bleeding from the upper digestive tract // Annals of Surgery. -2009. - No. 4.
39. Topuzov E.G., Plotnikov Yu.V., Bardakhanov E.T. Acute bleeding from a chronic duodenal ulcer in elderly and senile patients // 8th All-Russian Congress of Surgery - Krasnodar. -1995. -p.279-281.
40. Fedorov E.D. [and others] Endoscopic hemostasis using argon plasma coagulation for acute gastrointestinal bleeding: the first clinical experience // Clinical endoscopy -2003. -No. 1. -P.12-15.
41. Fetyukov A.I., Gridina I.G. Causes of mortality and postoperative complications in elderly and senile patients. //Bulletin of Surgery - 1997. - No. 4. - p. 127-129.
42. Khudaibergenov Sh.N., Eshonkhodzhaev O.D., Irisov O.T. etc. Practical recommendations for the use of the developed biocompatible implant "Geprocel" for the prevention and treatment of aero- and hemostasis disorders in lung surgery // Journal "Problems of Biology and Medicine". -2018. -No. 4(104). -P.122-137.
43. Cherepanin A., Sherov R., Antonov O. Endoscopic methods of hemostasis for ulcerative gastroduodenal bleeding. First Moscow State Medical University named after I.M. Sechenov. Moscow E-mail: oantonov78@mail.ru. //DOCTOR magazine. -2015. -No. 7. -P.45-48.
44. Yudin S.S. Sketches of gastric surgery. -1955. -p. 264.
45. Ulcerative gastroduodenal bleeding. National clinical guidelines of the Russian Ministry of Health. Medical newspaper No. 90 dated December 2, 2015.
46. Yarema I.V., Dzyubanovsky I.Ya. Surgery of peptic ulcer in elderly and senile patients // Bulletin of surgery - 1996. -No. 4. -SPb. - pp. 84-88.
47. Alali A.A., Barkun A.N. An update on the management of non-variceal upper gastrointestinal bleeding. Gastroenterol Rep (Oxf). 2023 Mar 20;11: goad011.
48. Antonio T., Federico C., Fausto C. Perforated and bleeding peptic ulcer: WSES guidelines, World Journal of Emergency Surgery 15, Article number: 3 (2020).
49. Barkun A.N. [et al.] International Consensus Recommendations on the Management of Patients with Nonvariceal Upper Gastrointestinal Bleeding //Ann Intern Med. - 2010. - Vol. 15, № 2.- P. 101-113.
50. Barkun A.N., Almadi M., Kuipers E.J. Et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations from the International Consensus Group. Ann Intern Med. 2019 Dec 3;171(11):805-822.
51. Beg S., Al-Bakir I., Bhuva M. et al. Early clinical experience of the safety and efficacy of EndoClot in the management of non-variceal upper gastrointestinal bleeding. //Endosc. Int. Open. -2015; 3 (6): E605-9.
52. Capela T.L., Silva V.M., Freitas M. Et al. Acute Nonvariceal Upper Gastrointestinal Bleeding in Patients Using Anticoagulants: Does the Timing of Endoscopy Affect Outcomes? Dig Dis Sci. 2023 Dec 20.
53. Chiu P. Second look endoscopy in acute non-variceal upper gastrointestinal bleeding //Best Pract. Res. Clin. Gastroenterol. - 2013; 27 (6): 905-11.
54. Ferguson C. Nonvariceal upper gastrointestinal bleeding: standart and treatment //Gastroenterol. Clin. N. Am. - 2005; 34: 607-21.
55. Hamoui N. Gastrointestinal hemorrhage: is the surgeon obsolete? //Emerg Med Clin N. -2003. -Vol. 21. р.1017-1056.
56. Jaka H. Fibreoptic endoscopic study of upper gastrointestinal bleeding at Bugando Medical Centre in northwestern Tanzania: A retrospective review of240 cases // BMC Research Notes. - 2012; 5 (200): 5-14.
57. Konstantinides A. Endoscopic treatment for high-risk bleeding peptic ulcers: a comparison of epinephrine alone with epinephrine plus ethanolamine //Ann. Gastroenterol. - 2011; 24: 1017.
58. Laine L., Barkun A.N., Saltzman J.R. Et al. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021 May 1;116(5):899-917.
59. Larissa L. Fujii-LauMD. Techniques in Gastrointestinal Endoscopy, 2016-10-01, Том 18, Выпуск 4, С. 210-218.
60. Mackiewicz-Pracka A., Nehring P., Przybylkowski A. Emergency Endoscopic Interventions in Acute Upper Gastrointestinal Bleeding: A Cohort Study. Diagnostics (Basel). 2023 Dec 1;13(23):3584.
61. Oakland K. Changing epidemiology and etiology of upper and lower gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2019;42-43:101610.
62. Orpen-Palmer J., Stanley A.J. Update on the management of upper gastrointestinal bleeding. BMJ Med. 2022 Sep 28;1(1): e000202.
63. Patel S.D., Desai R., Patel U. Et al. Thirty-day readmissions after upper and lower gastrointestinal hemorrhage: a national perspective in the United States. J Clin Gastroenterol 2019; 53:582-90.
64. Sheasgreen C. Recent advances on the management of patients with non-variceal upper gastrointestinal bleeding // Ann. Gastroenterol. - 2013; 26: 191-7.
65. Sinha R., Lockman K.A., Church N.I., Plevris J.N., Hayes P.C. The use of hemostatic spray as an adjunct to conventional hemostatic measures in high-risk nonvariceal upper GI bleeding (with video). Gastrointest. Endosc. 2016; PII: S0016-5107(16)30062-1.
66. Sung J. Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis //Gut. - 2007; 56: 1364-73.
67. Timen L. Glucose, ascorbic acid and hydrogen peroxide as ingredients of endoscopic hemostasis in bleeding ulcer //Eksp. Klin. Gastroenterol. - 2013; 5: 89-92.
68. Toapanta-Yanchapaxi L., Chavez-Tapia N., Tellez-Avila F.: Cyanoacrylate spray as treatment in difficult-to-manage gastrointestinal bleeding. World J Gastrointest Endosc 2014; 6: pp. 448-452.
69. Zed P. J. Meta-analysis of proton pump inhibitors in treatment of bleeding peptic ulcers //Ann. Pharm. -2001. -Vol. 35 (12). р.1528-1534.
70. Мохира, Т. (2015). ЖАНРА РАССКАЗА С ТОЧКИ ЗРЕНИЯ ИССЛЕДОВАТЕЛЕЙ И ЕГО ПРИМЕНЕНИЕ В ДЕТСКОЙ ЛИТЕРАТУРЕ. Вестник Таджикского национального университета. Серия филологических наук, (4-5), 201-206.
71. Atkhamova, S. (2024). HYPERTENSIVE CONDITIONS DURING PREGNANCY. A MODERN VIEW OF THE PROBLEM. (LITERATURE REVIEW). Science and innovation, 3(D5), 462-467.
72. Zufarova, S., & Turakulova, S. (2024). WAYS TO CORRECT MENSTRUAL DYSFUNCTION IN WOMEN WITH OBESITY. Science and innovation, 3(D5), 527-531.
73. Абдуллаев, Р. Н., Абдуллаева, М. А., & Собирова, М. Р. (2018). Интраоперационный метод лечения и профилактики спаечной болезни малого таза у пациенток с трубно -перитонеальным бесплодием. Москва. Проблемы науки,(11), 35.
74. Зияева, Э. Р., Рузиева, Н. Х., & Собирова, М. Р. К. (2022). СИНДРОМ ХРОНИЧЕСКОЙ ТАЗОВОЙ БОЛИ ПРИ ХРОНИЧЕСКОМ САЛЬПИНГООФОРИТЕ-СОВРЕМЕННЫЙ ВЗГЛЯД НА ПАТОГЕНЕЗ. Re-health journal, (2 (14)), 1-5.
75. Зияева, Э. Р., Абдуллаев, Р. Н., & Собирова, М. Р. (2018). ИЗМЕНЕНИЕ НЕСПЕЦИФИЧЕСКИХ ФАКТОРОВ ЗАЩИТЫ БОЛЬНЫХ ХРОНИЧЕСКИМ САЛЬПИНГООФОРИТОМ ПОД ДЕЙСТВИЕМ КОМПЛЕКСНОЙ ФИЗИЧЕСКОЙ РЕАБИЛИТАЦИИ. In Молодежь-практическому здравоохранению (pp. 415-418).
76. Alieva, M. A., & Sobirova, M. R. (2023). JINSIY A'ZOLAR PROLAPSI BO'LGAN AYOLLARNI JARROHLIK YO'LI BILAN DAVOLASHNI SAMARADORLIGI. Евразийский журнал медицинских и естественных наук, 3(4 Part 2), 65-70.
