I. Upper Gastrointestinal Bleeding

I. Upper Gastrointestinal Bleeding

The upper gastrointestinal tract refers to the portion of the digestive system above the TreTTr ligament; bleeding in this area is referred to as upper gastrointestinal bleeding. Bleeding from the esophagus, stomach, duodenum, gallbladder, pancreas, and common bile duct all fall under this category. Due to portal hypertension in cirrhosis, the submucosal vessels throughout the digestive system become congested and dilated. Esophageal veins and gastric fundal veins are particularly prominent; at this time, gastric acid secretion increases, and the gastric, intestinal, and pancreatic secretory systems are activated. Dietary habits, emotions, and physical exertion can all trigger enhanced gastrointestinal motility, leading to rupture of esophageal veins and gastric fundal veins and the occurrence of upper gastrointestinal hemorrhage. Additionally, due to liver dysfunction, the levels and quality of various coagulation factors—such as prothrombin, factor VIII, and thrombin—decline, thereby promoting bleeding. Moreover, long-term restriction of fatty foods reduces the absorption of fat-soluble vitamins D and K; vitamin K is a major coagulation factor and a key component of prothrombin. Vitamin D plays a role in calcium absorption and utilization, and like calcium, vitamin K is also an important coagulation factor. Therefore, in the entire digestive tract, besides major hemorrhages caused by rupture of esophageal and gastric fundal veins, chronic mucosal leakage and small, frequent bleedings also occur. As a TCM and Western medicine practitioner, we must first accurately assess the amount of bleeding. When the volume exceeds 5 ml, occult blood begins to appear; when it exceeds 50 ml, black stools of varying degrees may occur; when it exceeds 250 ml, vomiting may occur; when it exceeds 500 ml, blood pressure drops and shock may develop. Hematocrit is also an important indicator for assessing bleeding volume: the lower limit of normal hematocrit is 40%, while at 30%, bleeding volume ranges from 500 to 1000 ml; at 20%, bleeding volume reaches 1000 to 2000 ml. The speed of the pulse is also closely related to the amount of bleeding—pulse rate and blood pressure are generally inversely correlated. When the bleeding volume exceeds 500 ml, blood pressure begins to drop; let’s take systolic blood pressure as a standard for explanation. When systolic blood pressure is around 16.7 kPa (80 mmHg), the pulse rate is 100 beats per minute. When blood loss accounts for about 1/4 of total circulating blood volume, it is considered mild shock; when systolic blood pressure is around 9.3 kPa (70 mmHg), the pulse rate rises to 120 beats per minute, and blood loss accounts for about 1/3 of total circulating blood volume, indicating moderate shock; when systolic blood pressure falls below 8.0 kPa (60 mmHg), the pulse rate becomes unclear, and blood loss is about 1/2 of total blood volume. Treatment for upper gastrointestinal hemorrhage:

1. Blood transfusion is the most critical measure in rescuing upper gastrointestinal bleeding. Typically, 400 ml of fresh blood can increase hemoglobin levels; for blood transfusions less than 2000 ml, stored citrate blood can be used, but calcium gluconate must be supplemented to prevent hyperkalemia caused by excessive blood transfusion. The transfusion rate should not be too fast—30–40 drops per minute is ideal. If 2000 ml of blood needs to be transfused in the first hour, both pipelines should be infused simultaneously.
2. Pituitary posterior hormone: It can be administered via injection or drip; each dose is 10 units, added to 5%–10% glucose solution, with a drip rate of 30–40 drops per minute being optimal. This medication has been used for decades to treat massive hemorrhages from ruptured esophageal and gastric fundal veins; due to its proven efficacy, it is often chosen as a first-line treatment. However, this medication has several side effects—increased intestinal motility, abdominal pain, and diarrhea are the most common; sometimes it can even cause myocardial ischemia, even angina pectoris, though this is relatively rare.
3. Somatostatin: Includes octreotide and somatostatin, belonging to the growth hormone inhibitors class. Octreotide is an 8-peptide growth hormone inhibitor, while somatostatin is a 14-peptide growth hormone inhibitor. Each dose is 0.3 mg for octreotide and 3 mg for somatostatin, administered via intravenous drip in 10% glucose solution. The original function of growth hormone inhibitors is to suppress the secretion of various glands; initially used clinically for thymomas and gastrinomas, recent studies have shown that their broad inhibitory effect on digestive system glands makes them highly effective in treating massive upper gastrointestinal bleeding. After clinical trials, this drug gained significant attention from clinicians due to its remarkable efficacy.
4. Vasoactive drugs, such as dopamine and phenylephrine, can help restore blood pressure and improve organ blood flow; they must be used in conjunction with large-volume blood transfusions to be effective. Administer 20 mg of dopamine and 40 mg of phenylephrine in 500 ml of 5% glucose solution, infused intravenously at a rate of 20–30 drops per minute. Dopamine directly stimulates α and β receptors, while phenylephrine stimulates indirectly; the two drugs complement each other and work together to improve peripheral circulation.
5. Hemostatic agents: The most commonly used hemostatic agents include hemostatic acid, hemostatic敏, hexamethylenetetramine, and Liti. All four medications can be administered via intramuscular injection or intravenous drip. The dosage of hemostatic acid should be 0.6 g per drip, hemostatic敏 2 mg, hexamethylenetetramine 6 g, Liti 100 u; additionally, 500 u of compound thrombin can be dissolved in 40–80 ml of cold saline solution and administered as a single dose, or 100 ml of cold saline solution containing 0.08% of regular renin can be administered as a single dose—each method has a certain local hemostatic effect.
6. Antacids: Administer 200–400 mg of metoclopramide or 100–200 mg of ranitidine via intravenous drip, or 20 mg of omeprazole orally three times a day. All of these medications provide good antacid effects. Antacids are a prerequisite for hemostasis; they can promote the effectiveness of hemostasis.
7. The once-popular triple-lumen double-balloon tube was found to have irreparable flaws—such as causing patients to self-harm, and both balloon placement and removal can exacerbate bleeding. Therefore, it is now rarely used in clinical practice. Traditional Chinese Medicine and Chinese herbal medicine’s understanding of upper gastrointestinal bleeding dates back to the Eastern Han Dynasty, when the renowned physician Zhang Zhongjing suggested two highly effective formulas.
8. Xie Xin Tang: 10 g of Rheum officinale, 3 g of Coptis chinensis, 10 g of Scutellaria baicalensis, decocted in water and taken orally. According to “Jin Gui,” “When heart qi is insufficient, and blood is vomited or nosebleeds occur, Xie Xin Tang is the primary remedy.” According to “Jin Jian,” “When deficiency is present, it should be considered excess”—when qi is abundant, it is fire; when fire is strong and forces blood to run abnormally, blood is vomited. Tang Rongchuan said, “Xie Xin means to clear fire; clearing fire means to stop blood.” This formula provides a precise definition for hemostasis in Xie Xin Tang. Tang believed that vomiting blood is “like overturning the heavens and earth.” Task output rules: Translate this markdown block from Chinese to English. Preserve markdown markers, links, and formatting. Keep headings and list structure unchanged. Return only the translated block.

Input: The "image" suggests that if the qi in the stomach is not properly regulated due to a sudden drop in the potency of rhubarb, the qi in the stomach will be forced to rise and cause blood to surge upward—this is precisely why it must be brought down. The meridians, skin, and internal organs all experience similar conditions.

When the qi in the body is in an abnormal state, it cannot help but become unbalanced. Based on Tang's theories, I developed a formula: 10g of rhubarb, 3g of coptis, 10g of scutellaria, 20g of raw ochre powder (dissolved in water), and 3g of cinnamon. This formula is decocted in water to yield 200ml, which is divided into four doses, with each dose taken at intervals of 30–60 minutes. This formula was routinely used in the Integrated Traditional and Western Medicine Ward of the Gansu Provincial Academy of Medical Sciences for the emergency treatment of severe upper gastrointestinal bleeding, and it showed varying degrees of therapeutic effects in most patients; it also demonstrated significant efficacy in treating bleeding caused by esophageal variceal rupture and gastric fundal variceal rupture.

2. Huangtu Decoction: 6g of licorice, 12g of rehmannia root, 10g of atractylodes macrocephala, 6g of processed aconite, 10g of donkey-gelatin, and 10g of scutellaria. This formula is decocted in water and taken once daily. According to the Jin Gui, “In cases of bloody stools, blood appears after bowel movements—this is considered distant blood; Huangtu Decoction is the primary remedy for such conditions.” The “distant blood” referred to by Zhongjing means that the source of the bleeding is far from the anus, specifically in the upper digestive tract. This formula is highly effective in treating black stools, confirming that Zhongjing’s observations were correct. When using this formula, I often added 15g of codonopsis to enhance its effect, as it also carries the same meaning as Fuzi Lizhong Decoction. In situations where severe bleeding occurs accompanied by black stools, the bleeding often begins to subside; at this stage, the primary issue is often a disruption in the autonomic nervous system of the gastrointestinal tract, along with excessive intestinal peristalsis, which frequently leads to black stools. Traditional Chinese medicine believes that the middle qi urgently needs to be regulated at this time, so Fuzi Lizhong Decoction is employed. However, patients with black stools may still experience recurrent bleeding in both the stomach and esophagus, so I increased the dosage of rhubarb to 3g, coptis to 3g, scutellaria to 10g, pinellia to 6g, and raw ochre to 20g in this formula.