Bleeding from dilated veins of the esophagus is a dangerous complication that can develop in a number of diseases of the liver and upper digestive tract. This pathology is characterized by profuse hemorrhage into the lumen of the internal organs. This condition develops, as a rule, rapidly and responds very poorly to conservative therapy. To prevent the development of this pathology, it is extremely important to find out what provokes it, what symptoms it manifests and how to help a patient with bleeding from esophageal varices.
Description of disease
Among the complications of portal hypertension syndrome, bleeding from the dilated veins of the esophagus is most often diagnosed. According to ICD-10 (code (I85.0)) this pathology belongs to the category of diseases of the circulatory system.
Speaking about the mechanism of development of hemorrhage, first of all, we should mention a sharp jumppressure within the portal vein or bleeding disorders. Sometimes bleeding from dilated veins of the esophagus (in the ICD-10 the disease is classified in the subsection "Diseases of the veins, lymphatic vessels and lymph nodes, not elsewhere classified") is regarded as the first clinical manifestation of portal hypertension. Hemorrhage often develops in childhood in patients who have already been operated on due to enlarged blood vessels in the esophagus.
Reason for development
Pathology can be the result of a number of diseases of the digestive system, ranging from ailments that directly affect the esophagus and gastrointestinal tract, and ending with problems with the liver. By the way, disorders in the functioning of the gland caused by its viral or toxic damage are the most common cause of bleeding from the dilated veins of the esophagus. Cirrhosis and other chronic liver pathologies are characterized by portal stasis of blood and varicose veins. A natural result of the progression of such diseases is the expansion of the superficial venous plexus in the lower part of the esophagus. Since the blood vessels are localized very close to the mucous membrane, directly below it, they can easily be injured and become a source of intense bleeding. In some cases, the only way to stop a hemorrhage is through surgery.
Among the local factors provoking the development of this complication, it is worth noting even seemingly insignificant episodesdamage to the mucous membrane of the esophagus. These include:
- reflux esophagitis;
- Barrett's esophagus;
- malignant tumors (especially often squamous cell carcinoma or adenocarcinoma).
In addition to these reasons, bleeding can occur as a result of trauma to the surface of the esophageal walls with a foreign body, as well as burns of the mucous membrane or exposure to toxic substances. Esophageal diverticulum and strangulated diaphragmatic hernia sometimes become probable factors in the development of hemorrhage.
To a separate category of causes of bleeding from varicose veins of the esophagus include medical errors. Damage to this section of the gastrointestinal tract occurs during careless diagnostic procedures and surgical procedures.
Main signs of chronic bleeding
The risk of hemorrhage is relatively low, and therefore this pathology is extremely rare. But at the same time, bleeding from the dilated veins of the esophagus should not be confused with chronic bleeding caused by minor damage to the mucous membrane. Such a hemorrhage is of a recurrent permanent nature and is manifested by the so-called anemic syndrome, which is characterized by:
- quick physical and mental fatigue;
- pallor of skin and mucous membranes;
- headache attacks;
- dizziness.
These and other symptoms of anemia should be the basis for the delivery of a clinical blood test, according to the resultswhich any specialist will reveal reduced levels of red blood cells and hemoglobin. They will be the reason for a more thorough diagnosis. Rarely, bleeding can cause snoring during pregnancy.
Symptoms of acute hemorrhage
Types of bleeding from dilated veins of the esophagus in the ICD-10 are not divided into chronic and acute. Moreover, the latter is intense, it is characterized by a separate symptom complex. The main symptom of acute bleeding from dilated veins of the esophagus is hematemesis. The masses erupting from the oral cavity are bright red in color without blood clots, which indicates a massive hemorrhage caused by damage or perforation of the walls of the organ.
For comparison, in chronic bleeding from varicose veins of the esophagus of small volume, the color and consistency of the vomit resembles coffee grounds due to the conversion of hemoglobin under the influence of hydrochloric acid. In this case, the vomit acquires a cherry hue, clots are observed in them.
Another common symptom is changes in stool. With constant blood entering the intestines, feces are converted into melena, so the feces resemble a black, semi-liquid, tar-like mass. Such a chair is observed not immediately after the hemorrhage, but some time after the rupture of the vessels, which is explained by the corresponding time period for the passage of blood through the gastrointestinal tract to the anus. In most cases for acute bleedingfrom varicose veins of the esophagus (according to ICD-10 code I85.0), patients develop pain in the lower part of the thoracic or upper epigastric part of the abdomen.
Examination of patients with suspected bleeding
If the patient has a history of diseases that can provoke hemorrhage from the veins of the esophagus (liver cirrhosis, gastrointestinal diseases, hepatitis, gastroesophageal reflux disease, ulcer), the doctor should ask in detail about the origin of this complication of the patient or his relatives, conditions the onset of symptoms characteristic of the pathology, whether they were preceded by weight lifting, the use of drugs.
Informative and the easiest way to confirm chronic bleeding is a classic blood test, which allows you to determine the reduced level of hemoglobin in the blood and the missing red blood cells. In addition, if there are difficulties in making a diagnosis, the patient is recommended to study excrement for occult blood, especially if the patient complains of specific changes in the stool.
Endoscopy of the lumen of the esophagus is capable of putting an end and determining the diagnosis with absolute accuracy. This diagnostic procedure makes it possible to visually detect the fact of hemorrhage in the esophagus, determine the source of blood flow and build further treatment tactics. The choice of therapeutic technique will largely depend on the volume and nature of the lesion, the abundance of blood loss, sinceWe are talking about an emergency and life-threatening condition of the patient. With bleeding from the dilated veins of the esophagus, treatment should not be delayed.
Conservative Therapy
In uncomplicated cases, non-radical treatments are very effective. When establishing a diagnosis, a transfusion of freshly citrated blood is carried out, compatible in group and Rh-affiliation. Infusion is carried out through the subclavian vein. The volume of injected blood is determined by the general well-being of the patient, the level of hemoglobin and erythrocytes, as well as the hematocrit and blood pressure indicators. The minimum amount of blood for transfusion is 200-250 ml, but in case of severe bleeding from varicose veins of the esophagus, which does not stop, the patient may receive more than 1.5 liters of blood during the first day. In addition, plasma, "Vikasol", "Pituitrin" are necessarily injected. Additionally, they can prescribe drugs containing aminocaproic acid, install a hemostatic sponge.
Eating orally during the treatment period is unacceptable. Until the bleeding is stopped, the patient is prescribed special drugs for parenteral administration. In addition, it is important to replenish the balance of fluid, electrolytes, s alts and vitamins in his body. The infusion of drugs is carried out slowly, because due to a sharp overload of the vascular bed, re-bleeding may develop. In order to prevent hyperthermic syndrome, therapeutic solutions are cooled to a temperature of 32-33 ° C, and an ice compress is placed on the epigastric region.
Follow-up treatment
Bleeding from varicose veins of the esophagus requires the appointment of antibacterial drugs and other medications that will help to cope with the general intoxication of the body. In severe anemia, which threatens the development of hypoxia, the patient is fitted with nasal catheters to supply humidified oxygen.
In case of complicated intractable bleeding, steroid preparations (Dexamethasone, Prednisolone) are included in the therapeutic program. If portal hypertension develops inside the kidneys, then in order to develop insufficiency, a solution of "Glutamic acid" is prescribed in a one percent concentration.
If the therapy was carried out in a timely manner, the patient's condition will begin to improve steadily after 6-8 hours: stabilization of the pulse, blood pressure is observed, pain in the sternum and upper abdomen disappears. Despite the stop of bleeding from the dilated veins of the esophagus, it is impossible to refuse further treatment. The drip system is removed only 24-36 hours after the last bout of hematemesis.
The patient does not stop transfusions of blood and vitamins until the level of hemoglobin stabilizes. The course of antibacterial drugs is completed on the 7-10th day, even earlier they stop taking hormonal drugs. As soon as the patient's general condition returns to normal, he is prescribed repeated blood tests for biochemical parameters, splenoportography and tonometry. According to the results of diagnosis in the dynamics of recovery, it is accepteddecision on the choice of further treatment method.
Diet
During the first week from the moment when the patient is allowed to eat food orally, the patient can only be fed liquid food. In the early days, you can drink cold kefir or milk. You need to be very careful when introducing new foods into your diet. Only on the fourth day, liquid mashed potatoes, semolina, chicken broth are allowed.
From the eighth day, the diet has been significantly expanded, now the patient's menu can include chopped boiled or steamed lean meat, rice or buckwheat porridge, stewed vegetables.
Surgery
Simultaneously with conservative treatment, the doctor often decides to try to mechanically stop the hemorrhage, which is achieved by inserting a Blackmore obstructive probe into the esophagus. While the device is in the esophagus, the patient is prescribed sedatives and painkillers. If the bleeding has not stopped during the probing, the question arises of an urgent surgical operation.
The choice of method of intervention depends on the patient's general well-being, as well as whether the person has already undergone surgery for portal hypertension. For patients who have undergone previous splenectomy with the creation of organ anastomoses, the operation is reduced to ligation of varicose veins or the cardial part of the stomach. Surgery aims to reduce pressure in the portal vein by reducing blood flow to thedilated vessels of the esophagus.
Esophageal vein ligation technique
This method is used not only to eliminate hemorrhage, but also to prevent it in the future. The patient takes a position on the right side for thoracotomy in the left seventh intercostal space. Manipulation is carried out under general anesthesia. When opening the pleural cavity, the lung is moved upward, then the mediastinal pleura is opened and the esophagus is removed in its lower segment by 6-8 cm and rubber holders are placed under it.
The next step during the operation is a longitudinal esophagotomy in the area of 5-6 cm. Large knots of veins are clearly visible in the lumen of the organ and the submucosal layer. A twisting suture is placed on them in a checkerboard pattern, and the esophageal wound is closed with two-row sutures in layers. The surgeon also sews up the mediastinal pleura, after which the lung is expanded with the help of the device and the wound of the chest is sutured.
This operation has a lot of disadvantages, since at the time of stitching the knots of varicose veins there is a high risk of puncture of the vessel and the development of severe bleeding. In addition, the process of esophagectomy itself is often complicated by infection of the mediastinum, the development of purulent pleurisy or mediastenitis.
Relapse Prevention
To prevent recurrent episodes of esophageal hemorrhage and reduce blood flow to the altered veins, the Tanner operation is performed. Prevention of bleeding from varicose veins of the esophagusconsists in flashing the veins of the precordial region without opening the gastric lumen. Such manipulation has a positive effect on the outcome of surgery, which is especially important for both complex non-stop and chronic bleeding.
