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The principles of treatment of bleeding from the gastrointestinal tract with portal hypertension
Bleeding from varicose nodes is the most abundant of all types of bleeding that occurs in the upper parts of the gastrointestinal tract, in which the patient requires emergency medical care. In more than 90% of cases of such bleeding, the hematocrit level drops sharply and becomes less than 30% of normal, resulting in the need for blood transfusion. But, as with other types of bleeding from the upper gastrointestinal tract, bleeding from varicose veins in 70-80% of cases stops on its own. However, with this type of bleeding, it is important to immediately conduct an endoscopic examination in order to diagnose acute bleeding to stop it and prevent relapse. In patients with cirrhosis of the liver, damage to varicose nodes is usually multiple, but in half or even a third of cases, the cause of bleeding is not associated with the presence of varicose veins. Thus, with the appearance of bleeding from the upper gastrointestinal tract, it is necessary to conduct an endoscopic examination to clarify the location and nature of the bleeding.
There are many ways to stop bleeding from varicose veins, but all are based on two main principles:
1. Reducing the pressure in the portal system with medication or through a bypass operation.
2. Obliteration of varicose nodes.
Treatment approaches depend on the goal: stop bleeding during relapse, prevent rebleeding, or stop the first bleeding. However, all methods of stopping bleeding do not affect the course of the underlying disease, because they affect the effect, and not the cause. Patients who have been able to successfully prevent and treat bleeding often die from other complications of cirrhosis of the liver - from kidney failure, infections. The only cardinal solution to the problem is a liver transplant.
To reduce portal pressure in acute bleeding, vasopressin, somatostatin or its analogues are administered intravenously. The use of nitrates together with vasopressin improves the effect and reduces the toxic effect of vasopressin on the cardiovascular system. In the treatment of patients with a high degree of risk of bleeding, constant use of propranolol is practiced. Although propranolol is also used to prevent repeated bleeding, its effectiveness in this case is lower than that of other drugs.
Portal pressure can be reduced by surgically creating a shunt between the portal and common venous systems (from the lower v.
cava or its branches). But despite the good results in preventing repeated bleeding, this operation has a high degree of risk in patients with cirrhosis. Large medical centers currently use the percutaneous shunt method (transjugular intrahepatic portosystemic shunt). With this operation, a good shunt effect is achieved with less risk of complications and mortality. The disadvantage of these operations is a high percentage of occlusions (30% of cases within 6 months), which requires repeated surgical interventions. For a certain part of patients with cirrhosis of the liver, who are at high risk with extensive surgery and in the absence of the effect of drug and endoscopic treatment, such bypass surgery is the method of choice. It is often performed as a step in preparation for a liver transplant.
The second way to prevent and treat bleeding from varicose veins is obliteration of varicose nodes. Most often, endoscopic sclerotherapy is performed. In this procedure, a needle is passed through the endoscope channel, and the sclerosing substance is introduced either into the varicose nodes, or in their immediate vicinity. This leads to the formation of scar tissue and vascular thrombosis. Sclerotherapy is successfully used to stop bleeding and to prevent it. Usually it is carried out several times until the obliteration of all nodes is complete, which sometimes takes from several weeks to several months. And only after complete obliteration of varicose veins the risk of rebleeding is reduced. Sclerotherapy does not have significant advantages in the prevention of first bleeding. A more modern treatment method with a lower risk of complications and better results than sclerotherapy is the application of rubber rings to varicose nodes. They squeeze the nodes, which leads to thrombosis and scarring (Fig. 9-5). In acute bleeding resulting from an unsuccessful endoscopic treatment, direct tamponade of bleeding vessels is used by inflating a special balloon located on a nasogastric catheter (Sengstaken-Blackmore probe). One balloon is inflated at the junction of the esophagus into the stomach, and the other directly in the esophagus. You can inflate one or more cylinders. This method is used to temporarily stop bleeding, because after the balloon (s) is deflated, bleeding can resume.
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The principles of treatment of bleeding from the gastrointestinal tract with portal hypertension
- Bleeding in gastric ulcer as an example of bleeding from the upper gastrointestinal tract
Gastric and duodenal ulcers cause about 50.% of cases of bleeding from the upper gastrointestinal tract (Table 9-2). Despite the introduction of new effective methods of treating peptic ulcer in the past 15 years, the frequency of bleeding with this pathology has not practically decreased. One of the reasons for this situation is the fact that often peptic ulcer
- Prognosis for bleeding from the upper gastrointestinal tract
There are several criteria for poor prognosis for bleeding from the upper gastrointestinal tract. The most important is the cause of the bleeding. So, for bleeding from varicose veins, the highest frequency of repeated bleeding (relapses) and deaths is characteristic. In primary hospitalization, mortality in this type of bleeding is 30%, with repeated - 50-70%.
- Gastrointestinal bleeding
Gastrointestinal bleeding is a problem that doctors in the USA often encounter (300 thousand hospitalizations annually). The degree of hemorrhage varies from small slow bleeding to life-threatening conditions that contribute to the development of iron deficiency anemia. Mortality from upper gastrointestinal tract in the USA is 8%. This indicator has not changed much.
- Bleeding from the upper gastrointestinal tract
It is customary to talk about bleeding from the upper gastrointestinal tract (GIT) in cases where the source of bleeding is located either in the esophagus, or in the stomach, or in the duodenum (duodenum). Pathophysiology The most common causes of bleeding in adults are: duodenal ulcer; erosion of the stomach and duodenum; varicose veins
- Acute and chronic bleeding from the gastrointestinal tract
There are many causes of gastrointestinal bleeding. Bleeding develops according to one of two primary mechanisms: 1. Violation of the integrity of the mucous membrane, leading to exposure of deep vessels, their erosion. For example, bleeding from a stomach ulcer, bleeding from the intestines during infectious or idiopathic processes, from the small and large intestines during ischemia. 2.
- Diagnosis of bleeding from the gastrointestinal tract
Diagnosis of gastrointestinal bleeding
- Etiology of bleeding from the lower gastrointestinal tract
Lesions in the anal region and rectum. Small amounts of bright red blood on the surface of feces and toilet paper often appear with hemorrhoids; bleeding in this case is usually aggravated by the difficult passage of solid feces. Similarly, fissures and fistulas in the anal region can occur. Another source of rectal bleeding is proctitis; he
- Vascular ectasia as an example of chronic bleeding from the gastrointestinal tract
Vascular ectasia, or angio dysplasia, is one of the common causes of both profuse and minor prolonged bleeding from the lower parts of the gastrointestinal tract. Most of them are associated with age-related degenerative changes in the vascular wall in the elderly. In other age groups, vascular wall disorders can be congenital. Two thirds of patients with angio dysplasia
- EMERGENCY ASSISTANCE FOR DISEASES OF THE GASTROINTESTINAL TRACT
EMERGENCY ASSISTANCE FOR DISEASES OF THE GASTROINTESTINAL
- Examination and treatment of a patient with gastrointestinal bleeding
The approach to the examination of a patient with bleeding depends on the place of its localization, vastness and intensity. With bloody vomiting, there is usually more blood loss (often more than 1000 ml) than with melena (usually 500 ml or less), and the mortality rate in the first case is about twice as high as in the second. For the first time, a doctor can be called to a patient in a state of shock. Before
- Nutrition for diabetes mellitus with diseases of the gastrointestinal tract (gastritis, peptic ulcer of the stomach or duodenum)
In the diet for diabetes with diseases of the gastrointestinal tract, it is necessary to comply with all the requirements for the nutrition of a diabetic. However, it is necessary to spare the gastric mucosa. In order to avoid its mechanical, chemical, and thermal irritation, all dishes are cooked in a boiled and steamed form. The fractional diet is 5-6 times a day. RECOMMENDED
- Gastrointestinal Lymphoma
In systemic dissemination of non-Hodgkin lymphoma (see chapter 13), any segment of the gastrointestinal tract may be involved again. However, up to 40% of lymphomas develop not in the lymph nodes, but in other organs, among which the intestine is the most frequent localization. By the time of recognition of the primary lymphoma of the gastrointestinal tract, the tumor process does not affect either the liver or
- Gastrointestinal metabolism
Liquid and electrolytes are excreted in large quantities with digestive secretions in the gastrointestinal tract, but under normal conditions they are mostly reabsorbed (Fig. 20). Fig. 20. Secretion of water and electrolyte (meq / l of the amount of secretion indicated in the table) (Geigy). Potassium is excreted in the intestines (especially in the large intestine), and it is replaced during the exchange process with sodium (Gooptu with