Varicose veins of the esophagus

Varicose veins of the esophagus - a serious pathology, provoked by diseases of the liver, heart, digestive organs and much less often venous walls. It is more often observed in the lower parts together with the lesion of the stomach veins in men after 50 years.

Massive bleeding can be unexpected and the only sign. Timely diagnosis is necessary for preventive measures. To eliminate esophageal varices, 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 a background of another pathology.

How does the outflow of blood through the veins of the esophagus?

Esophagus with blood supply is associated with many organs of the thoracic and abdominal cavity. Arterial branches to it go from the thoracic aorta. The venous apparatus is unevenly developed. Blood through the veins of the esophagus drains into the vessels of an unpaired and semi-unpaired vein, then passes through the anastomoses through the veins of the diaphragm into the lower vena cava, and along the venous network of the stomach into the portal vein of the liver.

From the upper parts of the esophagus the venous outflow goes to the vessels of the superior vena cava. The anatomical location and connections form the venous esophagus apparatus as an intermediary between the three outflow systems: the portal vein, the lower and upper cavity.

This feature provokes the emergence of compensatory varicose veins at the esophagus level by opening auxiliary vessels( collaterals) for diseases of the spleen, intestines, accompanied by a block of their own veins.

Reasons for the expansion of

Varicose veins of the esophagus are provided by two mechanisms. There is either obstruction of outflow due to a mechanical obstruction in the underlying sections of the venous system( increased pressure, thrombosis, phlebitis), or loss of tone of the venous wall due to impaired synthesis of collagen fibers( varicose veins of the VBW).

The reason for stagnation in the upper divisions is more often malignant goiter. In the lower part of the esophagus, venous blood flow is delayed due to:

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

Vascular swelling( angioma) and venous changes in Rundu-Osler syndrome are considered rare causes of the formation of varicose veins of the esophagus( HSV).

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

There is a proliferation of dense scar( connective) tissue, replacement of functioning cells in the mounds with the formation of liver failure. In these conditions, the blood vessels are compressed both arterial and venous. The decrease in oxygen intake aggravates the situation, causing ischemia of the organ.

Disturbance of venous outflow leads to increased pressure in the portal system( hypertension)

Cirrhosis of the liver can cause:

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

Banty syndrome - impairment of circulation in the veins of the spleen( splenichepatomegaly) occurs in young women against anemia, thrombocyto- and leukopenia, congestive liver phenomena with portal hypertension and cirrhosis. It causes infectious diseases( brucellosis, malaria, syphilis, leishmaniasis).

Rundu-Osler syndrome( hereditary telangiectasia), in addition to skin and mucosal lesions, causes multiple angiomatous changes in the internal organs with a tendency to bleeding. Localization in the esophagus creates conditions for the expansion of veins. To prevent bleeding from the expanded venous network of the esophagus, it is required to treat the disease-cause.

Current classification of

There are several proposed classifications of the disease. The signs are revealed in esophagogastroscopic examination. The most acceptable is the division of esophagus varicose by the degree of change of veins.

• 1 degree - the maximum diameter of the vessels is 5 mm, they are elongated, localized in the lower part of the esophagus;
• 2 degree - determined by the tortuosity of the veins, diameter increased to 1 cm, reach the middle third of the organ;
• 3 degree - draws attention to the thinning and tension of the walls of venous vessels, the diameter is more than 10 mm, go side by side, on the surface there are characteristic markers of red color from the smallest capillaries.

The initial stage is characterized by the absence of crimp veins

According to another classification( Vitenasoma and Tamulevichute) it is suggested to take into account the 4 stages of the disease course:

• 1 - the diameter of the veins is 2-3 mm, they are bluish in color, straight in shape;
• 2 - veins become sinuous, knobby, in diameter increase over 3 mm;
• 3 - distinctly different varicose nodules, significant crimp, there is protrusion into the lumen of the esophagus;
• 4 - the nodes grow to a gruff-like shape, the gullet of the esophagus is narrowed considerably, on the outer surface a thin network of small capillaries is seen.

In addition, the diagnosis takes into account:

• congenital form, proceeding against the background of pathologies of unknown origin;
• acquired - caused by various diseases.

How is varicose disease of the esophagus manifested?

Symptoms of the disease depend on the pathology that caused varicose veins of the esophagus. The initial period proceeds without clinical manifestations, patients are unaware of the development of pathology. But cases of progressive course with sudden bleeding are not uncommon.

Deterioration occurs within 4-5 days. Patients feel the growing weight behind the sternum, compression. This sign is considered a harbinger of massive bleeding and requires urgent measures, as surgeons' observations link it to death.

All the symptoms of varicose veins are determined by threatened manifestations of blood loss. In chronic course with a small amount of isolated blood, the body gradually weakens. Hypochromic anemia is formed. The patient differs pallor, grows thin, hardly moves, it is disturbed by shortness of breath. Sometimes there is liquid black feces.

Bleeding precursors and initial signs of varicose veins may be:

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

Heartburn and eructation are explained by a violation of the function of esophageal sphincters, a reverse( reflux) cast from the stomach. Some patients feel "tickling in the throat", perspiration, a salty taste in the mouth before the onset of bleeding.

With acute bleeding,

• shows a growing pallor of the skin;
• vomiting with blood( "coffee grounds");
• persistent dizziness;
• liquid tarry stool;
• darkening in eyes;
• sharp weakness.

Bleeding is provoked by lifting of gravity, physical work, fever, reception of anticoagulants, procedure of fibrogastroscopy. But sometimes it arises spontaneously against the background of general health. Differentiating bleeding is necessary from the disintegrating tumor of the esophagus and stomach, the germination of the tumor into a large vessel and its breakthrough, injuring the vessels with a foreign body.

Diagnosis

Diagnosis can be suspected, but can not be confirmed without esophagogastroduodenoscopy. This is almost the only way to establish the connection of bleeding with esophagus varicose, often simultaneously detect varicose veins of the stomach.

The X-ray can detect inflammation, tumors, spastic contraction with violation of the passableness of the

. The procedure allows to establish the degree of deformation of the veins, the stage of the disease, visually determine the state of the vascular walls, predict the rupture. It is almost impossible to conduct a study during bleeding.

The contrast radiography of the esophagus is scheduled, and before the shot, the patient is given a mixture of barium. A series of radiographs track the movement of contrast and spreading it in the lumen of the esophagus.

Lab:

• it is necessary to establish the presence of anemia by the content of erythrocytes, platelets, color index;
• for acute bleeding counts hematocrit;
• necessarily make the analysis of indicators of coagulation;
• determine the liver function according to enzyme tests, protein level, glucose, bilirubin, deviations of the results give the possibility to suspect the influence of hepatic pathology on the change in the venous esophagus system;
• in the presence of signs of bleeding determine the blood group and Rh factor for the case of the necessary blood transfusion.

How is oesophageal pathology treated?

Treatment of varicose veins of the esophagus is different planned version and the scheme, depending on the occurrence of an emergency problem, life-threatening bleeding.

In the absence of massive bleeding, the patient needs the therapy of the underlying disease, the increased administration of hemostatic agents. The patient must be hospitalized in the profile department. Mode - bed, head end of the bed is raised.

Diet requirements

Therapeutic diet provides for the absence of irritating products( spicy seasonings, fried and smoked meat products, coarse vegetables, whole fruits, crusts of bread, bones, carbonated water).Categorically prohibited alcohol, chocolate.

The diet is built from a high-calorie, but liquid, cooled food. We recommend slightly warm broth, boiled liquid porridge, milk noodles, cottage cheese, sweet fruit jelly, cooled tea, pulp of white bread, meat in the form of boiled minced meat.

Preference is given to cooked products

Treatment with medicines

To reduce the activity of cirrhotic changes in the liver, the treatment regimen includes:

• antiviral drugs( with slow hepatitis);
• steroid hormones;
• antibiotics for bacterial damage;
• diuretics for lowering pressure in the inferior vena cava;
• cardiac glycosides, if cirrhosis is caused by myocardial decompensation;
• hepatoprotectors;
• vitamin preparations in high doses to restore all kinds of metabolism.

Vitamins K, C, D, E. are of particular importance in the therapy of varicose veins. Vikasol is administered intramuscularly or intravenously. If the patient has anemia with impaired coagulability, then a freshly frozen single-group plasma( 1-2 doses), erythrocyte or platelet mass is administered.

To stop bleeding, intravenous injection of Octreotide is widely practiced. The drug is able to suppress the release into the blood of hormones that dilate the blood vessels. Still apply Vasopressin and Terlipressin, but in comparison with Octreotide they have more side effects. Intravenous solution of calcium chloride is introduced.

With the continuation of bleeding use: washing the esophagus with hot water( 40-45 degrees) through the probe, installing a rubber inflating probe - there are standard corrugated products( probes-obturators) for pressing a bleeding vessel in the esophagus and stomach ulcer.

Balloon dilatation of the esophagus is used both to stop bleeding and to treat narrowed areas of the

What helps surgery?

An unsuccessful clinical course serves as an indication for endoscopic ligation. The technique is to stitch the veins of the esophagus with an endoscope. Surgeons consider it more effective than the introduction of sclerosing agents into the veins( sclerotherapy), which requires a repetition of at least four times a year.

Treatment of esophageal varicose with bleeding due to therapeutic methods requires surgery for emergency indications. The goal of surgical intervention is to reduce pressure in the portal vein by creating shunts and discharging into the lower vole.

The creation of an artificial anastomosis( the installation of a metal stent) between the portal and hepatic veins is called a transjugular intrahepatic portosystemic shunting. The operation is technically complex. Experts believe that it can be successfully executed in 95% of cases.

It is accompanied not only by technical difficulties, but also by early relapse of bleeding, inflammation. In 1/3 of patients, a re-installation is required, since the stent is rapidly thrombosed, blocking the lumen. Within a month, up to 13% of patients die. This classifies the operation as an emergency measure of choice.

Another method of improving portocaval blood flow is the creation of an anastomosis between the splenic and left renal veins. The technique of the operation is complex and risky for the patient, accompanied by a high lethality. The operation of devascularization consists in the excision and removal of the affected veins and their replacement with prostheses.

Creating a workaround reduces the pressure in the portal system by half

Can I be treated with folk remedies?

The use of folk remedies in the presence of bleeding is inconclusive. But you can use them in the therapy of the main cause of varicose veins - liver damage. For this purpose a long reception of broths is suitable:

• from milk thistle;
• of chicory root;
• corn stigmas;
• Japanese Sophora;
• oats;
• fruits of mountain ash;
• rose hips.

Forecast of

In the initial stages of esophageal varices with constant treatment, sufficient functional state of the liver, adherence to recommendations on diet and regimen, bleeding can be stopped in 80% of patients. In 2/3 patients after a single bleeding repeat within 1-2 years. They are constantly at high risk. Survival of persons with severe cirrhosis is low.

Varicose veins of the esophagus refers to disease-complications. It in itself is already a sign of severe damage to the body. Support can be provided only by timely detection using the endoscopy method and monitoring the patient.