II. Integrated Emergency Treatment with Traditional Chinese and Western Medicine

II. Integrated Emergency Treatment with Traditional Chinese and Western Medicine

The principle for managing upper gastrointestinal bleeding, especially massive acute upper gastrointestinal bleeding, is to replenish blood volume as early and quickly as possible to correct shock and prevent further bleeding. On this point, traditional Chinese medicine and Western medicine share a very consistent view: in terms of pharmacological hemostasis, according to numerous recent clinical reports, the traditional Chinese herb Dahuang has excellent hemostatic effects, while the use of Western medicine thrombin has greatly improved hemostatic efficiency. It must be emphasized that treatments primarily based on traditional Chinese medicine are most effective for bleeding caused by peptic ulcers, gastric cancer, and gastritis, whereas for bleeding caused by esophageal and gastric fundal varices, due to the intensity of the bleeding, integrated treatment combining traditional Chinese and Western medicine is essential for comprehensive rescue.

(1) General Emergency Measures

1. Bed Rest and Quiet Environment Adopt a supine position with legs elevated, keep the airway open, and administer oxygen if necessary.

2. Close Monitoring of Condition Includes:

   • ① Status of hematemesis and melena;
   • ② Changes in consciousness;
   • ③ Pulse, blood pressure, and respiratory status;
   • ④ Whether limbs are warm, nail beds and skin color;
   • ⑤ Fullness of peripheral veins, especially neck veins;
   • ⑥ Hourly urine output;
   • ⑦ Regular rechecks of red blood cell count, hemoglobin, hematocrit, and blood urea nitrogen;
   • ⑧ Central venous pressure measurement when necessary; elderly patients require electrocardiographic monitoring.

3. No Need for Fasting in General Liquid or semi-liquid diets can be given, such as milk, soy milk, lotus root starch, steamed eggs, meat broth, and soft noodles—warm, bland, non-irritating foods without residue. However, if there is hematemesis or substantial bleeding, fasting is required.

4. Aggressive Blood Volume Replacement Immediately arrange blood matching (including blood type testing and cross-matching), and promptly start intravenous infusion using large-bore needles, or insert a subclavian vein catheter for infusion and central venous pressure measurement. Infusion should begin very quickly, using normal saline, Ringer’s solution, and low-molecular-weight dextran; the total volume over 24 hours should not exceed 1000 ml. Sufficient whole blood should be administered early to restore blood volume and ensure effective circulation, preferably maintaining hemoglobin levels above 9–10 g. Blood stored for a long time in blood banks contains higher levels of blood ammonia, which can induce hepatic encephalopathy in patients with liver cirrhosis, so fresh blood is recommended. At the same time, care should be taken to avoid acute pulmonary edema caused by excessive blood transfusion or infusion, especially for elderly patients; infusion volume should be adjusted based on central venous pressure measurements. Here, the author recalls a famous saying from the Qing dynasty physician Cheng Zhongling’s “Insights into Medicine”: “Visible blood cannot be produced quickly, but invisible qi must be stabilized urgently.” This refers to the TCM principle of medication during massive blood loss leading to collapse (i.e., hypovolemic shock). Due to limitations in medicinal delivery methods at the time, it was impossible to replenish blood volume quickly, so only large doses of qi-tonifying herbs could be used. Qi tonification and stabilization of collapse essentially involved using vasoconstrictive agents to temporarily maintain blood pressure. Today, with intravenous infusion and blood transfusion available, “visible blood” can be rapidly replenished in a short time, while the solitary ginseng decoction used to urgently stabilize invisible qi has been replaced by pressor drugs like dopamine and metaraminol. Nevertheless, the therapeutic principle advocated by this ancient maxim still holds guiding significance today.

5. Hemostatic Measures

(1) Traditional Chinese Medicine Hemostasis: ① Raw Dahuang powder (or tablets), 3 g each time, three times daily, taken orally. According to clinical observations of 2,000 cases, the hemostatic effectiveness rate is 95%–97.5%, with an average hemostasis time of 1.5 days. The Dahuang variety from Lixian County in Gansu Province shows relatively stable efficacy. Indications: bleeding associated with ulcers or gastritis, especially when melena is predominant and the bleeding volume is less than 500 ml; upper gastrointestinal bleeding where coagulation drugs are contraindicated, such as cerebral thrombosis; cases where other hemostatic drugs are ineffective and surgery is not advisable. Use with caution for arteriosclerosis-related bleeding; also avoid use for patients with surgical indications or over 45 years of age. For massive bleeding, if more than 800 ml of blood is transfused within 8 hours and blood pressure remains unstable, surgery may be considered. Domestic scholars have proven through clinical and experimental studies that adding Baiji to Dahuang enhances the hemostatic effect, because Baiji contains Baiji glue, which is highly adhesive, has astringent and hemostatic properties, promotes cell and platelet aggregation to form clots and achieve hemostasis, and also exhibits local hemostatic effects superior to gelatin sponge. This claim is well-founded and credible, worth trying. ② Senna leaf capsules, 2 capsules each time (0.5 g per capsule), three times daily, taken orally. According to observations of 109 cases, the hemostatic effectiveness rate is 94.5%, with an average hemostasis time of 2.68 days. Use with caution for massive hematemesis or obvious gastric irritation symptoms; contraindicated for gastrointestinal tumors with bleeding. Other relatively effective traditional Chinese medicines include Sanqi powder, Huairui stone, Yunnan Baiyao, Xuejie, cuttlefish bone, Zizhu grass, Xianhe grass, and Diyu, among others.

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(2) Western hemostatic agents that can be selected include: thrombin 5 units, administered orally three times daily. The hemostatic characteristic of thrombin is that it rapidly forms a clot at sites of mucosal and vascular injury in the upper gastrointestinal tract, thereby effectively sealing off the bleeding. The introduction of thrombin has added a new, effective method for treating upper gastrointestinal bleeding. In addition, aminocaproic acid 10 mg can be given by intramuscular injection; vitamin K₃ 8 mg by intramuscular injection; hemostatic agent 25 mg by intramuscular injection; tranexamic acid 0.6 g diluted in 250 mg of normal saline for intravenous drip; or 6-aminocaproic acid 6 g added to 250 ml of 5% glucose solution for intravenous drip. Alternatively, norepinephrine 4–8 mg can be added to 150 ml of normal saline for divided oral administration, or for gastric cavity instillation; posterior pituitary extract 20 units can be added to 200 ml of 5% glucose solution for slow intravenous infusion over 20 minutes, to reduce portal venous pressure and achieve hemostasis in cases of ruptured esophageal and gastric fundal varices; if necessary, this can be repeated every 4 hours, for a total of 3–4 administrations. However, it is contraindicated in patients with coronary atherosclerotic heart disease. Cimetidine 400 mg can be added to 250 ml of 10% glucose solution for intravenous drip every 6 hours, continuously for 5 days. It is particularly effective for acute bleeding caused by peptic ulcers or acute gastric mucosal damage. In recent years, clinical application of hemostatic agents has shown good efficacy: adults receive 1–2 units each time, via intramuscular injection or intravenous drip, which can reduce blood flow velocity without forming thrombi, making it relatively safe; the only drawback is its high price, which makes it difficult to widely use in primary-level and rural medical institutions.

(3) Three-lumen balloon tamponade for hemostasis: suitable for bleeding due to ruptured esophageal and gastric fundal varices; after 24 hours of hemostasis, deflate the gas inside the balloon; avoid prolonged compression that may lead to mucosal erosion, continue observation for another 24 hours, and if no rebleeding occurs, the tube can be removed.

(4) Gastric cooling for hemostasis: insert a gastric tube and repeatedly irrigate with ice-saline solution to lower the gastric temperature, achieving the purpose of hemostasis.

(5) High-frequency electrocautery or laser hemostasis under direct fiberoptic endoscopic visualization.

III. Treatment Based on Syndrome Differentiation

Treatment based on syndrome differentiation is suitable for patients with small amounts of bleeding, or those who only present with melena or a positive fecal occult blood test, as well as for cases of massive upper gastrointestinal bleeding where, after combined traditional Chinese and Western medical emergency treatment, the bleeding has been basically controlled. Since syndrome differentiation involves identifying the underlying cause through careful examination, it alleviates and eliminates the internal factors that lead to bleeding, thus having important clinical significance for long-term disease control and prevention.