Esophageal and gastric varices and their rupture
Introduction
Introduction of esophagogastric varices and rupture Esophageal varices is one of the main clinical manifestations of portal hypertension and is a common cause of upper gastrointestinal bleeding. basic knowledge The proportion of illness: 0.0002% Susceptible people: no special people Mode of infection: non-infectious Complications: liver cirrhosis, hepatic encephalopathy, stomach disease
Cause
Esophageal varices and the cause of rupture and hemorrhage
(1) Causes of the disease
Esophageal varices is the main clinical manifestation of portal hypertension, and portal hypertension is mainly caused by cirrhosis, which is also one of the main pathophysiological changes of cirrhosis. The direct consequence of portal hypertension is portal vein and systemic circulation. The establishment and opening of the collateral circulation, the most clinically significant in the portal-body collateral circulation is the esophagogastric varices, because the varicose veins are easily affected by the increase of portal pressure; the negative pressure of the thoracic cavity Increased venous return blood flow; acid reflux in the stomach erodes the esophageal mucosa; and damage caused by rough food or alcohol-induced damage, and become the most common complication and cause of death in patients with cirrhotic portal hypertension The other two major causes of upper gastrointestinal bleeding in patients with cirrhosis are: peptic ulcer and acute gastric mucosal lesions, which are also related to the increase of portal pressure to some extent. Studies have shown that portal pressure is lower than 2.65 kPa (27 cm H2O) or hepatic venous pressure. When the gradient is less than 1.6kPa (16cmH2O), bleeding rarely occurs. Therefore, the main purpose of treating portal hypertension is to reduce the portal pressure to control and pre- First bleeding esophageal varices in patients with recurrent bleeding.
(two) pathogenesis
After the portal pressure rises, many collateral circulations are formed, especially in the esophagus and stomach. It can also occur in other parts of the stomach and in the intestine. The pressure in the varicose veins is directly affected by the portal pressure. When the pulse pressure suddenly rises, the varicose veins can rupture, so the bleeding often ruptures after exerting force or vomiting, the portal pressure continues to rise, the pressure in the varicose veins increases, the wall becomes thinner, and the radius of the blood vessels increases. The basic conditions of rupture, it is generally believed that the portal pressure gradient (portal pressure minus the inferior vena cava pressure) is less than 11 ~ 12mmHg (1.466 ~ 1.6kPa) will not rupture bleeding, tissue support around the varicose vein is of great significance, Vascular varicose to a certain extent, if there is strong tissue support around it, it will not rupture, but the supporting tissue mucosal surface may be damaged by local factors such as inflammation and erosion, so that the tissue support strength is weakened and easily broken.
The tension of the varicose vein wall is regulated by the interaction of several factors, which can be expressed by the following formula according to Laplace's law:
Varicose vein wall tension = (P1-P2) × r / w
Where P1 is the varicose vein pressure, P2 is the pressure in the esophageal lumen, r is the radius of the varicose vein, w is the thickness of the varicose vein wall, and it can be seen that the large varicose veins and the varicose veins increase the pressure, causing the varicose veins The tension of the vein wall is increased, and the degree of varicose veins is on time.
For example, when the varicose veins are IV°, the wall is thin, and the cherry red dot is visible under the endoscope. Even if the pressure in the varicose vein is not high, the risk of bleeding is still great. If the tissue support is not strong or the inhalation is esophagus Negative pressure in the lumen increases the risk of bleeding. Therefore, when the varicose vein tension increases to a high degree of risk, any factor that increases the portal pressure, or any defect in the surrounding supporting tissue, will cause variceal bleeding. In fact, these changes have a certain development process, and thus related to the course of the disease, hematemesis and/or black stools occur in about 1/4 of the cases within 3 to 4 years after the diagnosis of cirrhosis.
Non-sclerosing intrahepatic diseases and portal hypertension caused by extrahepatic factors, as well as esophageal varices bleeding, the more obvious esophageal varices, the greater the risk of bleeding, and the rate of rebleeding is also high.
Recently, histological studies have found that there are many dilated tubules under the epithelium in the specimens of esophageal varices. Under electron microscopy, the ducts are stained with atypical endothelial cells and positive for factor VIII-related antigens. The tube is consistent with the cherry red spots seen during endoscopy, and these tubes are considered important for rupture of varicose veins.
The varicose veins of the stomach are generally coarser and deeper, and there are fewer ruptures and bleedings, but once ruptured, the blood loss is large.
Prevention
Esophageal varices and prevention of rupture and bleeding
1. Active and effective treatment of liver disease, prevention of cirrhosis caused by portal hypertension caused by esophageal varices and rupture is the key.
2. Treatment of gastric mucosal erosion, inflammation or ulcers, prevention of esophageal and gastric varices.
Complication
Esophageal varices and complications of rupture and bleeding Complications liver cirrhosis hepatic encephalopathy stomach disease
In patients with cirrhosis, gingival, subcutaneous and mucosal hemorrhage are common symptoms. If the gastrointestinal tract is obviously bleeding (hematemesis and melena), the main source of bleeding is variceal rupture and portal hypertensive gastropathy. The varicose vein is mainly the esophagogastric vein. Varicose varicose, also in other parts of the stomach or any part of the intestine, a large number of rapid blood loss can immediately appear hemodynamic changes, blood volume is rapidly reduced, blood flow to the heart is also reduced, cardiac output is reduced, blood pressure is reduced, pulse compression is small The heart rate is accelerated, the perfusion of various organs in the body is insufficient, and the lack of oxygen leads to functional and morphological damage, and the condition is more complicated.
A large amount of blood loss reduces cerebral blood flow, and patients experience irritability, apathy or loss of consciousness. When cerebral blood flow is reduced to 50%, these phenomena are obvious, and hepatic encephalopathy can also occur later.
Symptom
Esophageal varices and its rupture and bleeding symptoms Common symptoms Liver palm weakness, irritability, ascites, loss of appetite, diarrhea, edema, black stool, weight loss
Patients with portal hypertension often have three clinical manifestations:
1. The manifestations of primary disease: 90% of portal hypertension is caused by cirrhosis, while patients with cirrhosis often have fatigue, fatigue, loss of appetite, weight loss, 10% to 20% of patients have diarrhea, visible dull skin or even dark or light Degree of jaundice, subcutaneous or mucosal bleeding points, spider mites, liver palm, splenomegaly and endocrine disorders, such as low sexual function, irregular menstruation (menopause or excessive) and male breast development.
2. Portal hypertension manifestations: ascites and edema, abdominal varicose veins and varicose veins and splenomegaly.
3. Bleeding and its secondary effects: gingival, subcutaneous and mucosal bleeding in patients with cirrhosis is a common symptom.
If the gastrointestinal tract is obviously bleeding (hematemesis and melena), the main source of bleeding is variceal rupture and portal hypertensive gastropathy. The varicose veins are mainly esophageal and gastric varices, but also in other parts of the stomach or any part of the intestine. A large number of rapid blood loss can immediately appear hemodynamic changes, blood volume is rapidly reduced, blood volume is reduced, cardiac output is reduced, blood pressure is decreased, pulse compression is small, heart rate is accelerated, and various organs in the body are insufficiently perfused and hypoxic. Lead to functional and morphological damage, the condition is more complicated, after blood loss, through the self-regulation, first sympathetic nerve excitation, volume vasoconstriction, blood circulation does not immediately have obvious hemodynamic changes; such as continued bleeding, resistance vessels When contraction, the temperature of the peripheral skin is decreased, but the sympathetic excitation does not significantly affect the contraction of the visceral (heart, brain, etc.) blood vessels, which allows the circulating blood volume to supply more vital organs, when this compensatory effect cannot When the vascular bed adapts to a decrease in blood volume, the ventricular filling pressure is reduced, the cardiac output is reduced, the central venous pressure is decreased, and the heart rate is accelerated. Insufficient blood perfusion in organ tissues, consequent metabolic disorders, accumulation of acidic metabolites, resistance vessels can not maintain their high tension, no longer respond to adrenergic stimulation, increase capillary permeability, fluid leakage, further cause blood Flow dynamics changes, leading to severe tissue damage, resulting in arrhythmia, heart failure and further deterioration of liver function, even jaundice, edema and ascites increased and hepatorenal syndrome, patients with irritability, apathy or loss of consciousness, may be a large number of blood loss This is caused by a decrease in cerebral blood flow. When the cerebral blood flow is reduced to 50%, these phenomena are obvious, and hepatic encephalopathy can also occur later.
In patients with blood loss, when the palm is stretched after fists, the wrinkles on the palm are pale, suggesting a 50% loss of blood volume. If the patient has shock in the supine position, the blood volume is lost by about 50%; if there is shock in the standing position, the blood loss is about 20%. %~30%, if the patient's head is raised by 75°, the blood pressure drops by 20~30mmHg after 3min, or the blood pressure and pulse rate of the patient in the supine position are checked. Compared with the examination result in the upright position, the blood pressure in the upright position is reduced by 10mmHg. When the pulse rate is increased by 20 times/min, the blood loss exceeds 1000 ml, and therefore, the approximate blood loss can be estimated based on clinical symptoms.
After a large amount of blood loss, the spider mites and the liver palm can temporarily disappear, and the spleen can be reduced. After the blood volume is replenished, the circulatory function can be restored after recovery.
Examine
Esophageal varices and examination of rupture and bleeding
Patients often have varying degrees of anemia, but most of them are mild anemia, leukopenia, and spleen hyperfunction is reduced in whole blood cells, but reticulocytes are increased, bone marrow hyperplasia is active, patients often have abnormal liver function, serum albumin is reduced, serum balls Increased protein, often white / globulin inverted, transaminase mildly elevated, prothrombin time prolonged, white blood cells temporarily increased after hemorrhage, the original level was restored after blood stopped, 6 ~ 24h (or even 72h) blood was Dilution, hemoglobin, red blood cell and hematocrit began to decline, blood urea nitrogen increased, blood ammonia increased, so it is easy to induce coma after bleeding.
1. Fiber endoscopy:
For the easiest and most effective method of examination, although the examination after the cessation of bleeding is safe, but the active bleeding lesions are not visible; while the blood is being examined, the rushing blood often covers the lesions, which is difficult to see clearly. Classen et al. Research data from Germany, Germany, and Australia suggest that 85% to 97% of cases of early gastroscopy can be diagnosed. The experience accumulated by domestic scholars suggests that except for patients with shock, patients with severe heart and lung disease, and patients with extreme exhaustion, A safe endoscopy examination currently advocates a gastroscopy within 48 hours of bleeding to determine the location and nature of the bleeding lesion.
Under normal circumstances, the lower end of the esophagus is centered on the cardia, and the submucosal vessels less than 0.1 cm in diameter are radially distributed. The blood vessels are well-proportioned. When the portal hypertension is high, the submucosal vessels are thickened and beaded or braided. The bulge, the vein of the proximal part of the esophagus near the cardia is an annular bulge, and the center of the varicose vein of the bulge sees a blood-like bulge of about 0.2 cm, indicating that bleeding is about to occur, and the varicose veins have reached the middle part of the esophagus, and there are more than two. The varicose veins, the ulnar varicose veins protrude into the esophageal cavity, and cannot be flattened after inflation, the mucous membrane on the surface of the varicose veins is congested, and there are cherry red spots, etc., all of which are expected to bleed, and when the fundus vein is observed, The head side is 15 ° ~ 20 ° high, and inserted into the irrigation tube through the biopsy hole, rinsed out, in order to observe, although the degree of gastric varices is heavier than esophageal varices, but the part is deep, the mucosal changes are not obvious. Gastroscopic examination is easy to miss diagnosis. Sometimes large varicose veins can be misdiagnosed as tumors. It is not easy to distinguish from mucosal folds. Therefore, the diagnosis of gastric varices is not as good as X. For the examination of esophageal varices, the gastroscope is superior to the X-ray. Okuda et al have compared the effects of gastroscopy and X-ray on gastric varices, 46 cases of gastric varices found by X-ray, and the correct diagnosis by gastroscopy. At only 80%, we found that some patients had normal esophagus on the X-ray, and esophageal varices were found by gastroscopy.
After the portal pressure rises, many collateral circulations are formed. Varicose veins often occur in the esophagus and fundus, and may also be accompanied by other parts, or occur in other parts, such as the stomach, antrum, pylorus and intestines. Cases can also occur in areas other than the digestive tract, such as the peritoneum, gallbladder, common bile duct, vagina and bladder, called ectopic varicose veins. Lebrec et al believe that ectopic varices in patients with cirrhosis are about 1% to 3%. Patients with extrahepatic portal hypertension are much higher, up to 20% to 30%, especially in those who have undergone abdominal or pelvic surgery. Once these varicose veins rupture, it is often difficult to identify the source of bleeding and The nature of the lesion, but also endangers the life of the patient. Intestinal varices occur in the colon. The colon below the liver is more common. Colonoscopy can detect the lesion and whether it is bleeding. It occurs in the small intestine, sometimes in surgery. Can be found by enteroscopy or by other methods.
2. Angiography and selective angiography:
If endoscopy fails, or if endoscopy is not possible due to the condition, angiography should be considered. This method almost completely replaces spleen-door angiography, and the minimum bleeding rate that can be detected is 0.5ml/min, which exceeds this bleeding rate. , the phenomenon of contrast agent overflowing blood vessels can be seen on a series of X-ray films, and the bleeding site can be determined accordingly, and abnormal hepatic artery tortuosity can be seen, and the basic situation of opening of the portal vein, superior mesenteric vein and splenic vein can be obtained. For patients with esophageal varices bleeding, although the contrast agent has been diluted in the venous system, the phenomenon that the contrast agent overflows from the varicose vein is still visible, especially for small intestinal bleeding, and the effect is better than other methods, if the bleeding is too It is too fast, although it is difficult to maintain the stability of the circulation state, it is impossible to carry out angiography. In addition, the contrast agent is hyperosmotic, which can cause hyperosmolar diuresis, and patients with renal dysfunction should be cautious.
3. Portal venography:
At present, there are many methods of portal venography, which can show the portal system and its collaterals. There may be no obvious abnormalities in the early stage of cirrhosis. As the disease progresses, the portal vein can be expanded, prolonged, distorted, and a large number of collateral vessels are filled. , distort, some like the tree in the wind, the extrahepatic portal vein or its branches obstructed, the obstruction is narrow or interrupted, the collateral vessels go to the transverse sac, the chest wall or the abdominal wall, and the vicinity of the obstruction gradually shows the sponge due to the collateral circulation. Changes in the shape, the intrahepatic branches are not clear.
A safe and reliable method is umbilical-portal venography, which is inserted through the umbilical vein to the left branch of the portal vein. The range of the portal vein is determined by the position of the tip of the catheter and the pressure of the injected contrast agent. When the portal hypertension is high, the force can be injected to make the portal vein. The blood is reversed, so that an image of the portal system can be obtained, confirming the condition of the collateral circulation.
Hepatic venography and retrograde portal venography, intubation through the femoral vein or anterior median vein of the elbow, through the vena cava into the hepatic vein, injection of contrast agent to observe the hepatic vein and its branches, and then advance the catheter to the embedding position, inject contrast agent Portal vein branch imaging, so called "embedded hepatic venography" or "reverse portal venography", is valuable for the diagnosis of cirrhosis, can understand the abnormalities of the portal system.
Percutaneous transhepatic portal venography, the portal vein, splenic vein and portal-body collateral circulation showed good, but the operation technique is more complicated, the safety is lower than other methods, intraoperative or laparoscopic venous puncture Contrast, although effective, may not be tolerated by patients.
Intra-arterial digital subtraction portal vein indirect angiography, catheter delivery to the splenic artery or superior mesenteric artery, injection of contrast agent to imaging the portal system, mainly to observe the morphological changes of the portal vein and its branches, with or without obstruction, collateral circulation formation As well as the direction of blood flow, it is very important to determine the stage of the lesion, the choice of treatment plan and the prognosis.
4. X-ray examination chest:
The abdominal X-ray film only shows the liver, the size of the spleen, and the increase of the left paravertebral shadow. It may be caused by the semi-singular vein dilatation and the transposition of the pleural reflex between the aorta and the spine. The esophageal collateral circulation is obviously enlarged. When the chest flat film can appear similar to the mediastinal block shadow, such as mediastinal tomography, can reveal the expansion of the azygous vein, esophagus, stomach sputum meal examination, should be prepared with two kinds of tincture and thinner, swallowed under fluoroscopy, Observe the esophageal activity and filling, change the position, observe the mucosal morphology from different angles, and then take the esophageal strip at the end of inhalation. The normal esophageal mucosa is arranged in a slender line. The varicose veins appear as filling defects, which are more common under the esophagus. 1/3, can also extend to the entire esophagus, and often accompanied by gastric varices, like a worm-like crossing the end of the stomach to the stomach, some patients only involve the esophagus and the stomach is not affected, and vice versa, without esophageal varices alone It is rare to have gastric varices. In general, esophageal varices X-ray barium examination is easy to find. When varicose veins are not obvious, it is necessary to use gastroscopy to find out. X-ray examination is superior to gastroscopy, especially gas sputum double contrast, the rate of discovery of gastric varices can reach more than 80%, the filling defect indicated by varicose veins should be different from mucosal folds, and the anterior position of gas sputum after double contrast It is particularly clear that the fundus varices are sometimes lobulated, similar to cancer, and can be effectively identified by portal venography. Samuel once summarized the X-ray signs of gastric varices as 4 points:
(1) Thick and distorted pleats, such as polyps, are located on the large curved side and extend to the cardia.
(2) The morphological changes of the mucosa showed a blister-shaped circular area.
(3) There are also esophageal varices.
(4) There is a swollen spleen.
The collateral circulation of the stomach and esophagus is also affected by the increase of portal pressure, and the effect of negative pressure on the esophagus is greater, which may be the reason why esophageal varices are more common than gastric varices. Of course, X-ray barium even if veins are found. The varicose does not indicate whether the bleeding has broken.
Small intestine X-ray angiography has an important role in the diagnosis of small bowel disease. Cases of variceal hemorrhage in the small intestine can be sent to the small intestine with Miller-Abbott tube, and the intestinal juice is taken at regular intervals, in the place where bloody intestinal fluid is aspirated. Local barium angiography can help diagnose, but patients with acute massive hemorrhage should not be used for small bowel angiography. Selective angiography should be appropriate.
X-ray barium enema examination is very valuable for the diagnosis of colonic lesion hemorrhage, especially low-tension gas angiography, which can clearly show the microscopic changes of colonic mucosa.
5. Radionuclide scanning For a small amount of bleeding, when the bleeding rate is 0.1ml/min, it is suitable for radionuclide scanning, and the red blood cells of 99mTc are injected intravenously. The half-life of 99mTc in the blood is about 3min, most of which is rapidly reticulated. The system clears, the marked red blood cells overflow in the bleeding site, forming a dense staining area, thereby determining the bleeding site. This method has a long monitoring time, but false positives and positioning errors may occur, and the diagnosis must be determined in combination with other examinations.
Diagnosis
Diagnosis and diagnosis of esophagogastric varices and rupture
diagnosis
Timely collection of detailed medical history is very important for the diagnosis of hematemesis and melena. However, patients with acute massive blood loss often enter the state of shock quickly. It is difficult to tell the medical history in detail. The medical history data provided by the escort may not be complete, and may not be reliable. Urgent treatment, close observation, grasp the opportunity to carry out the necessary inspections, and when the condition is relatively stable, then ask the medical history in detail and arrange for further examination.
The patient had hepatitis, especially those with abnormal liver function or transaminase; long-term hepatitis virus, especially type B, hepatitis C virus; had received blood transfusion or blood products; had history of cholelithiasis or chronic biliary infection; history of schistosomiasis Or history of schistosomiasis water exposure; long-term alcohol abuse; long-term medication or exposure to poison; abdominal trauma or surgical history, etc., should first consider the esophagogastric varices bleeding may be.
Differential diagnosis
Upper gastrointestinal bleeding refers to the digestive organs above the ligament of the ligament, including esophagus, stomach, duodenum, pancreas, biliary tract bleeding, bleeding in the upper jejunum after gastrojejunostomy is also the range, upper gastrointestinal bleeding is the most Common gastrointestinal emergency, high mortality.
