Bleeding from dilated veins of the esophagus is a dangerous complication that can develop with 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 very poorly amenable to conservative therapy. To prevent the development of this pathology, it is extremely important to find out what provokes it, what symptoms are manifested, and how to help a patient with bleeding from varicose veins of the esophagus .
Description of the disease
Among the complications of portal hypertension syndrome, bleeding from dilated veins of the esophagus is most often diagnosed. According to ICD-10 (code (I85.0)), this pathology belongs to the category of circulatory system diseases.
Speaking about the mechanism of hemorrhage, the first thing to mention is a sharp jump in pressure within the portal vein or a violation of blood coagulation. Sometimes bleeding from dilated veins of the esophagus (in ICD-10, the disease is classified in the section “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 an increase in the blood vessels of the esophagus.
Development reasons
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 liver problems. By the way, disorders in the work of the gland caused by its viral or toxic injuries are the most common cause of bleeding from the dilated veins of the esophagus. For cirrhosis and other chronic liver pathologies, portal stagnation of blood and varicose veins is characteristic. 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 blood vessels are localized very close to the mucous membrane, directly beneath it, they can easily be injured and become a source of intense bleeding. In some cases, hemorrhage can only be stopped by a surgical method.
Among the local factors provoking the development of this complication, it is worth noting even insignificant at first glance episodes of damage to the esophagus mucosa. 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 esophagus walls of a foreign body, as well as burns of the mucosa or exposure to toxic substances. The probable factors in the development of hemorrhage sometimes become a diverticulum of the esophagus and an impaired diaphragmatic hernia.
Medical errors are considered a separate category of causes of bleeding from varicose veins of the esophagus. Damage to this section of the gastrointestinal tract occurs during careless diagnostic procedures and surgical procedures.
The main signs of chronic bleeding
The risk of hemorrhage is relatively low, and therefore such a 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 has a recurring permanent nature and is manifested by the so-called anemic syndrome, which is characterized by:
- physical and mental fatigue;
- pallor of the skin and mucous membranes;
- headache attacks;
- dizziness.
These and other symptoms of anemia should be the basis for a clinical blood test, according to which any specialist will detect reduced red blood cell and hemoglobin counts. They will become 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 has a separate symptom complex. The main sign of acute bleeding from the dilated veins of the esophagus is bloody vomiting. The masses erupting from the oral cavity have a bright red color without blood clots, which indicates a massive hemorrhage that has opened, caused by damage or perforation of the walls of the organ.
For comparison, in chronic bleeding from small-volume esophagus varicose veins, the color and texture of the vomit contents resembles coffee grounds due to the conversion of hemoglobin under the influence of hydrochloric acid. In this case, the vomit becomes cherry, clots are observed in them.
Another common symptom is a change in stool. With a constant entry of blood into the intestines, feces are converted into melena, so the feces resemble a black, semi-liquid, tar-like mass. Such a stool is observed not immediately after hemorrhage, but some time after rupture of blood vessels, which is explained by the corresponding time period for the passage of blood through the digestive tract to the anus. In most cases, for acute bleeding from varicose veins of the esophagus (according to ICD-10 it has code I85.0), patients experience pain in the lower chest 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 tract diseases, hepatitis, gastroesophageal reflux disease, ulcer), the doctor should inquire in detail about the origin of this complication of the patient or his relatives, the conditions for the occurrence of symptoms characteristic of the pathology whether weight lifting, the use of drugs preceded their appearance.
The most informative and easiest way to confirm chronic bleeding is the classic blood test, which allows you to determine a reduced level of hemoglobin in the blood and missing red blood cell counts. In addition, in case of difficulties in making a diagnosis, the patient is recommended to study excrement for occult blood, especially if the patient complains about specific changes in the stool.
An endoscopy of the lumen of the esophagus is able to put a point and determine the diagnosis with absolute accuracy. This diagnostic procedure makes it possible to visually detect the fact of hemorrhage in the esophagus, to determine the source of blood flow and to 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, since this is 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 methods of treatment are very effective. When a diagnosis is made, a transfusion of freshly citrated blood is carried out, compatible in the group and Rh accessories. The 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 red blood cells, as well as the hematocrit and blood pressure. 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, more than 1.5 liters of blood can be injected into the patient during the first day. In addition, plasma, “Vikasol”, “Pituitrin” are necessarily introduced. Additionally, drugs containing aminocaproic acid can be prescribed, a hemostatic sponge can be installed.
Oral ingestion during the treatment period is unacceptable. Until the bleeding stops, the patient is prescribed special preparations for parenteral administration. In addition, it is important to replenish the balance of fluids, electrolytes, salts and vitamins in his body. The infusion of drugs is carried out slowly, since repeated bleeding may develop due to a sharp overload of the vascular bed. 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 cope with general intoxication of the body. In severe anemia, which threatens the development of hypoxia, nasal catheters are installed for the patient to supply moistened oxygen.
In the case of complicated non-stopping 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 one percent concentration.
If the therapy was carried out in a timely manner, the patient's condition will begin to improve confidently after 6-8 hours: stabilization of the pulse, blood pressure is observed, pain in the sternum and upper abdomen passes. Despite stopping the bleeding from the dilated veins of the esophagus, it is impossible to refuse further treatment. The system for drip infusion is removed only after 24-36 hours after the last attack of bloody vomiting.
The patient does not stop doing transfusions of blood and vitamins until the hemoglobin level is stabilized. The course of antibacterial drugs is completed on the 7th-10th day; hormonal drugs are taken off even earlier. As soon as the general condition of the patient is normalized, he is prescribed a second blood test according to biochemical parameters, splenoportography and tonometry. Based on the results of diagnosis in the dynamics of recovery, a decision is made on the choice of a further treatment method.
Diet
During the first week from the moment when the patient is allowed to eat food orally, only liquid food can be fed to the patient. In the early days, you can drink cold kefir or milk. Include new foods in the diet very carefully. Only on the fourth day, liquid mashed potatoes, semolina, chicken broth are allowed.
From the eighth day, the diet expands significantly, now the patient’s menu may include crushed boiled or steam lean meat, rice or buckwheat, stewed vegetables.
Surgical intervention
Simultaneously with conservative treatment, the doctor often makes a decision to try to mechanically stop the hemorrhage, which is achieved by introducing Blackmore into the esophagus. While this device is in the esophagus, the patient is prescribed sedatives and painkillers. If the bleeding has not stopped during the sounding, the question of urgent surgery arises.
The choice of the method of intervention depends on the general well-being of the patient, as well as on whether the person already had to undergo surgery for portal hypertension. Patients who have previously undergone splenectomy with the creation of organoanastomoses, the operation is reduced to ligation of varicose veins or the cardiac section of the stomach. The operation aims to reduce the pressure in the portal vein by reducing the flow of blood to the dilated vessels of the esophagus.
Esophagus dilated vein ligation technique
This method is used not only to eliminate hemorrhage, but also to prevent it in the future. The patient occupies a position on the right side for thoracotomy in the left seventh intercostal space. Manipulation is carried out under general anesthesia. At the opening of the pleural cavity, the lung is pushed up, 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 longitudinal esophagotomy in the area of 5-6 cm. Large venous nodes are clearly visible in the lumen of the organ and submucosal layer. A stitching stitch is stitched on them in a staggered manner, and the esophageal wound is closed with double-row stitches in layers. The surgeon also sutures the mediastinal pleura, after which the lung is straightened with the help of the apparatus and the chest wound is sutured.
This operation has a lot of disadvantages, because at the time of flashing of the nodes of varicose veins there is a high risk of puncture of the vessel and the development of severe bleeding. In addition, the process of esophagotomy is often complicated by infection of the mediastinum, the development of purulent pleurisy or mediastinitis.
Relapse prevention
In order to prevent repeated episodes of esophageal hemorrhage and reduce blood flow to the altered veins, Tanner surgery is resorted to. Prevention of bleeding from varicose veins of the esophagus consists in flashing the veins of the precardial region without opening the gastric lumen. Such manipulation has a positive effect on the outcome of surgical intervention, which is especially important for complex unstoppable and chronic bleeding.