esophageal varicose veins

Diagnostic endoscopy for esophageal varices

Esophageal varicose veins are a serious pathology caused by diseases of the liver, heart, digestive organs, while the incidence of the vein wall is much lower. After 50 years, it is more common in the lower part with the failure of the gastric vein in men.

Heavy bleeding may be unexpected and the only sign. Prompt diagnosis is necessary and preventive measures are taken. To eliminate esophageal varices, special surgical methods are developed in vascular surgery.

In the international classification, the disease is explained by different codes:

  • I85. 9 - no bleeding;
  • I85. 0 - bleeding;
  • I98. 2 - In the context of another pathology.

How does blood flow through the veins of the esophagus?

The esophagus is connected to many organs in the chest and abdominal cavity by a blood supply. Its arterial branches come from the thoracic aorta. Uneven development of venous organs. Blood flows through the esophageal vein into the vessels of the unpaired and semi-paired veins, then through the anastomotic stoma, through the phrenic vein into the inferior vena cava, and through the gastric venous network into the gastric portal vein. liver.

From the upper part of the esophagus, venous outflow enters the vessels of the superior vena cava. Anatomically arrange and connect the venous apparatus that forms the esophagus, acting as an intermediary between three outflow systems: the portal vein, the inferior vena cava, and the superior vena cava.

This feature triggers the development of compensatory varicose veins at the level of the esophagus due to the patency of auxiliary vessels (collaterals) in the spleen, intestinal disease, accompanied by obstruction of the own veins.

Reason for expansion

Esophageal varices are provided by two mechanisms. Difficulty in outflow due to mechanical obstruction of the lower part of the venous system (hypertension, thrombosis, phlebitis) or loss of tone of the vein wall due to impaired synthesis of collagen fibers (varicose veins). SMV).

The cause of upper segment stasis is usually a malignant goiter. In the lower part of the esophagus, venous blood flow is delayed due to:

  • Portal hypertension due to cirrhosis;
  • Portal vein thrombosis.

Rare causes of esophageal varices (EVV) are hemangiomas (hemangiomas) and venous changes in Rendu-Osler syndrome.

Cirrhosis is a long-term chronic disease that complicates hepatitis (primarily viral hepatitis B), alcoholic disease with steatosis. Pathological changes manifest as violations of the structure of the hepatic lobules and surrounding spaces.

Dense scar (connective) tissue proliferates and functional cells are replaced by nodules, resulting in liver failure. Under these conditions, both arterial and venous vessels are compressed. Reduced oxygen supply can worsen the situation, leading to ischemia to the organs.

Liver cirrhosis can cause:

  • drug;
  • Defective congestive heart failure, complications of extensive infarction, myocardial dystrophy, heart disease;
  • Inherited diseases with metabolic changes (galactosemia, hepatic-cerebral dystrophy, hemochromatosis);
  • Fetal hepatitis occurs in the newborn when the mother has an infection (rubella, herpes, cytomegalovirus) when the pathogen is transmitted across the placental barrier to the fetus.

Esophageal varices due to collateral opening can cause bowel and liver tumors, peritonitis, spleen, and lymphadenopathy.

Bounty Syndrome - Disorders of splenic venous circulation (splenohepatomegaly) in young women in the context of anemia, thrombocytopenia and leukopenia, liver congestion with portal hypertension, and cirrhosis. It is caused by infectious diseases (brucellosis, malaria, syphilis, leishmaniasis).

Randu-Osler syndrome (hereditary telangiectasia) causes multiple hemangioma-like changes in internal organs and a tendency to bleed, in addition to damage to the skin and mucous membranes. Positioning in the esophagus creates conditions for venous dilation. To prevent bleeding from the dilated venous network of the esophagus, the cause needs to be treated.

current category

There are several proposed disease classifications. Signs were detected by esophagogastroscopy. The most acceptable is to classify esophageal varices according to the degree of venous change.

  • 1 degree - the maximum diameter of the vessels is 5 mm, they are elongated and located in the lower part of the esophagus;
  • Grade 2 - determined vein tortuosity, increasing to 1 cm in diameter, reaching the middle third of the organ;
  • Grade 3 - Note the thinning and tension of the venous vessel walls, more than 10 mm in diameter, which line up side by side with the characteristic red markings of the smallest capillaries on the surface.

According to another classification (Vitenas and Tamulevichiute), it is recommended to consider 4 stages of the disease process:

  • 1 - The vein is 2-3 mm in diameter, blue in color and straight in shape;
  • 2 - tortuous veins, multi-segmented, with an increase in diameter of more than 3 mm;
  • 3 - varicose veins with obvious lymph nodes, obvious tortuousness, protrusions in the lumen of the esophagus;
  • 4 - The nodule grows into a grape-like shape, the lumen of the esophagus is markedly narrowed, and a small network of capillaries is visible on the outer surface.

Additionally, the diagnosis takes into account:

  • Congenital forms occurring in the context of a pathological background of unknown origin;
  • The day after tomorrow - caused by various diseases.

What are the symptoms of esophageal varices?

The symptoms of the disease depend on the pathology that caused the esophageal varices. There are no clinical manifestations at the initial stage, and the patient is unaware of the development of the pathology. But progressive cases of sudden bleeding are not uncommon.

Progression occurs in 4-5 days. The patient feels heavier and more compressed behind the sternum. This sign is considered a harbinger of major bleeding and requires urgent action because the surgeon's observation has linked it to a fatal outcome.

All symptoms of varicose veins are determined by the threat of blood loss. In the chronic process of distributing small amounts of blood, the body gradually weakens. Hypochromic anemia occurs. The patient was pale, lost weight, had difficulty moving, and was concerned about shortness of breath. Sometimes stool is black liquid.

The first signs of bleeding and varicose veins may be:

  • chest pain;
  • severe heartburn;
  • belching after meals;
  • Difficulty swallowing dry food.

Heartburn and belching are caused by esophageal sphincter dysfunction, gastric reflux (regurgitation). Some patients experience "itchy throat", sweating, and a salty taste in the mouth before bleeding.

Acute bleeding occurs:

  • increased skin paleness;
  • vomiting blood ("coffee grounds");
  • persistent dizziness;
  • liquid tarry stools;
  • darkening of the eyes;
  • serious weakness.

Heavy lifting, physical labor, elevated body temperature, taking anticoagulants, and fiberoptic gastroscopy procedures can cause bleeding. But sometimes it happens spontaneously in the context of general health. It is necessary to distinguish hemorrhage from rotting tumors of the esophagus and stomach, where the tumor germinates into large blood vessels and breaks through, and foreign bodies damage the blood vessels.

diagnosis

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

X-rays can show inflammation, tumors, spastic contractions, and impaired esophageal patency

The program allows you to determine the degree of deformation of the vein, the stage of the disease, visually determine the state of the vessel wall and predict rupture. It is nearly impossible to conduct research during bleeding.

In a planned manner, a contrast radiograph of the esophagus was performed; prior to the picture, the patient was given a barium mix. From a series of radiographs, the movement of the contrast agent and its spread in the lumen of the esophagus is monitored.

Laboratory method:

  • It is necessary to determine the presence of anemia by the content of red blood cells, platelets, color index;
  • In acute bleeding, the hematocrit is calculated;
  • Analysis of coagulation indicators must be done;
  • Determination of liver function, protein, glucose, bilirubin levels by enzymatic tests, deviations in the results make it possible to suspect the influence of liver pathology on changes in the esophageal venous system;
  • If there are signs of bleeding, determine blood type and Rh factor in case a blood transfusion is needed.

Gregson's response to occult blood confirmed minimal excretion of blood in feces.

How is esophageal venous disease treated?

The treatment of esophageal varices varies in planning options and protocols, depending on the occurrence of an urgent problem, namely, life-threatening bleeding.

In the absence of profuse bleeding, the patient requires treatment of the underlying disease with enhanced administration of hemostatic agents. Patients must be hospitalized in specialized departments. Mode - Bed with head end raised.

dietary needs

Therapeutic Nutrition provides no harsh foods (spicy spices, fried and bacon products, raw vegetables, whole fruits, crusts, bones, soda). Alcohol and chocolate are strictly prohibited.

The diet is made of sufficiently high-calorie but liquid cooled foods. Meat in lukewarm broth, boiled liquid porridge, milk pasta, cottage cheese, sweet jelly, herbal tea, white bread pulp, boiled mince is recommended.

For esophageal varicose veins, prefer cooked foods

medical treatement

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

  • antiviral drugs (chronic hepatitis);
  • Steroids;
  • antibiotics for bacterial infections;
  • Diuretics reduce pressure on the inferior vena cava system;
  • Cardiac glycosides, if cirrhosis is caused by myocardial decompensation;
  • Hepatoprotective drugs;
  • A high-dose vitamin preparation to restore all types of metabolism.

Vitamins K, C, D, and E are especially important when treating varicose veins. Synthetic water-soluble analogs of vitamin K can be administered intramuscularly or intravenously. If coagulation-compromised anemia is detected in a patient, transfusion of a single set of freshly frozen plasma (1-2 doses), red blood cells, or platelets is prescribed.

To stop bleeding, an octapeptide that mimics natural somatostatin is widely used intravenously. The drug inhibits the release of hormones into the bloodstream, which dilate blood vessels. Intravenous calcium chloride solution.

Attention should be paid to drugs that increase blood pressure, which can increase bleeding.

If bleeding continues, use the following: wash the esophagus with hot water (40-45 degrees) through the probe, install a rubber balloon probe - there is a standard corrugated product (obturator probe) to compress the bleeding vessels in the esophagus and stomachulcer.

Esophageal balloon dilation can be used both to stop bleeding and to treat strictures.

How does surgery help?

An adverse clinical course is an indication for endoscopic ligation. The technique involves suturing the esophageal vein using an endoscope. Surgeons believe it is more effective than sclerotherapy (sclerotherapy) injected into a vein, which needs to be repeated at least four times a year.

Treatment of esophageal variceal bleeding has not been eliminated therapeutically and requires emergency surgery. The purpose of the surgery is to reduce pressure in the portal vein by creating a shunt and dumping into the inferior vena cava.

An artificial anastomosis (installation of a metal stent) between the portal and hepatic veins is called a transjugular intrahepatic portosystemic shunt. This operation is technically difficult. Experts believe that it can be successfully executed in 95% of cases.

Not only is it accompanied by technical difficulties, but also with early recurrence of bleeding and inflammation. Reinstallation is required in 1/3 of patients because the stent can rapidly form a thrombus, blocking the lumen. Within a month, as many as 13% of patients died. This makes the operation an emergency measure of choice.

Another way to improve portal blood flow is to create an anastomosis between the splenic vein and the left renal vein. The surgical technique is complex, the patient risk is high, and the mortality rate is high. The procedure of devascularization involves excising and removing the affected veins and replacing them with prostheses.

Can it be treated with folk remedies?

The use of folk remedies in cases of bleeding is inconclusive. But you can use them for the main cause of varicose veins - liver damage. For this reason, it is suitable for long-term use of decoctions:

  • from milk thistle;
  • chicory root;
  • corn stigma;
  • Japanese Sophora japonica;
  • oat;
  • Rowan fruit;
  • wild rose.

disease prognosis

In the initial stage of esophageal varices, with continued treatment, adequate liver function status, adherence to treatment regimens and dietary recommendations, 80% of patients can stop bleeding. 2/3 of patients after a single recurrent bleeding within 1-2 years. They are always at high risk. Patients with severe cirrhosis have a poor survival rate.

Esophageal varices are a complication of the disease. It is already a sign of serious damage to the body in itself. Support can only be provided if the patient is detected and observed in a timely manner using endoscopic methods.