Varicose veins of the esophagus

Varicose veins of the esophagus is observed in the distal esophagus or proximal stomach, caused by increased pressure in the portal venous system, which is characteristic of cirrhosis of the liver. Varicose veins may be complicated by massive bleeding without prior symptoms. The diagnosis is made by endoscopy, and treatment includes, first of all, endoscopic flashing and intravenous administration of octreatide. Sometimes transjugular intrahepatic portosystemic (portocaval) shunting is necessary.

Causes of esophageal varices

The main symptom of any vascular disease of the esophagus is almost always a symptom of esophageal bleeding. These bleedings can occur when the esophagus and a large vessel lying nearby are wounded, for example, when a large foreign body is fixed in the esophagus with sharp and cutting edges; during germination of the esophagus tumor in any large vessel of the mediastinum and its breakthrough, for example, in the descending part of the aorta. Bleeding from the vessels of the esophagus itself is most often observed when its wall is damaged by a stiff esophagoscope, an acute foreign body, arroses of the vessel by the ulcer process or a decaying tumor; with congenital or acquired varicose veins of the esophagus. Acquired varicose veins of the esophagus are much more common than congenital, and sometimes reach significant sizes. Bleeding from these sacciform venous masses can occur both spontaneously and even with very carefully performed fibroesophagoscopy.

The cause of varicose veins of the esophagus in the lower part of the esophagus are congestion in the portal portal vein of the liver, which occurs during liver cirrhosis and thrombosis v. Portae. In the upper section, varicose veins of the esophagus occurs in malignant goiter. Among other reasons, it should be noted angioma of the esophagus and vascular changes in the disease Randy - Osler.

Bleeding can occur spontaneously, when straining, lifting weights, raising blood pressure, common gastrointestinal diseases, feverish conditions. It can recur, occur without any symptoms among the "full health" and, becoming abundant, lead to death. A precursor of such bleeding may be a slight tickling in the throat, a peculiar salty-sour taste in the mouth, and then there is a sudden vomiting of scarlet, and sometimes blood, resembling coffee grounds. With significant blood loss, anxiety, weakness, blackening in the eyes with photopsies, dizziness, and other signs of increasing blood loss appear.

Varicose veins of the esophagus with respect to other causes of esophageal bleeding is very common, especially in persons suffering from cirrhosis of the liver.

Liver cirrhosis is a chronic disease characterized by a violation of the structure of the liver due to the proliferation of connective tissue and pathological regeneration of the parenchyma, manifested by severe signs of failure of numerous liver functions and portal hypertension. The most common causes of cirrhosis in adults are chronic alcoholism and viral hepatitis, mainly hepatitis B. The development of cirrhosis can be caused by taking certain drugs (methotrexate, isoniazid, etc.), exposure to a number of hepatotoxic drugs, less often they are observed in some hereditary diseases - galactosemia, beta1-antitrypsin deficiency, hepatocerebral dystrophy, hemochromatosis, etc. Liver cirrhosis caused by venous congestion in the liver (congestive liver cirrhosis) is observed I at long heart failure, a disease of the hepatic veins and inferior vena cava. Cirrhosis of the liver in children can be observed already in the neonatal period due to liver damage in the antenatal period (fetal hepatitis). The reason may be mother-borne viral infections (hepatitis, cytomegaly, rubella, herpes infection), in which the virus is transmitted to the fetus through the placenta.

The cause and pathogenesis of esophageal varicose veins are determined by the anatomical connection of the esophagus veins with the venous system of the portal vein and the veins of the spleen, as well as other abdominal organs, the diseases of which lead to the blockade of their venous networks and the development of esophageal varicose veins. The development of these pathological formations in the veins of the esophagus can be caused by compression of the portal vein also in diseases such as tumors, peritonitis, adenopathy, portal vein thrombosis, its angiomas, splenomegaly, etc. Circulatory disorders in the venous system of the spleen can be caused by such diseases like Banti syndrome (secondary splenogenic splenohepatomegalic symptom complex - anemia, thrombocytopenia, leukopenia, congestive splenomegaly, portal liver cirrhosis with symptoms of portal hypert nzii; often occurs in women younger than 35 years; the disease, but modern ideas, is polyetiological; this syndrome may develop as a result of intoxication and various infections, especially malaria, syphilis, brucellosis, leishmaniasis, etc.), atrophic cirrhosis of Laennec, chronic lymphocytic leukemia and others. Among other causes that can cause varicose veins of the esophagus, it is necessary to name some diseases of the stomach and pancreas, as well as hemodynamic disturbances in the superior vena cava. For the development of varicose veins of the esophagus, age does not matter. The whole process is determined by an emerging condition that interferes with normal blood flow in the portal vein system.

[1], [2]

Symptoms of varicose veins of the esophagus

The symptoms of varicose veins of the esophagus and the clinical course are determined by the cause of this disease (gastroenterology) diseases of the gastrointestinal tract. Most often, the evolution of the disease is characterized by progressive development. Most often, the initial period of development of the disease is asymptomatic as long as no bleeding from the esophagus develops. Bleeding can be from minor to profuse with a fatal outcome. Chronic blood loss, even of small amounts of blood, leads to hypochromic anemia, general weakening of the body, weakness, shortness of breath, pallor, and emaciation. Melena is often observed.

The evolution of the disease can proceed very slowly or develop very quickly. With the slow development of varicose veins of the esophagus, patients remain for a long time in the dark about the development of a terrible disease in them, in other cases, with the rapid development of the varicose process in the esophagus a few days before bleeding, patients experience a feeling of constriction in the chest. Sometimes the feeling of heaviness and pressure in the chest can be the harbingers of fatal bleeding. Data from some foreign researchers indicate a high level of legality from bleeding with varicose veins of the esophagus, an average of 4 deaths per 5 patients. Hence the importance of early diagnosis of this disease.

Diagnosis of varicose veins of the esophagus

The diagnosis of varicose veins of the esophagus is made by means of fibroesophagoscopy, which establish the causes of bleeding, the presence or absence of extraesophageal factors, determine the degree of dilatation of the veins and the condition of their walls, predict rupture of another aneurysm. With current bleeding, it is often difficult to establish its cause due to the impossibility of effectively performing esophagoscopy. Many other causes may also be implicated in the hyoid bone, details of which are given in subsequent sections on esophageal diseases. Certain information about the nature of esophageal varicose veins can be obtained by x-ray examination of the esophagus with contrast.

Since varicose veins are usually associated with severe liver disease, an evaluation of possible coagulopathy is important. Laboratory tests include a complete blood count with quantification. platelets, Prothrombin time, APTT, functional liver tests Patients with bleeding need to determine blood type, Rh factor and cross-compatibility test for 6 doses of erythrocyte mass.

[3], [4], [5]

Treatment of varicose veins of the esophagus

Treatment of varicose veins of the esophagus is aimed at compensating for hypovolemia and hemorrhagic shock. Patients with impaired coagulation (eg, an increase in MHO) require intravenous transfusion of 1-2 doses of fresh frozen plasma and 2.5-10 mg. vitamin K intramuscularly (or intravenously with heavy bleeding).

Since esophageal varicose veins are primarily diagnosed with endoscopy, primary treatment involves endoscopic hemostasis. Endoscopic vein flashing is preferable to injection sclerotherapy. At the same time, octreotide (synthetic somatostatin analogue) should be administered intravenously. Octreotide increases visceral vascular resistance by inhibiting the release of visceral vasidilating hormones (eg, glucagon and vasoactive intestinal peptide). The usual dose is 50 µg intravenously, followed by an infusion of 50 µg / hour. The use of octreotide is preferable to the use of other medications, such as vasopressin and terlipressin, since this drug has fewer side effects.

If, despite the treatment, the bleeding continues or recurs, the use of emergency methods of shunting (discharge) of blood from the portal system into the inferior vena cava can reduce portal pressure and reduce the bleeding. Transjugular intrahepatic portosystemic shunting (TIPS) is an emergency intervention of choice: the method is an invasive endovascular under x-ray control procedure in which the metallic conductor from the vena cava penetrates the portal bloodstream. The resulting fistula expands with a balloon catheter and a metal stent is inserted, creating a shunt between the portal blood flow and the hepatic veins. The size of the stent is fundamentally important: if it is too wide, hepatic encephalopathy develops due to too much discharge of portal blood from the liver into the systemic circulation. On the other hand, small stents tend to be occluded. Surgical portocaval shunting, such as the distal spleno-renal anastomosis, has a similar mechanism, but is more risky and entails a higher mortality rate.

For severe bleeding, rubber blowing probes are used to stop bleeding by pressing a bleeding vessel, such as the Sengstaken-Blakemore probe. Currently, for this there are corrugated probes, obturators, which are used to stop bleeding from the varicose veins of the esophagus and when the stomach ulcer is bleeding.

Through the probe, introduced below the bifurcation, you can wash the esophagus with hot water (40-45 ° C) than sometimes it becomes possible to bleed. Repeated bleeding requires the use of all those measures for any prolonged bleeding (intravenous administration of 10-20 ml of 10% calcium chloride solution, intramuscular injection - Vikasol). To introduce a means of increasing blood pressure, to a complete stop of bleeding should not be because of the danger of increasing the latter.

With massive blood loss, intravenous administration of blood, plasma, blood-substituting fluids, pituitrin, platelet mass, etc., is performed.

When repeated bleeding may require intervention on the vessels of the portal vein of the liver. With the damage of very large vessels, patients die quickly.

Forecast

In approximately 80% of patients, bleeding from varicose veins stops spontaneously. However, esophageal varicose veins have a high mortality rate and often more than 50%. Mortality depends primarily on the severity of the underlying liver disease, and not on the severity of bleeding; bleeding is often fatal in patients with severe hepatocellular insufficiency (eg, progressive cirrhosis of the liver), while patients with good liver function usually recover.

In surviving patients with a high risk of bleeding from varicose veins, usually in 50-75% of cases there is a relapse of bleeding over the next 1-2 years. Continuous endoscopic and drug treatment of esophageal varicose veins significantly reduces this risk, but overall the effect on long-term survival remains extremely low, mainly due to the underlying liver disease.

[6]