Varicose veins of the esophagus

Diagnostic endoscopy for esophageal varicose veins

Varicose veins of the esophagus are a serious pathology provoked by diseases of the liver, heart, digestive organs, and much less frequently of the venous walls. It is more often observed in the lower sections along with the defeat of the veins of the stomach in men after 50 years.

Massive bleeding may be unexpected and the only sign. Timely diagnosis is necessary to take preventive measures. To eliminate esophageal varicose veins, 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 the background of another pathology.

How does blood flow through the veins of the esophagus?

The esophagus is connected by blood supply to many organs of the chest and abdominal cavity. Arterial branches to it go from the thoracic aorta. The venous apparatus is unevenly developed. Blood flows through the veins of the esophagus into the vessels of the unpaired and semi-unpaired veins, then passes through the 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, venous outflow goes into the vessels of the superior vena cava. Anatomical arrangement and connections form the venous apparatus of the esophagus, as an intermediary between the three outflow systems: portal vein, inferior and superior vena cava.

This feature provokes the occurrence of compensatory varicose veins at the level of the esophagus due to the opening of auxiliary vessels (collaterals) in diseases of the spleen, intestines, accompanied by a blockage of their own veins.

Reasons for expansion

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

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

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

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

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

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

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 newborn babies occurs when the mother has an infection (rubella, herpes, cytomegalovirus), when the pathogen is transmitted to the fetus through the placental barrier.

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

Bunty's syndrome - a violation of circulation in the veins of the spleen (splenohepatomegaly) occurs in young women against 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 lesions of the skin and mucous membranes, causes multiple angiomatous changes in the internal organs with a tendency to bleeding. Localization in the esophagus creates conditions for the expansion of the veins. To prevent bleeding from an expanded venous network of the esophagus, it is required to treat the disease-cause.

Current classification

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

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

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

  • 1 - the diameter of the veins is 2-3 mm, they are bluish in color, straight in shape;
  • 2 - veins become tortuous, knotty, increase in diameter over 3 mm;
  • 3 - varicose nodes are clearly distinguished, tortuosity is significant, a protrusion appears in the lumen of the esophagus;
  • 4 - the nodes grow to a grape-like shape, 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 occurring against the background of pathologies of unknown origin;
  • acquired - caused by various diseases.

How does esophageal varicose veins manifest?

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

Deterioration of the condition occurs in 4-5 days. Patients feel the growing heaviness behind the sternum, compression. This sign is considered a harbinger of massive bleeding and requires urgent measures, since observations of surgeons associate it with a fatal outcome.

All symptoms of varicose veins are determined by the threatened manifestations of blood loss. In a chronic course with a small amount of allocated blood, the body gradually weakens. Hypochromic anemia develops. The patient is pale, loses weight, moves with difficulty, he is worried about shortness of breath. Sometimes there is a liquid black feces.

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

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

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

With acute bleeding appear:

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

Bleeding is provoked by weight lifting, physical work, elevated body temperature, taking anticoagulants, and the fibrogastroscopy procedure. But sometimes it occurs spontaneously against the background of general health. It is necessary to differentiate bleeding from a decaying tumor of the esophagus and stomach, tumor germination into a large vessel and its breakthrough, injury to vessels by a foreign body.

Diagnostics

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

X-ray can reveal inflammation, tumors, spastic contraction with impaired patency in the esophagus

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

In a planned manner, a contrast radiography of the esophagus is prescribed; before the picture, the patient is given a mixture of barium to drink. According to a series of radiographs, the movement of the contrast and its spreading in the lumen of the esophagus are monitored.

Laboratory way:

  • it is necessary to establish 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;
  • determine the function of the liver by enzyme tests, the level of protein, glucose, bilirubin, deviations of the results make it possible to suspect the influence of hepatic pathology on changes in the venous system of the esophagus;
  • if there are signs of bleeding, the blood type and Rh factor are determined in case of a necessary blood transfusion.

Even minimal excretion of blood in the feces is confirmed by the Gregersen 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 emergency problem, life-threatening bleeding.

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

dietary requirements

Therapeutic nutrition provides for the absence of irritating foods (spicy spices, fried and smoked meat products, coarse vegetables, whole fruits, bread crusts, bones, soda water). Alcohol and chocolate are strictly prohibited.

The diet is built from sufficiently high-calorie, but liquid, cooled food. Slightly warm broths, boiled liquid porridges, milk noodles, cottage cheese, sweet fruit jelly, cooled tea, pulp of white bread, meat in the form of boiled minced meat are recommended.

With varicose veins of the esophagus, preference is given to boiled foods

Medication treatment

In order to reduce the activity of cirrhotic changes in the liver, the treatment regimen includes:

  • antiviral drugs (with sluggish hepatitis);
  • steroid hormones;
  • antibiotics for bacterial infection;
  • diuretics to reduce pressure in the system of the inferior vena cava;
  • 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 particular importance in the treatment of varicose veins. A synthetic water-soluble analogue of vitamin K is administered intramuscularly or intravenously. If anemia with impaired clotting is detected in a patient, then a transfusion of fresh frozen single-group plasma (1-2 doses), erythrocyte or platelet mass is prescribed.

To stop bleeding, intravenous administration of an octapeptide that mimics natural somatostatin is widely practiced. The drug is able to suppress the release of hormones into the blood that dilate blood vessels. A solution of calcium chloride is administered intravenously.

Care should be taken with drugs that increase blood pressure, they increase bleeding.

If bleeding continues, the following is used: washing the esophagus with hot water (40–45 degrees) through a probe, installing a rubber balloon probe - there are standard corrugated products (obturator probes) to press the bleeding vessel in the esophagus and in the stomach ulcer.

Balloon dilatation of the esophagus is used both to stop bleeding in esophageal varicose veins, and in the treatment of narrowed areas.

How does surgery help?

An unfavorable clinical course is an indication for endoscopic ligation. The technique consists in stitching the veins of the esophagus using an endoscope. Surgeons consider it more effective than sclerosing agents (sclerotherapy) injected into the veins, which requires repetition at least four times a year.

Treatment of esophageal varicose veins with bleeding that has not been eliminated by therapeutic methods requires emergency surgery. The goal of surgery is to reduce pressure in the portal vein by creating shunts and dumping into the inferior vena cava.

Creating an artificial anastomosis (installation 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 successfully performed in 95% of cases.

Accompanied not only by technical difficulties, but also by early recurrence of bleeding, inflammation. In 1/3 of patients, re-installation is required, since the stent quickly thromboses, blocking the lumen. Within a month, up to 13% of patients die. This makes the operation an emergency measure of choice.

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

Is it possible to be treated with folk remedies?

The use of folk remedies in the presence of bleeding is inconclusive. But you can use them in the treatment of the main cause of varicose veins - liver damage. For this, a long-term intake of decoctions is suitable:

  • from milk thistle;
  • chicory root;
  • corn stigmas;
  • Japanese Sophora;
  • oats;
  • rowan fruits;
  • wild rose.

Disease prognosis

In the initial stages of esophageal varicose veins with constant treatment, a sufficient functional state of the liver, adherence to recommendations on the regimen and diet, it is possible to stop bleeding in 80% of patients. In 2/3 of patients after a single repeated bleeding 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 diseases-complications. It in itself is already a sign of severe damage to the body. Support can only be provided by timely detection using the endoscopy method and observation of the patient.