Duodenal varicose veins
Introduction
Introduction to duodenal varices In addition to common esophageal and gastric varices bleeding, portal hypertension can cause varicose veins in the duodenum, bladder, biliary tract and other rare parts. Duodenal varicose (duodenalvaricosis) is easy to find due to endoscopy, and clinical reports are relatively More than others. basic knowledge The proportion of illness: 0.02% Susceptible people: no special people Mode of infection: non-infectious Complications: shock
Cause
Cause of duodenal varices
Cause:
When the extrahepatic portal hypertension or a branch of the portal vein is embolized, the portal vein blood flow can branch through the gastric colon and superior mesenteric vein to the pancreaticoduodenal vein, and then through the superior duodenal vein, pylorus or gastric retina. Right venous return to the portal vein, it is easy to cause duodenal variceal bleeding, Japan reported that the portal hypertension caused by cirrhosis is the majority, portal hypertension caused by cirrhosis, the blood flow of the superior mesenteric vein can flow through the retroperitoneal vein Venous vein, in patients with stenosis of the splenic vein, often with gastric retinal vein as the gastroduodenal vein, collateral circulation of the pancreaticoduodenal vein, so the above veins can see vasodilation, rare cases from the pancreas There is a snake varicose vein between the duodenal vein and the abnormal blood vessels in the liver, which forms a shunt from the abnormal blood vessel to the paraumbilical vein.
Prevention
Duodenal varices prevention
Active treatment of primary disease: cirrhosis, portal hypertension, vascular malformations.
Successful prognosis cases have a good prognosis. Endoscopic variceal sclerotherapy combined with venous venous embolization and endoscopic ligation combined with embolization of the ileal vein has also achieved good results, but compared with the above treatment methods, The difference in efficacy was not significant.
Complication
Duodenal varices complications Complications
Once the duodenal varices occur, due to the rich blood flow, it is difficult to stop bleeding, and it is easy to fall into shock, which can lead to death.
Symptom
Duodenal varices Symptoms Common symptoms Repeated vomiting, local venous tenderness, blood stasis, varicose veins
The unique symptoms are lacking. With the advancement of diagnostic techniques such as endoscopy, there are many cases of accidental findings. The venous variceal hemorrhage is also the initial clinical manifestation. In this case, hematemesis occurs, and blood donors are more, accounting for 70%. Rich in flow, easy to fall into shock.
Examine
Examination of duodenal varices
1. Blood changes:
In the early stage of hemorrhage, the patient's hemoglobin, red blood cell count and hematocrit may be unchanged. Only when the tissue fluid infiltrates into the blood vessel or replenishes the isotonic fluid to expand the blood volume, the blood is diluted and the anemia appears. The patient often presents positive cells. Pigmented anemia, reticulocytes often rise, after a large bleeding, white blood cell count can reach 10,000 to 20,000, 2 to 3 days after the cessation of bleeding to return to normal, cirrhotic portal hypertension patients after bleeding, white blood cell count may not increase, the reason is the patient There is often hypersplenism.
2. Nitrogenemia:
After upper gastrointestinal bleeding, as the blood enters the intestine, its protein digestion products are absorbed by the intestinal mucosa, which can cause the blood urea nitrogen concentration to increase, which means that the intestinal urea nitrogen is increased. After the hemorrhage, the urea nitrogen can be Increase, generally peaks at 24 to 48h, such as urea nitrogen continues to rise, may be due to continued bleeding or massive bleeding, due to reduced blood volume, renal blood flow and renal glomerular filtration rate caused by renal decline Urea nitrogen is increased. Therefore, monitoring the change of blood urea nitrogen is a useful indicator to determine whether bleeding stops after removing the factors of renal urea nitrogen elevation.
Film degree exam
1. Upper gastrointestinal angiography:
Upper gastrointestinal angiography is difficult to diagnose qualitatively. The angiography often shows polypoid or giant wrinkles. It must be differentiated from duodenal ulcer, duodenal polyps and duodenal submucosal tumors.
2. Upper gastrointestinal endoscopy:
Endoscopic duodenum can be seen in the varicose veins of the intestine, which is cystic or nodular, and the color can be blue or consistent with the surrounding mucosa. The surface can be eroded, covered with a little gray yellow moss or bloody material, and Gastrointestinal angiography should also be differentiated from polyps and submucosal tumors. Biopsy may cause major bleeding. Special attention should be paid to prevent biopsy. Biopsy can be used to pressurize the bulge before biopsy to determine its elasticity. It is difficult to diagnose bleeding during activity. There is a lot of blood accumulation in the duodenum. It is necessary to repeatedly wash the blood and clean it. After observing the mucosal surface in detail, the surface of the hemorrhagic lesion is often erosive and often manifests as bleed bleeding. Even if it is bleeding, it is difficult to make it immediately. Diagnosis of duodenal varices, previous history of suspected variceal bleeding, endoscopy should think of the disease and try to insert the mirror to the distal end of the duodenum.
3. Abdominal CT:
The presence of cirrhosis, the degree of hepatic atrophy, and the presence or absence of ascites can be determined. An angiographic CT examination can reveal abnormally dilated blood vessels connected to the duodenal wall. The bleeding period can determine whether the contrast agent leaks from the blood vessels.
4. Abdominal angiography:
First, the celiac artery and superior mesenteric artery angiography were performed to determine the non-vascular leakage of the contrast agent in the arterial phase. The gastroduodenal vein was seen in the venous phase, the pancreaticoduodenal vein was thickened, the snake or nodular varicose veins and the contrast agent flow downward. The vena cava can be diagnosed. When the bleeding is obvious, the contrast agent leaks out of the blood vessel. It is also highly valuable to percutaneous transhepatic portography when the disease is suspected. The contrast of the portal vein can obtain a very vivid image of the portal vein. The celiac artery and superior mesenteric artery angiography are easy to obtain the angiographic image of the cause, and embolization can be continued after the examination.
Diagnosis
Diagnosis and diagnosis of duodenal varices
diagnosis
According to clinical manifestations (hematemesis, blood in the stool) and auxiliary examination (upper gastrointestinal angiography, endoscopy, abdominal angiography, etc.) can be diagnosed.
Differential diagnosis
Because of the many causes of upper gastrointestinal bleeding, there are many diseases to be identified. The following is a brief identification of common diseases.
1. Stomach and duodenal ulcer disease:
(1) is the most common cause of upper gastrointestinal bleeding, gastric ulcer accounts for about 10% to 15% of the cause of upper gastrointestinal bleeding, and duodenal ulcer accounts for about 25% to 30% of the cause of upper gastrointestinal bleeding.
(2) There is a history of ulcer disease or a history of ulcer disease, and most patients have a good winter and spring season.
(3) The pain is mostly in the upper abdomen, which is mostly painful and burning pain. Most duodenal ulcers have hunger pain or night awakening.
(4) The pain is generally rhythmic. The gastric ulcer is mostly 1/2~1h postprandial pain, lasting for 1~2h, and the pain is gradually relieved before the meal; the duodenal ulcer pain is more than 3~4h after the meal. (ie pain when starving), the pain often disappears after eating.
(5) Taking an antacid, the H2 receptor antagonist or the proton pump inhibitor may relieve or disappear.
(6) A few cases may have no abdominal pain, no acid reflux, belching and other symptoms, but only hematemesis and/or melena as the first symptom, this case accounts for about 10% to 15% of the total number of peptic ulcer cases.
(7) X-ray barium meal examination, if found, the shadow mark is important for diagnosis.
(8) Gastroscopic examination, the shape and size of the ulcer can be observed under direct vision, and the diagnosis can be established by combining the histopathological examination.
2. Acute gastric mucosal lesions:
(1) is one of the important causes of upper gastrointestinal bleeding, accounting for about 20% of the cause of upper gastrointestinal bleeding.
(2) There are often incentives for gastric and duodenal mucosal damage. These causes include:
1 Have taken non-steroidal anti-inflammatory drugs such as aspirin, adrenal glucocorticoids, certain antibiotics, etc.
2 drinking, especially after drinking alcohol.
3 kinds of stress states, such as craniocerebral trauma, acute cerebrovascular disease, severe burns, etc.
4 sepsis, severe liver, kidney damage and so on.
(3) often have upper abdominal pain or dull pain, acid reflux, nausea, vomiting and other prodromal symptoms, can also vomit blood and (or) black stool as the first symptom.
(4) Emergency gastroscopy within 24 to 48 hours after hemorrhage, if the stomach, duodenal mucosa diffuse hyperemia, edema, multiple hemorrhage lesions can be diagnosed.
3. Gastric cancer:
(1) is the common cause of upper gastrointestinal bleeding, bleeding due to gastric cancer accounted for about 1% to 3% of bleeding cases, gastric cancer is more common in male patients over 40 years old, but in recent years young people under the age of 30 are not Rare.
(2) patients often have no specific symptoms in the early stage, mostly with loss of appetite, upper abdominal discomfort or dull pain as the main performance, with the disease progress to the middle, late, patients often have weight loss, anemia, upper abdominal pain aggravated or persistent, A small number of patients can have a hard, often difficult to move mass in the upper abdomen.
(3) patients with gastric cancer are slow, a small amount of bleeding is more common, and those with large bleeding are less common, and fecal occult blood tests are often persistent positive.
(4) patients with advanced gastric cancer, such as cancer, distant metastasis, often can be on the left clavicle and swollen, more fixed lymph nodes.
(5) X-ray barium meal examination is an important measure for the diagnosis of gastric cancer. The size, shape, and gastric mucosa around the cancer can be found. The positive rate of X-ray barium meal diagnosis of gastric cancer can reach 80%-90%.
(6) Gastroscopic examination can observe the size, shape, location and infiltration of gastric cancer under direct vision. The biopsy can be distinguished from benign ulcer. The diagnosis rate of gastric cancer can reach more than 95%.
(7) Although CT and MRI examinations have important auxiliary value for the diagnosis of gastric cancer, they are generally not the preferred method of examination because they are expensive.
