Varicose veins of the esophagus

Diagnostic endoscopy of varicose veins of the esophagus

Varicose veins of the esophagus are a serious pathology caused by diseases of the liver, heart, digestive organs, and much less often the venous walls. It is more commonly seen in the lower extremities along with gastric vein defeat in men after 50 years.

Massive bleeding may be unexpected and the only sign. Timely diagnosis is necessary to take preventive measures. Special surgical approaches in vascular surgery have been developed to remove varicose veins of the esophagus.

In the International Classification, the disease is considered under different codes:

  • I85. 9 - no bleeding;
  • I85. 0 - with bleeding;
  • I98. 2 - in the background of another pathology.

How does blood flow through the esophageal veins?

The esophagus is connected with the blood supply to many organs of the chest and abdominal cavity. The arterial branches reach it from the thoracic aorta. The venous apparatus is unevenly developed. Blood flows through the veins of the esophagus into the vessels of unpaired and semi-unpaired veins, then passes through anastomoses through the veins of the diaphragm into the inferior vena cava, and through 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 arrangement and connections form the venous apparatus of the esophagus, as a mediator between the three effusion systems: portal veins, inferior and superior vena cava.

This characteristic causes the formation of compensatory varicose veins at the level of the esophagus due to the opening of auxiliary vessels (collaterals) in diseases of the spleen, intestines, followed by blockage of one's own veins.

Reasons for enlargement

Esophageal varicose veins provide two mechanisms. There is either difficult outflow due to mechanical obstruction in the lower parts of the venous system (high blood pressure, thrombosis, phlebitis), or loss of venous wall tone due to impaired synthesis of collagen fibers (varicose veins SMV).

The cause of stagnation in the upper parts is often malignant goiter. In the lower esophagus, venous blood flow is delayed due to:

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

Rare causes of varicose veins of the esophagus (EVV) are vascular tumor (angioma) and venous changes in Randu-Osler syndrome.

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

There is a proliferation of dense scar (connective) tissue, replacement of functional cells with tubercles with the occurrence of liver failure. Under these conditions, compression of both arterial and venous vessels occurs. Decreased oxygen supply exacerbates the situation, causing organ ischemia.

Cirrhosis of the liver can cause:

  • medicines;
  • congestive heart failure with defects, complication of extensive infarction, myocardial dystrophy, cardiopathy;
  • hereditary diseases with metabolic changes (galactosemia, hepatocerebral dystrophy, hemochromatosis);
  • fetal hepatitis in newborns occurs when the mother has an infection (rubella, herpes, cytomegalovirus), when the causative agent is transmitted to the fetus through the placental barrier.

Varicose veins of the esophagus due to the opening of collaterals can cause tumors of the intestines and liver, peritonitis, any enlargement of the spleen, lymph nodes.

Bunty's syndrome - a disorder of circulation in the veins of the spleen (splenohepatomegaly) occurs in young women in the background of anemia, thrombocytopenia and leukopenia, congestion in the liver with portal hypertension and cirrhosis. It is caused by infectious diseases (brucellosis, malaria, syphilis, leishmaniasis).

Randu-Osler syndrome (hereditary telangiectasia), in addition to skin and mucous membrane lesions, causes multiple angiomatous changes in internal organs with a tendency to bleed. Localization in the esophagus creates conditions for varicose veins. In order to prevent bleeding from the dilated venous network of the esophagus, it is necessary to treat the cause of the disease.

Current classification

There are several proposed classifications of diseases. Signs are detected by esophagogastroscopic examination. The most acceptable is the division of varicose veins of the esophagus according to the degree of change of veins.

  • 1 degree - the maximum diameter of the veins is 5 mm, they are elongated, localized in the lower esophagus;
  • Stage 2 - the curvature of the veins is determined, the diameter increases to 1 cm, they reach the middle third of the organs;
  • Grade 3 - draws attention to the thinning and tension of the walls of venous vessels, over 10 mm in diameter, go side by side, the surface is characterized by red markers of the smallest capillaries.

According to the second classification (Vitenas and Tamulevichiute), it is proposed to take into account 4 stages of the disease course:

  • 1 - the diameter of the veins is 2-3 mm, they are bluish in color, of the right shape;
  • 2 - veins become crooked, knotty, increase in diameter over 3 mm;
  • 3 - varicose nodes are clearly distinguished, curvature is significant, a bulge appears in the lumen of the esophagus;
  • 4 - nodules grow to the shape of grapes, significantly narrow the lumen of the esophagus, a thin network of small capillaries is visible on the outer surface.

In addition, the diagnosis takes into account:

  • congenital form that occurs in the background of pathologies of unknown origin;
  • acquired - caused by various diseases.

How do varicose veins of the esophagus manifest?

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

Worsening of the condition occurs in 4-5 days. Patients feel an increasing weight behind the sternum, compression. This sign is considered a sign of massive bleeding and requires urgent measures, because the surgeon's observations connect it with a fatal outcome.

All the symptoms of varicose veins are determined by the threatening manifestations of blood loss. In a chronic course with a small amount of donated blood, the body gradually weakens. Hypochromic anemia develops. The patient is pale, loses weight, has difficulty moving, is worried about lack of air. Sometimes there is liquid black feces.

Signs of bleeding and initial signs of varicose veins can be:

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

Heartburn and belching are explained by esophageal sphincter dysfunction, reverse (reflux) reflux from the stomach. Some patients experience a "tickle in the throat", sweating, and a salty taste in the mouth before bleeding begins.

In acute bleeding, the following occur:

  • increasing pallor of the skin;
  • vomiting of blood ("coffee grounds");
  • constant dizziness;
  • liquid tarry stool;
  • darkening of the eyes;
  • severe weakness.

Bleeding is caused by lifting weights, physical work, fever, taking anticoagulants and fibrogastroscopy. But sometimes it occurs spontaneously in the background of general health. It is necessary to distinguish bleeding from a decaying tumor of the esophagus and stomach, the germination of the tumor in a large vessel and its perforation, injury to blood vessels by a foreign body.

Diagnosis

The diagnosis may be suspected but cannot be confirmed without esophagogastroduodenoscopy. This is practically the only way to establish a connection between bleeding and varicose veins of the esophagus, and often varicose veins of the stomach are detected at the same time.

X-ray can detect inflammation, tumors, spastic contraction with impaired esophageal patency

The procedure allows you to determine the degree of deformation of the veins, the stage of the disease, visually determine the condition of the vascular walls and predict rupture. It is almost impossible to conduct research during bleeding.

Contrast-enhanced esophageal radiography is routinely prescribed, and the patient is given a barium mixture before imaging. Based on a series of X-rays, the movement of the contrast and its spread in the esophageal lumen are monitored.

Laboratory method:

  • it is necessary to determine the presence of anemia by the content of erythrocytes, platelets, color index;
  • in acute bleeding, hematocrit is calculated;
  • be sure to do an analysis of coagulation indicators;
  • determination of liver function by enzyme tests, protein levels, glucose, bilirubin, deviations of results allow to suspect the influence of liver pathology on changes in the venous system of the esophagus;
  • if there are signs of bleeding, blood group and Rh factor are determined in case of necessary blood transfusion.

Even minimal excretion of blood in the feces is confirmed by Gregersen's reaction to occult blood.

How is esophageal vein disease treated?

Treatment of varicose veins of the esophagus differs in the planned option and scheme, depending on the occurrence of an urgent problem, life-threatening bleeding.

In the absence of massive bleeding, the patient needs therapy for the underlying disease, increased use of hemostatic agents. The patient must be hospitalized in a specialized ward. Mode of operation - bed, headboard raised.

nutritional needs

Therapeutic diet ensures the absence of irritating foods (spicy spices, fried and smoked meat products, coarse vegetables, whole fruits, bread crusts, bones, carbonated water). Alcohol and chocolate are strictly forbidden.

The diet is made up of enough caloric, but liquid, chilled food. Slightly warm soups, cooked liquid porridges, milk noodles, cheese, sweet fruit jellies, chilled tea, white bread porridge, meat in the form of cooked minced meat are recommended.

In varicose veins of the esophagus, preference is given to cooked food

Drug treatment

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

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

Vitamins K, C, D, E are of special importance in the treatment of varicose veins. The synthetic water-soluble vitamin K analogue is administered intramuscularly or intravenously. If the patient is diagnosed with anemia with impaired clotting, then a transfusion of fresh frozen single plasma (1-2 doses), erythrocyte or platelet mass is prescribed.

Intravenous octapeptide that mimics natural somatostatin is widely used to stop bleeding. The drug is able to suppress the release of hormones into the blood that dilate blood vessels. Calcium chloride solution is given intravenously.

One should be careful with drugs that increase blood pressure, increase bleeding.

If the bleeding continues, use: rinsing the esophagus with warm water (40-45 degrees) through the probe, placing a rubber balloon probe - there are standard corrugated products (probe obturator) to suppress bleeding in the esophagus and gastric ulcer.

Esophageal dilatation balloon is used both to stop bleeding in varicose veins of the esophagus and in the treatment of narrowed areas.

How does surgery help?

Unfavorable clinical course is an indication for endoscopic ligation. The technique consists of suturing the esophageal veins with an endoscope. Surgeons consider it more effective than sclerosing agents (sclerotherapy) injected into veins, which requires repetition at least four times a year.

Treatment of varicose veins of the esophagus with bleeding that is not eliminated by therapeutic methods requires urgent surgery. The goal of the operation is to reduce the pressure in the portal vein by creating shunts and releasing it into the inferior vena cava.

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

Accompanied not only by technical difficulties, but also by the early recurrence of bleeding and inflammation. 1/3 of patients need re-installation, because the stent thromboses quickly, blocking the lumen. Up to 13% of patients die within a month. This makes the operation an urgent measure of choice.

Another method to improve blood flow through the porto-caval is to create an anastomosis between the spleen and the left renal vein. The technique of the operation is complicated and risky for the patient, accompanied by high mortality. Devascularization surgery consists of excision and removal of the affected veins and their replacement with dentures.

Is it possible to be treated with folk remedies?

The use of folk remedies in the presence of bleeding is unconvincing. But you can use them to treat the main cause of varicose veins - liver damage. Long-term intake of decoctions is suitable for this:

  • of milk thistle;
  • chicory root;
  • corn stigmas;
  • Japanese sophora;
  • oats;
  • oren fruits;
  • wild rose.

Disease prognosis

In the initial stages of varicose veins of the esophagus, with constant treatment, sufficiently functional liver condition, adherence to the recommendations on diet and nutrition, it is possible to stop bleeding in 80% of patients. In 2/3 of patients after one repeated bleeding within 1-2 years. They are constantly at high risk. Survival of people with severe cirrhosis is low.

Varicose veins of the esophagus refer to diseases-complications. This in itself is a sign of serious damage to the body. Support can only be provided through timely endoscopic detection and observation of the patient.