Esophageal varices (esophageal varices). What to do if there is bleeding from varicose veins? Stopping bleeding of esophageal varices

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 shown schematically, 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 mmHg. . 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)