Bleeding from varicose veins of the esophagus in portal hypertension syndrome. Bleeding from varicose veins of the esophagus: why it occurs and how to eliminate it

Bleeding from the esophagus of the stomach of the duodenum

Symptoms

With small single or periodic bleeding, vomiting may be absent; in this case, 12-24 hours after bleeding, tarry stool. Symptoms of bleeding may occur long before vomiting of blood occurs.

Urgent Care

2. Calcium (sodium) chloride - 10 ml of a 10% solution intravenously. Calcium gluconate - 10 ml of a 10% solution intravenously or intramuscularly.

3. Blood transfusion - 50-25 ml (single group blood)

4. Vikasol - 1-2 ml of 1% solution intramuscularly.

Bleeding from esophageal varices

Symptoms

Bleeding from the veins of the esophagus is deadly, as it leads to rapid anemization and death.

Urgent Care

Fig.4. Stopping bleeding from varicose veins of the esophagus (scheme)

3. Gelatin - 50 ml of a 10% solution subcutaneously (preheat to body temperature).

4. Calcium (sodium) chloride - 10 ml of 10% solution intravenously. Calcium gluconate - 10 ml of a 10% solution intravenously. Vikasol - 1-2 ml of 1% solution intramuscularly.

5. Urgent hospitalization. Transportation is as gentle as possible, on a stretcher, only after the bleeding has stopped; with severe anemization, the head end of the stretcher should be lowered.

Bleeding from the intestines

Symptoms

Urgent Care

2. Calcium chloride - 10 ml of a 10% solution intravenously. Calcium gluconate - 10 ml of a 10% solution intravenously or intramuscularly. Sodium chloride - 10 ml of a 10% solution intravenously.

3. Hospitalization. Transportation is gentle, in the supine position.

V.F. Bogoyavlensky, I.F. Bogoyavlensky

Varicose veins of the esophagus: risk factors, symptoms, complications, treatment

It is unlikely that someone who does not have medical education offhand will say what the disease "phlebectasia" means. But having heard the phrase "varicose veins", many will be able to understand what in question. Simplified, this diagnosis sounds like varicose veins or varicose veins, which occurs both in older people and in young people. One of the forms of phlebectasia (from the Greek phlebos - vein and ektasis - stretching) is esophageal varicose veins.

Definition

Varicose veins of the esophagus are classified as pathological process during which deformation (lesion) of the veins of the esophagus occurs: not balanced the lumen of the venous vessels increases in the form of highlighting their walls, nodes are formed(local extensions). These deformed veins become tortuous, and the thinned mucosa over them becomes prone to inflammation or damage. Varicose veins appear during an increase in pressure in the blood circulation system that includes the vessels, that is, in. This phenomenon accompanies the process of outflow of blood into, serving as one of the largest veins in the human body. Its function is to collect venous blood from the lower body and delivering blood flow to right atrium where it opens up.

At the initial stage, varicose veins of the esophagus do not manifest themselves in any way, therefore, often a person with a similar disease does not even know about the impending threat and may long period do not complain to the doctor. Only when the veins, due to their fragility, begin to rupture and bleed, can one think of a disease. In addition, this bleeding is extremely dangerous for the life of a sick person.

Initial diseases

High pressure in the cavity of the portal vein, through which blood from the stomach, pancreas, spleen (digestive organs) passes to the liver, will be a factor causing esophageal varicose veins. High blood pressure syndrome allowable level, in the portal vein system in medicine is called, which, as a rule, accompanies the following diseases:

• Structural changes in the vessels of the liver and the organ as a whole ( chronic hepatitis, cirrhosis, tuberculosis, tumors, amyloidosis);
• Sclerosis;
• Thrombosis;
• Squeezing (narrowing of the lumen) of the portal vein: tumors of various sizes, including cysts, gallstones;

These diseases are defined as the main causes of varicose veins of the esophagus. In some cases, these primary sources of varicose veins are supplemented by another one - chronic, which causes an increase in pressure in the systemic circulation.

Depending on the pathology of the liver or of cardio-vascular system there are differences in the parameters of the affected veins:

1. If the cause of phlebectasia is liver disease, then the damaged veins are concentrated in the lower part of the esophagus or in central department stomach; if the cause of the disease is heart failure, then the deformed veins are localized throughout the organ;
2. In liver diseases, vascular nodes are 2-3 times larger than in cardiovascular insufficiency.

There is also congenital form esophageal varicose veins, the causes of which have not been established.

The root cause is cirrhosis of the liver

As medical practice shows, esophageal varicose veins are found in 70% of patients with cirrhosis of the liver.

The principle of interaction is simple: in cirrhosis, instead of healthy cells, scar tissue forms on the liver. This complicates the movement of blood, in the system of the portal vein of the liver there are congestion, which cause varicose veins in the lower (distal) zone of the esophagus. This chronic process accompanied by a violation of the healthy structure of the liver.

In adults, the most common causes of cirrhosis are:

• Frequent use of alcoholic beverages;
• Viral hepatitis;
• Reception medicines, negatively affecting the liver perenchyma;
• Some hereditary diseases.

Cirrhosis of the liver in newborns is usually the result of mothers suffering during pregnancy viral infections(rubella, herpes, hepatitis), which, having penetrated the placenta, affected the fetus in utero.

Signs of illness

According to medical statistics, the conclusion suggests itself that phlebectasia of the esophagus occurs in men 2 times more often than in women. Average age people who have been diagnosed specified disease, is 50 years old. The course of the disease is individual in each case. Development varicose disease the esophagus may be rapid or sluggish. In the first case, those with this disease for a long time may remain ignorant, and only minor symptoms will help to understand that certain disorders are occurring in the body. These include:

1. heartburn;
2. belching;
3. Slight difficulty swallowing food;
4. Discomfort and heaviness in the chest;
5. Cardiopalmus.

The listed symptoms often act as harbingers of esophagitis - an inflammatory process of the esophageal mucosa, which accompanies varicose veins.

The most serious and extremely unsafe complication of varicose veins of the esophagus is bleeding. With repeated blood loss due to development, the general condition of the human body worsens, weakness, shortness of breath, pallor appear, and weight is lost.

Danger of bleeding

Bleeding from the veins of the esophagus can often be imperceptible to a person, or profuse (significant), which poses a threat to life. Its prerequisites may be:

• Weight lifting;
• Increased blood pressure;
• Fever;
• Binge eating;
• Ordinary gastrointestinal diseases.

Before as there will be blood from damaged veins, a person may experience a slight tickling sensation in the throat and a salty taste in the mouth. After this, vomiting of blood is possible, the color of which ranges from scarlet to dark brown (the consistency and color of coffee grounds). Due to such blood loss, dizziness and darkening of the eyes are possible. without urgent medical intervention are fraught with death.

However, even in the case of minor blood loss, but with their repeated repetition (a vessel burst in the esophagus), there is a threat of development iron deficiency anemia, that is, there is a decrease in the concentration of iron, which is a constant component of heme in hemoglobin.

Diagnosis of the disease

It is possible to suspect varicose veins of the esophagus already during the initial examination by a therapist who, based on the history data, will prescribe laboratory and instrumental studies:

1. Disease history. An anamnesis in medicine is the totality of all the information obtained during the examination and questioning of the patient. Complaints of the patient about the current condition are listened to, it turns out whether the patient had previously suffered tumors, hepatitis. At medical examination the color of the skin and mucous membranes, the presence of edema are visually determined, palpation and percussion (percussion) are performed.
2. Laboratory research. The patient gives a general (with platelet count) blood test and biochemistry (liver enzymes, protein, albumin, serum iron, lipid spectrum). In some cases, there is a need for an in-depth study of the liver, since violations occurring in it can cause rupture of the vein of the esophagus and additional tests blood (coagulability and duration of bleeding, blood group according to the AB0 and Rhesus systems).
3. Row instrumental research(esophagoscopy, ultrasound, X-ray). These procedures are aimed at studying a specific area of ​​\u200b\u200bthe esophagus and peritoneal organs.

Formulating the diagnosis, the disease-root cause is indicated first, and then - varicose veins of the esophagus. Complications, if any, must be listed at the conclusion of the examinations.

X-ray and esophagoscopy

It is possible to detect dilated veins of the esophagus and obtain information about the nature of the disease when performing x-rays. The image will show the jagged contours of the esophagus, the convoluted shape of the mucosal folds, and possibly the presence of serpentine-like accumulations.

The most detailed and reliable information can be obtained by performing fibroesophagoscopy ( internal inspection surface of the esophagus). A damaged esophagus must be examined very carefully so as not to injure the fragile venous walls and not cause sudden bleeding. With the help of such a procedure, the causes of bleeding are identified, the degree of vein expansion and the condition of the venous walls are determined, whether there are extraesophageal bleeding factors, and a possible next rupture is predicted. It is often impossible to specifically establish the source of bleeding, because after the rupture the vessels subside, and the blood outlet is not determined.

In some cases, carrying out these two main studies helps to find the cause of bleeding: an ulcer, a collapsing tumor, Mallory-Weiss syndrome. The latter disease is accompanied by a rapid rupture of the mucous membrane of the lower esophagus, which can occur during vomiting.

Treatment Methods

The main goal of treatment for esophageal varices is to prevent bleeding.. However, if it does occur, then the first priority is to stop it and conduct therapy that prevents blood loss in the future.

Elimination of the threat of bleeding in the esophagus is possible if all efforts are directed to combat the disease that resulted in portal hypertension (hepatitis, thrombosis). Drugs used to treat heart disease (such as beta-blockers) can lower blood pressure and therefore the risk of bleeding. Nitroglycerin may also be an assistant in case of its long-term use.

The main classification of non-surgical treatment procedures is aimed at preventing and eliminating bleeding (hemostatic therapy) by reducing pressure in the vessels:

In cases where the listed methods are not enough to completely stop the bleeding and there is a risk of repeated damage to the vessels in the near future, they resort to operations: endoscopic or surgical.

Endoscopic interventions

Since the definition of such a diagnosis as varicose veins of the esophagus becomes possible, first of all, due to the ongoing endoscopy, the treatment of the disease often involves endoscopic hemostasis. Commonly used endoscopic procedures include:

1. Electrocoagulation;
2. The introduction of a probe to compress the veins, holding a tight tamponade;
3. Doping of the veins of the esophagus;
4. Bandage;
5. Application of thrombin or a special-purpose adhesive film to the affected areas of the veins.

Electrocoagulation involves the removal of damaged vein tissue electric shock. Sometimes doctors recommend to patients a procedure that involves the establishment of a bandage - small rubber discs that are fixed over dilated vessels. This helps stop bleeding.

The use of a rubber probe, for example, Sengstaken-Blackmore, to act on damaged veins involves pressing a bleeding vessel. This happens by inflating two balloons of the probe, which are securely fixed in the cardia and squeeze the deformed veins. Modern corrugated probes are also used in the treatment of stomach ulcers. However, if this method does not give the required results, compression with plugging balloons through the esophagoscope is used.

In case of poor tolerance of surgical interventions by patients, for example, with cirrhosis of the liver, doctors use the method of minimally invasive intervention - endoscopic ligation of varicose veins of the esophagus. This method of treatment consists in ligation of damaged veins with small elastic rings (from 1 to 3 rings are superimposed on each dilated vein) or with nylon loops in order to achieve complete collapse of the veins, followed by their sclerosis.

Surgical operations

Video: varicose veins of the esophagus

Bleeding from varicose veins of the esophagus, the treatment of which should be timely, is a life-threatening condition, a consequence of disease or damage to the vein by various factors.

Esophageal bleeding is a complication portal hypertension extreme gravity. It is characterized by an increase in pressure portal vein, splenomegaly and ascites. Portal hypertension appears when there is a violation of the venous outflow of different localization.

In most patients, the cause is in the liver, which causes bleeding from the veins of the esophagus in cirrhosis. Without appropriate treatment, this condition has an unfavorable prognosis, the patient can live no more than two years. ICD-10 code - esophageal varicose veins with bleeding 185.0.

We got acquainted with the issue of bleeding from the veins of the esophagus ICD 10, we move on. Bleeding in the esophagus as a complication of varicose veins develops due to damage to the mucosa or the vein itself by foreign sharp objects, ulcer, toxic and toxic substances. Less commonly, bleeding occurs due to aneurysm rupture, during and after surgery.

The cause of VRV () is directly stagnant processes that occur during cirrhosis or thrombosis of the liver. The disease of the upper part of the organ is associated with the formation of goiter and vascular pathology in the disease. Randu-Osler.

Bleeding from dilated veins of the esophagus and cardia develops suddenly under the influence of such factors:

• a sharp increase in blood pressure;
• exacerbation of pathologies of the gastrointestinal tract;
• straining and lifting weights.

precede this discomfort in the throat, vomiting blood, blurred vision and other symptoms of increasing blood loss.

Esophageal RVV bleeding is most commonly diagnosed in people with cirrhosis.

The development of varicose veins is due to the relationship venous system gastrointestinal tract and hepatobiliary system. Violation in any department can become a factor in the underlying disease and its subsequent complications, including bleeding.

Clinical signs and symptoms of bleeding from the esophagus

Clinical symptoms of bleeding from varicose veins of the esophagus include complaints in different period disease and at the time of blood loss, as well as external manifestations underlying pathology and related disorders. Patient complaints:

With such complaints, the doctor collects an anamnesis of the disease. It turns out which medicines the patient takes, and what kind of food he eats. In the anamnesis of patients with bleeding from the veins of the esophagus, there is often past illnesses liver, acute consumption, coarse food, heavy physical labor, previously carried out .

External signs when examining a patient:

• yellowness of the skin;
• cold sweat;
• increase in the volume of the abdomen;
• swelling of the legs;
• weak pulse and rapid breathing.

With severe blood loss, a person behaves restlessly, consciousness is inhibited and confused. Without timely assistance, a collapse is observed, which ends in a coma.

Diagnostics

Examination for such a phenomenon as bleeding from the esophagus includes:

If concomitant abnormalities are identified, an examination by a neurologist, oncologist, infectious disease specialist or cardiologist is prescribed.

Differential diagnosis is carried out with the disease Wilson-Konovalov, syndrome Mallory-Weiss, schistosomiasis.

First aid

On pre-medical stage help when bleeding from varicose veins of the esophagus is observed, conditions must be created to limit blood loss. The patient is placed on his back horizontal position, the head turns to the side so that the blood can go out with the vomit and not fall into the peritoneum. It is necessary to ensure a comfortable temperature, cover or free from clothing.

Pulse and blood pressure are monitored. When the pressure drops to 80 there is a risk hemorrhagic shock, anti-shock measures will be required. Loss of consciousness indicates severe blood loss. To avoid this, the patient can be given cold water. Other liquids and food are strictly contraindicated. Upon arrival of the ambulance, the patient is transported on a stretcher.

Methods of treatment

The main goal of treatment is to monitor the source of bleeding and prevent secondary blood loss. After stopping the bleeding, the patient is prescribed diet No. 5.

First of all, the following methods are considered:

• Blackmore probe;
• vein sclerosis;
• dressing using gastrectomy or endovascular embolization.

Emergency treatment includes the administration of sodium hydrochloride. At the inpatient level, treatment differs depending on the degree of blood loss. A solution of glucose, sodium lactate, sodium acetate and gelatin is injected intravenously in different concentrations and quantities.

Follow-up activities include drug treatment, elimination of accompanying deviations. Vasoconstrictor therapy may be prescribed, endoscopic sclerotherapy and surgery when conservative methods fail.

Medical therapy

Medicines are used already at the stage of first aid. The patient is injected intravenously with sodium hydrochloride or dopamine. In the hospital, drugs are prescribed to normalize portal pressure. Fixed assets - Meropenem, vasoconstrictor, and its analogues - Vapreotil or Octreotide.

Medications to stop bleeding in the veins of the esophagus:

With concomitant bacterial peritonitis appointed antibacterial drugs in a week. For this purpose, cephalosporins are used - Ceftazidime, Cefotaxime And Cefoperazone. Alternative Therapy administered with fluoroquinolones, Ciprofloxacin And Ofloxacin. When the condition of the kidneys worsens, it is prescribed intravenously sodium chloride, octreotide, albumen.

Non-drug methods

Treatment of bleeding from varicose veins of the esophagus is carried out by endoscopic sclerotherapy. A sclerosing drug is injected into the damaged vein. This method allows you to stop bleeding in 85% of cases. If carrying out two procedures does not give a result, they resort to other methods. A probe is inserted into the esophagus to compress the site of bleeding.

What other treatments are used? This:

• electrocoagulation;
• application of thrombin or adhesive film to the damaged vein
• endoscopic ligation.

Useful video

Why is bleeding from varicose veins of the esophagus dangerous? The clinic of this phenomenon is already clear. Measures that should be taken by patients are announced in this video.

Operation

Surgical treatment options:

• operation TIPS;
• transverse subcardial gastrotomy;
• operation M.D. Patsiors.

Indications for surgery are the ineffectiveness of pharmacological treatment, prolonged bleeding with the impossibility of endoscopic hemostasis. Operation Tips ( transjugular intrahepatic portocaval shunting) indicated for portal hypertension, asthenic syndrome and acute esophageal bleeding.

The effectiveness of surgical treatment is evaluated according to the following criteria:

• stop bleeding;
• no recurrence;
• improved prognosis;
• remission concomitant diseases GIT.

IN severe cases with cirrhosis, a decision is made on liver transplantation.

Prevention of secondary bleeding in VRV

After the main treatment, prevention of secondary blood loss is carried out. Appointed combination therapy with the use of drugs to normalize portal pressure. These are drugs Nadolol And propranolol. Sclerotherapy is performed if a different method was used at the stage of first aid.

Appointed ligation, with an interval of several weeks, rings are applied to the veins. The patient is constantly monitored, regular examinations are carried out by a hepatologist and a gastroenterologist.

Gap prediction

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

There is a clear correlation between the size of varicose veins seen during endoscopy and the likelihood of bleeding. The pressure inside the 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. Schematic representation of the incision of the liver in the area of ​​the gate, where nodes are visible, squeezing the portal vein. The rest of the liver looks normal.

An important factor influencing more likely bleeding, are red spots that can be seen with endoscopy.

To assess the function of hepatocytes 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 assigned to one of the groups. Child Group - most important indicator to assess the likelihood of bleeding. In addition, this group correlates with the size of 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 - allow the most reliable prediction of bleeding (Fig. 10-51).

Alcoholic cirrhosis has the highest risk of bleeding.

The likelihood of bleeding can be predicted using Doppler ultrasound. At the same time, the velocity 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), the likelihood of early development of bleeding is high.

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 the exclusion of spices, as well as the use of long-acting H2-blockers, do not prevent the development of coma.

Propranolol - non-selective b-blocker that reduces pressure in the portal vein by constriction of blood vessels internal organs and, to a lesser extent, a decrease cardiac output. It also reduces blood flow hepatic artery. The drug is prescribed at a dose that reduces the resting heart rate by 25% 12 hours after administration. The degree of pressure reduction in the portal vein is not the same in different patients. Taking even high doses in 20-50% of cases does not give the expected effect, especially with advanced cirrhosis. The pressure in the portal vein should be maintained at a level no higher than 12 mm Hg. . Monitoring of hepatic vein wedge pressure and endoscopically determined portal pressure is desirable.

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

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

Propranolol should not be prescribed for obstructive pulmonary disease. This may make it difficult resuscitation when bleeding occurs. In addition, it contributes to the development of encephalopathy. Propranolol has a significantly pronounced “first pass” effect, therefore, with advanced cirrhosis, in which the excretion of the drug by the liver is slowed down, unpredictable reactions are possible. In particular, propranolol somewhat suppresses mental activity.

A meta-analysis of 6 studies suggests a significant reduction in bleeding but not mortality (Fig. 10-52). A subsequent meta-analysis of 9 randomized trials found a significant reduction in 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 sizes of 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 vein dilatation. Similar results were obtained with the appointment overwhelmed. 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 therefore not be used in advanced cirrhosis with ascites.

Meta-analysis of studies on preventive sclerotherapy found generally unsatisfactory results. There are no data on the effectiveness of sclerotherapy in preventing the first episode of bleeding or improving survival. Preventive sclerotherapy is not recommended.

Diagnosis of bleeding

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

Bleeding may be mild and manifest as chalky rather than hematemesis. The bowel may fill with blood before bleeding that has lasted for several days is recognized.

Bleeding from varicose veins in cirrhosis adversely affects hepatocytes. The reason for this may be a decrease in oxygen delivery due to anemia or an increase in metabolic requirements 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.

Often there is also bleeding that is not associated with varicose veins: from an ulcer duodenum, erosions of the stomach or with Mallory-Weiss syndrome.

In all cases, endoscopic examination should be performed to identify the source of bleeding (Fig. 10-53). Ultrasound is also required to determine the lumen of the portal and hepatic veins and to exclude mass formation, such as HCC.

Rice. 10-52. Meta-analysis of 6 studies on the prophylactic use of propranolol (a beta-blocker). Mortality data are unreliable due to the incomparability of the studied groups. Nevertheless, a non-significant (ND) decrease in the frequency of bleeding was found.

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

Based biochemical analysis blood it is impossible to differentiate bleeding from varicose veins from ulcerative.

Forecast

In cirrhosis, mortality from bleeding from varicose veins is about 40% with each 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 hepatocellular insufficiency. The triad of unfavorable signs - jaundice, ascites and encephalopathy - is accompanied by 80% mortality. The one-year survival rate for low risk (Child groups A and B) is about 70%, and for high risk (Child group C) is about 30% (Table 10-5). The definition of survival is based on the presence of encephalopathy, prothrombin time, and the number of blood units transfused during the previous 72 hours. IN lower part the esophagus is injected with a conventional gastroscope with an end view and an additional probe is carried out under its control. Then the gastroscope is removed and a ligating device is fixed to its end. After that, the gastroscope is reintroduced into the distal esophagus, the varicose vein is identified, and it is aspirated into the lumen of the ligating device. Then, by 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. Each of them impose from 1 to 3 rings.

Table 10-7. Sclerotherapy of varicose veins

The method is simple and gives fewer complications than sclerotherapy, although more sessions are required for ligation of varicose veins)