Bleeding from varicose veins. Bleeding from esophageal varices in portal hypertension syndrome

Bleeding from these veins is usually hidden, difficult to stop, and usually occurs against the background of coagulopathy, thrombocytopenia, and sepsis.

Drugs that cause mucosal erosions, such as salicylates and other NSAIDs, can also cause bleeding. Varicose veins in other areas become a source of bleeding relatively rarely.

Bleeding from esophageal varices: diagnosis

Anamnesis collection and general examination allow us to suspect varicose veins as the cause gastrointestinal bleeding. In 30% of patients with liver cirrhosis, another source of bleeding is identified. If a disease is suspected, it is necessary to perform fibrogastroduodenoscopy as early as possible. Along with rupture of varicose veins of the stomach and esophagus, the cause of bleeding in in rare cases is hypertensive gastropathy.

Bleeding from esophageal varices: conservative therapy

Transfusion of blood, fresh frozen plasma and platelets depending on hematological parameters. Vitamin K is administered in a dose of 10 mg intravenously once to exclude its deficiency. Avoid excess transfusion.

Metoclopramide 20 mg is administered intravenously. This drug allows for a short-term increase in blood pressure lower section esophagus and thereby reduce blood flow in the v. system. azy-gos.

Antibacterial therapy. A sample of blood, urine, and ascitic fluid is collected for culture and microscopy. Several studies have found an association with sepsis. Antibiotics are prescribed. Duration antibacterial therapy should be 5 days.

Terlipressin causes vasospasm in the celiac trunk, thereby stopping bleeding from the esophageal varices of the esophagus (decreasing mortality by approximately 34%). Serious side effects occur in 4% of cases and include myocardial ischemia, spasm peripheral vessels, which may be accompanied by serious arterial hypertension, skin ischemia and circulatory disorders internal organs. Nitrates may reverse the peripheral effects of vasopressin but are not usually prescribed to treat the side effects of terlipressin. Octreotide - synthetic analogue somatostatin. It has no side effects on the heart, and therefore the administration of nitrates during its administration is not required. According to latest research from the Cochrane Database, octreotide does not affect disease mortality and has minimal effect on the need for transfusion therapy.

Endoscopic introduction of scerosing substances into the cervical veins and surrounding tissues makes it possible to stop acute bleeding. Side effects(serious - in 7%) include the occurrence of chest pain and fever immediately after injection, the formation of ulcers on the mucous membrane, late stricture of the esophagus. In the future, the administration of sclerosing substances should be continued until the veins are completely obliterated. The greatest difficulties arise when performing injections into the gastric varices, in in this case thrombin should be used.

Ligation of varicose veins is often used.

Balloon tamponade with a Sengstaken-Blakemore or Linton probe. Usually only this is enough to stop the bleeding. The probe should not be used for more than 12 hours due to the risk of ischemia, the risk of which increases with simultaneous administration of terlipressin.

Treatment liver failure: to prevent encephalopathy, lactulose should be prescribed orally or through a tube, 10-15 ml every 8 hours, as well as thiamine and multivitamin preparations. Patients with severe encephalopathy are prescribed magnesium sulfate and phosphate enemas.

In case of acute bleeding from varicose veins of the esophagus, the correction of hemodynamic disorders (infusion of blood and plasma products) is of utmost importance, since in conditions hemorrhagic shock blood flow in the liver decreases, which causes further deterioration of its functions. Even in patients with confirmed varicose veins veins of the esophagus, it is necessary to establish the localization of bleeding using FEGDS, since in 20% of patients other sources of bleeding are identified.

Local treatment

To stop bleeding from varicose veins of the esophagus, use endoscopic techniques, balloon tamponade and open dissection of the esophagus.

Esophageal vein ligation and sclerotherapy

These are the most commonly used initial methods treatment. Ligation - more complex procedure than sclerotherapy. If there is active bleeding, endoscopic procedures may be difficult. In such cases, balloon tamponade should be performed.

Balloon tamponade

A Sengstaken-Blakemore probe with 2 tamponade balloons is used. There are modified versions of the probe (for example, Minnesota tube) that allow aspiration of the contents of the stomach and esophagus. The probe is inserted through the mouth, its penetration into the stomach is controlled by auscultation epigastric region during balloon inflation or radiographically. Light traction is necessary to ensure compression of the varicose veins. The first step is to fill only the gastric balloon with air (200-250 ml) - this measure is usually sufficient to stop bleeding. Filling of the gastric balloon should be stopped if the patient experiences pain, since if the balloon is incorrectly placed in the esophagus, rupture may occur during its filling. If gastric tamponade is not enough to stop bleeding and you have to resort to esophageal tamponade, the esophageal balloon should be deflated for 10 minutes every 3 hours. The pressure in the esophageal balloon is monitored using a sphygmomanometer. Special attention When placing a tube, care should be taken to prevent aspiration of gastric contents (if necessary, the patient is intubated).

Esophageal dissection

Ligation of varicose veins can be done using a stapler, although there is a risk of further development of esophageal stenosis; the operation is usually combined with splenectomy. This procedure usually used if there is no effect from all other methods of therapy listed above and it is impossible to perform transjugular intrahepatic portacaval shunting. Operations are associated with frequent complications and high mortality.

X-ray vascular therapy methods

IN specialized centers transvenous intrahepatic portosystemic shunting is possible. Access through the jugular or femoral vein perform catheterization of the hepatic veins and between them (system low pressure) and portal venous system (high pressure) an expandable stent is inserted. The pressure in the portal vein should decrease to 12 mm or lower.

Surgery

Urgent portacaval shunting allows to stop bleeding in more than 95% of cases, but is characterized by high (>50%) intraoperative mortality and does not affect long-term survival. This treatment method is currently used only in isolated cases.

Prognosis for varicose veins of the esophagus

Mortality rate overall is 30%. It is higher in patients with severe liver disease.

The effectiveness of therapy aimed at stopping bleeding from the esophageal varices

Injection of sclerosing drugs or vein ligation - 70-85%.

Balloon tamponade - 80%.

Terlipressin - 70%.

Octreotide - 70%.

Vasopressin and nitrates - 65%.

Bleeding from varicose veins (hereinafter referred to as varicose veins) of the esophagus. Long-term therapy

Injection of a scerosing drug in a volume of 0.5-1 ml into the tissue around the cervical vein or 1-5 ml into varicose veins every week until the veins are completely obliterated; then at intervals of 3-6 months.

Ligation is carried out in the same regimen as sclerotherapy, with obliteration of varicose veins occurring faster (39 days versus 72 days).

The administration of propranolol reduces the frequency of relapses. No reduction in mortality was noted.

Transvenous intrahepatic portosystemic shunt and other shunt procedures are considered to be more reliable in preventing rebleeding, which can only occur if the shunt is blocked. However, when they are carried out, the incidence of chronic hepatic encephalopathy increases.

Prevention of rebleeding

During endoscopic ligation, varicose veins are aspirated into the lumen of a special endoscopic instrument and tied using elastic rubber bands. The ligated vein is subsequently obliterated. The procedure is repeated every 1-2 weeks until the veins are obliterated. In the future, regular endoscopic monitoring is necessary for timely treatment recurrence of varicose veins. Endoscopic ligation is generally more effective than sclerotherapy. To prevent secondary bleeding due to ulcerations induced by ligatures, antisecretory therapy with Na + , K + -ATPase (proton pump) inhibitors is prescribed.

Sclerosing therapy

Sclerotherapy is the introduction of sclerosing agents into varicose veins. After the introduction of endoscopic ligation this method used relatively rarely. Sclerosation therapy is not without its drawbacks, as it may be accompanied by transient pain, fever, temporary dysphagia, and sometimes esophageal perforation. It is also possible to develop esophageal strictures.

Transjugular intrahepatic portacaval shunt

The operation consists of installing an intrahepatic stent between the portal and hepatic veins, which provides portacaval shunting and reduces pressure. The procedure is performed under x-ray control. Patency must be confirmed before surgery portal vein using angiography and prescribe prophylactic antibiotic therapy. The occurrence of rebleeding is usually associated with narrowing or occlusion of the shunt (appropriate examination and treatment, such as angioplasty, is necessary). Transjugular intrahepatic portacaval shunting can provoke the development of hepatic encephalopathy; to relieve it, it is necessary to reduce the diameter of the shunt.

Portocaval shunt surgery

Portocaval shunt operations help prevent recurrent bleeding. The application of non-selective portacaval shunts leads to an excessive reduction in the flow of portal blood into the liver. Taking this into account, selective bypass operations were developed, in which the risk of developing postoperative hepatic encephalopathy below. However, over time, hepatic portal blood flow decreases.

P-adrenergic receptor antagonists (p-blockers)

Propranolol or nadolol reduce blood pressure. They can be used to prevent recurrent bleeding. However, for secondary preventionβ-blockers are rarely used. Treatment compliance with these drugs may be low.

Mallory-Weiss syndrome

Rupture of the mucous membrane in the area of ​​the esophagogastric anastomosis, which occurs as a result of strong gagging movements and is especially often observed with excessive alcohol consumption. At first, the vomit is of normal color, and then blood appears in it.

Treatment

• In most cases, bleeding stops spontaneously. Tamponade with a Sengsteken-Blakemore probe may be required.
• In some cases it is necessary to perform surgical operation with suturing of a bleeding vessel or selective angiography with embolization of the feeding artery.
• The Child score can effectively determine the severity of liver disease in a patient with cirrhosis. It should not be used in patients with primary biliary cirrhosis or spersosing cholangitis.
• Group A<6 баллов.

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Predicting the gap

Within 2 years after the diagnosis of liver cirrhosis, bleeding from varicose veins of the esophagus occurs in 35% of patients; the first episode of bleeding kills 50% of patients.

There is a clear correlation between the size of varicose veins visible during endoscopy and the likelihood of bleeding. The pressure inside varicose veins is not so important, although it is known that for the formation of varicose veins and subsequent bleeding, the pressure in the portal vein must be above 12 mm Hg. .

Rice. 10-50. Partial nodular transformation of the liver. A section of the liver in the portal area is schematically shown, where nodes compressing the portal vein are visible. The rest of the liver appears normal.

An important factor that indicates a greater likelihood of bleeding is the red spots that can be seen during endoscopy.

To assess hepatocyte function in cirrhosis, use Child's criteria system, which includes 3 groups - A, B, C (Table 10-4). Depending on the degree of dysfunction of hepatocytes, patients are classified into one of the groups. The Child group is the most important indicator for assessing the likelihood of bleeding. In addition, this group correlates with the size of the varicose veins, the presence of red spots on endoscopy, and the effectiveness of treatment.

Three indicators - the size of varicose veins, the presence of red spots and hepatocellular function - make it possible to most reliably predict bleeding (Fig. 10-51).

In alcoholic cirrhosis, the risk of bleeding is highest.

The likelihood of bleeding can be predicted using Doppler ultrasound. At the same time, the speed of blood flow through the portal vein, its diameter, the size of the spleen and the presence of collaterals are assessed. At high values stagnation index(the ratio of the area of ​​the portal vein to the amount of blood flow in it) there is a high probability of early development of bleeding.

Prevention of bleeding

It is necessary to strive to improve liver function, for example by abstaining from alcohol. Aspirin and NSAIDs should be avoided. Dietary restrictions, such as avoiding spices, or taking long-acting H2 blockers do not prevent the development of coma.

Propranolol - a non-selective b-blocker that reduces portal pressure by constricting the vessels of the internal organs and, to a lesser extent, reducing cardiac output. It also reduces blood flow through the hepatic artery. The drug is prescribed in a dose that reduces resting heart rate by 25% 12 hours after administration. The degree of decrease in pressure in the portal vein varies in different patients. Taking even high doses in 20-50% of cases does not give the expected effect, especially with advanced cirrhosis. The portal vein pressure should be maintained at a level not exceeding 12 mm Hg. . Monitoring of hepatic vein wedge pressure and portal pressure determined endoscopically is desirable.

Table 10-4. Classification of hepatic cell function in cirrhosis according to Child

Rice. 10-51. The significance of the increase in the size of varicose veins [small (M), medium-sized (S) and large (K)] in combination with the appearance of red spots (RS) on their surface (absent, single, many) and Child’s group (A, B, C) to determine the likelihood of bleeding over 1 year.

Propranolol should not be prescribed for obstructive pulmonary diseases. This may make resuscitation efforts difficult if bleeding occurs. In addition, it contributes to the development of encephalopathy. Propranolol has a significantly pronounced “first pass” effect, so in cases of advanced cirrhosis, in which the elimination of the drug by the liver is slow, unpredictable reactions are possible. In particular, propranolol somewhat suppresses mental activity.

A meta-analysis of 6 studies suggests a significant reduction in the incidence of bleeding, but not mortality (Fig. 10-52). A subsequent meta-analysis of 9 randomized trials found a significant reduction in the incidence of bleeding with propranolol treatment. It is not easy to select patients for whom this treatment is indicated, since 70% of patients with esophageal varices do not bleed. Propranolol is recommended for significant varicose veins and when red spots are detected during endoscopy. With a venous pressure gradient of more than 12 mm Hg, patients should be treated regardless of the degree of venous dilatation. Similar results were obtained when prescribing overdone. Similar rates of survival and prevention of the first episode of bleeding were obtained with treatment isosorbide-5-mononitrate [I]. This drug may impair liver function and should not be used in advanced cirrhosis with ascites.

Meta-analysis of studies on preventive sclerotherapy revealed generally unsatisfactory results. There is no evidence that sclerotherapy is effective in preventing the first episode of bleeding or improving survival. Prophylactic sclerotherapy is not recommended.

Diagnosis of bleeding

IN clinical picture of bleeding from varicose veins of the esophagus, in addition to the symptoms observed with other sources of gastrointestinal bleeding, symptoms of portal hypertension are noted.

Bleeding may not be severe and may appear as melena rather than bloody vomiting. The intestines may fill with blood before bleeding is recognized, lasting several days.

Bleeding from varicose veins in cirrhosis adversely affects hepatocytes. This may be due to decreased oxygen delivery due to anemia or increased metabolic demands due to protein breakdown after bleeding. A decrease in blood pressure reduces blood flow in the hepatic artery, which supplies blood to the regeneration nodes, as a result of which their necrosis is possible. Increased absorption of nitrogen from the intestine often leads to the development of hepatic coma (see Chapter 7). Deterioration of hepatocyte function can provoke jaundice or ascites.

Bleeding not associated with varicose veins is also often observed: from duodenal ulcers, gastric erosions or Mallory-Weiss syndrome.

In all cases, endoscopic examination should be performed to identify the source of bleeding (Fig. 10-53). An ultrasound is also required to determine the lumen of the portal and hepatic veins and to exclude a space-occupying lesion, such as HCC.

Rice. 10-52. Meta-analysis of 6 studies of prophylactic propranolol (beta blocker). Mortality data are unreliable due to the incomparability of the groups studied. However, a non-significant (ND) reduction in the incidence of bleeding was detected.

Rice. 10-53. Treatment of bleeding from varicose veins of the esophagus.

Based on a biochemical blood test, it is impossible to differentiate bleeding from varicose veins from ulcerative bleeding.

Forecast

In cirrhosis, the mortality rate from variceal bleeding is about 40% per episode. In 60% of patients, bleeding recurs before discharge from the hospital; Mortality within 2 years is 60%.

The prognosis is determined by the severity of hepatic cellular failure. The triad of unfavorable signs - jaundice, ascites and encephalopathy - is accompanied by 80% mortality. One-year survival rate at low risk (Child's groups A and B) is about 70%, and at high risk (Child's group C) - about 30% (Table 10-5). Determination of survival is based on the presence of encephalopathy, prothrombin time, and the number of units of blood transfused during the previous 72 hours. A conventional end-view gastroscope is inserted into the lower part of the esophagus and an additional probe is inserted under its control. Then the gastroscope is removed and a ligating device is fixed to its end. After this, the gastroscope is reinserted into the distal esophagus, the varicose vein is identified and aspirated into the lumen of the ligating device. Then, pressing on the wire lever attached to it, an elastic ring is put on the vein. The process is repeated until all varicose veins are ligated. From 1 to 3 rings are placed on each of them.

Table 10-7. Sclerotherapy for varicose veins

The method is simple and has fewer complications than sclerotherapy, although ligation of varicose veins requires more sessions)