Esophageal varicose veins

Diagnostic endoscopy for esophageal varicose veins

Esophageal varicose veins are a serious pathology caused by diseases of the liver, heart, digestive organs, and more or less often the venous wall. It is more frequently observed in the lower extremities along with the defeat of the abdominal veins in men after 50 years.

Massive bleeding may be unexpected and the only sign. Timely diagnosis is necessary to take preventive measures. To eliminate esophageal varicose veins, special surgical approaches have been developed in vascular surgery.

In the International Classification, the disease is accounted for under different codes:

  • I85. 9 - without bleeding;
  • I85. 0 - with bleeding;
  • I98. 2 - against the background of other pathologies.

How does blood flow through the esophageal veins?

The esophagus is connected to the blood supply to many organs of the chest and abdominal cavity. The branches of the arteries to him go from the thoracic aorta. The venous apparatus does not develop unevenly. Blood flows through the esophageal vein into the unpaired and semi -unpaired venous ducts, then through the anastomosis through the diaphragmatic vein into the inferior vena cava, and through the abdominal venous network into the portal vein. heart.

From the upper part of the esophagus, venous outflow enters the superior venous canal. The anatomical arrangement and connection form the esophageal venous apparatus, as an intermediary between the three outflow systems: the portal vein, the inferior vena cava and the superior vein.

This feature triggers the occurrence of compensatory varicose veins at the level of the esophagus due to the opening of additional channels (collateral) in diseases of the spleen, intestines, accompanied by blockage of their own veins.

Reason for expansion

Esophageal varicose veins are provided by two mechanisms. There is either difficulty in outflow due to mechanical obstruction in the basic part of the venous system (hypertension, thrombosis, phlebitis), or loss of venous wall tone due to disruption of collagen fiber synthesis (SMV varicose veins).

The cause of stagnation in the upper part is often malignant goiter. In the lower part of the esophagus, venous blood flow is delayed because:

  • portal hypertension caused by liver cirrhosis;
  • portal vein thrombosis.

Rare causes of esophageal varicose veins (EVV) are vascular tumors (angiomas) and venous changes in Rendu-Osler syndrome.

Cirrhosis of the liver is a long -term chronic disease that complicates hepatitis (in the first place - hepatitis B virus), an alcoholic disease with fatty degeneration. Pathological changes are expressed by violation of the structure of the hepatic lobules and the surrounding space.

There is proliferation of dense scar (connective) tissue, replacement of functioning cells with tubercles with the formation of liver failure. Under these conditions, both arterial and venous channels are compressed. A reduction in oxygen supply worsens the condition, causing organ ischemia.

Cirrhosis of the liver can cause:

  • medicines;
  • congestive heart failure with disability, complications of extensive infarction, myocardial dystrophy, cardiopathy;
  • hereditary diseases with metabolic changes (galactosemia, hepatocerebral dystrophy, hemochromatosis);
  • fetal hepatitis in the newborn occurs when the mother has an infection (rubella, herpes, cytomegalovirus), when the pathogen is transmitted to the fetus through the placental barrier.

Esophageal varicose veins due to the opening of collateral can trigger tumors of the intestine and liver, peritonitis, any enlargement of the spleen, lymph nodes.

Bunty's syndrome - a violation of circulation in the veins of the spleen (splenohepatomegaly) occurs in young women with a background of anemia, thrombocytopenia and leukopenia, congestion in the liver with portal hypertension and cirrhosis. It is caused by infectious diseases (brucellosis, malaria, syphilis, leishmaniasis).

Randu-Osler syndrome (hereditary telangiectasia), in addition to lesions on the skin and mucous membranes, causes a variety of angiomatous changes in internal organs with a tendency to bleeding. Localization in the esophagus creates conditions for vein expansion. To prevent bleeding from the expanded network of esophageal veins, it is necessary to treat the cause of the disease.

Current classification

There are several classifications of diseases proposed. Symptoms were detected by esophagogastroscopic examination. The most acceptable is the division of esophageal varicose veins according to the degree of change in the vein.

  • 1 degree - the maximum diameter of the vessel is 5 mm, it is elongated, localized in the lower part of the esophagus;
  • Grade 2 - tortuosity of the veins is determined, the diameter increases to 1 cm, they reach the middle third of the organ;
  • Grade 3 - draws attention to the thinning and tension of the venous wall of the veins, diameter of more than 10 mm, they go side by side, on the surface there is a characteristic red marker of the smallest capillaries.

According to other classifications (Vitenas and Tamulevichiute), it is proposed to take into account 4 stages of the disease course:

  • 1 - the diameter of the veins is 2-3 mm, they are bluish, straight in shape;
  • 2 - veins become tortuous, knotted, increase in diameter exceeding 3 mm;
  • 3 - varicose nodes are clearly distinguished, the twists are important, the protrusion appears in the lumen of the esophagus;
  • 4 - nodes grow into a grape -like shape, significantly narrowing the lumen of the esophagus, a thin network of small capillaries visible on the outer surface.

In addition, the diagnosis takes into account:

  • congenital forms occurring against a pathological background of unknown origin;
  • acquired - due to various diseases.

How are esophageal varicose veins real?

The symptoms of the disease depend on the pathology that causes esophageal varicose veins. The initial period continues without clinical manifestations, the patient is unaware of the development of pathology. But cases of progressive course with sudden bleeding are not uncommon.

Deterioration of the condition occurs in 4-5 days. The patient feels an increasing weight in the back of the sternum, compression. This sign is considered a sign of massive bleeding and requires immediate measures, as the surgeon’s observations associate it with a fatal outcome.

All symptoms of varicose veins are determined by the manifestation of threatened blood loss. In a chronic course with a small amount of blood allocated, the body gradually weakens. Hypochromic anemia develops. The patient is pale, losing weight, moving with difficulty, he worries about shortness of breath. Sometimes there is liquid black stool.

Signs of bleeding and early signs of varicose veins can be:

  • vague pain in the chest;
  • severe heartburn;
  • belching after eating;
  • difficulty swallowing dry food.

Heartburn and belching are explained by dysfunction of the esophageal sphincter, reverse reflux (reflux) from the stomach. Some patients feel a "tickle in the throat", sweating, a salty taste in the mouth before the onset of bleeding.

With acute bleeding appears:

  • increase skin pallor;
  • vomiting of blood ("coffee grounds");
  • persistent dizziness;
  • liquid prolonged stools;
  • dark in the eyes;
  • severe weakness.

Bleeding is triggered by weight lifting, physical work, high body temperature, taking anticoagulants, and fibrogastroscopy procedures. But sometimes it happens spontaneously against a general health background. It is necessary to distinguish bleeding from tumors of the esophagus and rotting stomach, the proliferation of tumors into the large ducts and their penetration, injury to the ducts by foreign bodies.

Diagnostics

The diagnosis can be suspected, but cannot be confirmed without esophagogastroduodenoscopy. This is arguably the only way to establish a link between bleeding and esophageal varicose veins, often at the same time, gastric varicose veins are detected.

X-rays may reveal inflammation, tumors, spastic contractions with impaired patency in the esophagus

This procedure allows you to determine the degree of vein deformation, the stage of the disease, visually determine the condition of the vascular wall, and predict its rupture. It is almost impossible to conduct research during bleeding.

Planned, esophageal contrast radiography was prescribed; before the picture, the patient is given a barium mixture to drink. According to a series of radiographs, the movement of the contrast and its spread in the lumen of the esophagus is monitored.

Laboratory method:

  • it is necessary to establish the presence of anemia with the content of erythrocytes, platelets, color index;
  • in acute bleeding, hematocrit is calculated;
  • make sure you do a freezing indicator analysis;
  • determining liver function by enzyme tests, protein levels, glucose, bilirubin, deviations of the results make it possible to suspect the influence of hepatic pathology on changes in the esophageal venous system;
  • if there are signs of bleeding, blood type and Rh factor are determined if a blood transfusion is necessary.

Even the minimal excretion of blood in the stool was confirmed by Gregersen’s response to the supernatural blood.

How is esophageal vein disease treated?

Treatment of esophageal varicose veins differs in the options and planned scheme, depending on the occurrence of emergency problems, life -threatening bleeding.

In the absence of massive bleeding, the patient requires therapy for the underlying disease, increased administration of hemostatic agents. The patient must be hospitalized in a specialized department. Mode - bed, the end of the headboard is raised.

dietary requirements

Therapeutic nutrition provides the absence of irritating foods (spicy spices, fried and smoked meat products, raw vegetables, fruits, bread crust, bones, soda water). Alcohol and chocolate are strictly prohibited.

The diet is built from foods that are high enough in calories, but liquid, cold. Slightly warm soups, boiled liquid porridge, milk noodles, cottage cheese, sweet fruit jelly, cold tea, white bread pulp, meat in the form of boiled minced meat are recommended.

With esophageal varicose veins, preference is given to boiled foods

Drug treatment

To reduce the activity of cirrhosis changes in the liver, treatment regimens include:

  • antiviral drugs (with moist hepatitis);
  • steroid hormones;
  • antibiotics for bacterial infections;
  • diuretics to reduce pressure in the inferior venous system;
  • cardiac glycosides, if cirrhosis is caused by myocardial decompensation;
  • hepatoprotector;
  • vitamin preparations in high doses to restore all types of metabolism.

Vitamins K, C, D, E are very important in the treatment of varicose veins. Synthetic water -soluble vitamin K analogues are given intramuscularly or intravenously. If anemia with impaired coagulation is detected in the patient, then plasma transfusion of a single group of fresh frozen (1-2 doses), erythrocytes or platelet mass is prescribed.

To stop bleeding, intravenous administration of octapeptides that mimic natural somatostatin is widely practiced. This drug is able to block the release of hormones into the blood that dilate the blood vessels. Calcium chloride solution is given intravenously.

Care should be taken with drugs that increase blood pressure, they increase bleeding.

If bleeding persists, the following are used: wash the esophagus with hot water (40–45 degrees) through a probe, install a rubber balloon probe - there is a standard corrugated product (obturator probe) to suppress the bleeding ducts in the esophagus and in stomach ulcers.

Esophageal balloon dilation is used to stop bleeding in esophageal varicose veins, and in the treatment of narrow areas.

How does surgery help?

An unfavorable clinical course is an indication for endoscopic binding. This technique consists of suturing the esophageal vein using an endoscope. Surgeons consider it more effective than a sclerosing agent (sclerotherapy) injected into a vein, which requires repetition at least four times a year.

Treatment of esophageal varicose veins with bleeding that has not been eliminated by therapeutic methods requires emergency surgery. The goal of surgery is to reduce pressure in the portal vein by creating a shunt and removal into the inferior vena cava.

Creating an artificial anastomosis (installation of a metal stent) between the portal and the hepatic vein is called transjugular intrahepatic portosystemic shunting. This operation is technically difficult. Experts believe that it can be successfully done in 95% of cases.

Accompanied not only by technical difficulties, but also by the initial recurrence of bleeding, inflammation. In 1/3 of patients, reassembly is required, because the stent is rapidly thrombotic, blocking the lumen. Within a month, up to 13% of patients died. This makes surgery an optional emergency measure.

Another method of increasing porto-caval blood flow is by creating an anastomosis between the spleen and left renal veins. Surgical techniques are complicated and risky for patients, accompanied by high mortality. Devascularization surgery consists of isolation and removal of the affected vein and its replacement with a prosthesis.

Is it possible to be treated with folk remedies?

The use of folk remedies in the presence of bleeding can not be inferred. But you can use it in the treatment of the main cause of varicose veins - liver damage. For this, long -term decoction intake is appropriate:

  • from milk thistle;
  • chicory;
  • corn stigma;
  • Japanese Sophora;
  • oat;
  • rowan fruit;
  • wild roses.

Prognosis of the disease

In the early stages of esophageal varicose veins with continuous treatment, adequate state of liver function, adherence to recommendations on the regimen and diet, it is possible to stop bleeding in 80% of patients. In 2/3 of patients after one recurrent bleeding within 1-2 years. They are always at high risk. The survival of people with severe cirrhosis is low.

Esophageal varicose veins refer to disease-complications. It itself is already a sign of severe damage to the body. Support can only be provided through timely detection using endoscopic methods and patient observation.