Varicose veins of the esophagus are a serious pathology caused by diseases of the liver, heart, digestive organs and much less frequently the venous walls. It is most often observed in the lower sections along with the defeat of the stomach veins in men after 50 years.
Massive bleeding can be unexpected and the only sign. A timely diagnosis is necessary to take preventive measures. To eliminate esophageal varicose veins, special surgical approaches in vascular surgery have been developed.
In the international classification, the disease is accounted for with 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 via the blood supply to many organs in the chest and abdominal cavity. The arterial branches to it go from the thoracic aorta. The venous system 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 enters the vessels of the superior vena cava. The anatomical arrangement and connections form the venous system of the esophagus, as an intermediary between the three outflow systems: portal vein, inferior and superior vena cava.
This feature causes the onset of compensatory varicose veins in the esophagus due to the opening of auxiliary (collateral) vessels 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 mechanical obstruction in the underlying parts of the venous system (hypertension, thrombosis, phlebitis), or a loss of tone of the venous wall due to impaired synthesis of collagen fibers (varicose veins of l '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 liver cirrhosis;
- portal vein thrombosis.
Rare causes of esophageal varicose veins (EVVs) are vascular cancer (angioma) and venous changes in Rendu-Osler syndrome.
Cirrhosis of the liver is a long-term chronic disease that complicates hepatitis (primarily - 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 (connective) scar 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 organ ischemia.
Cirrhosis of the liver can cause:
- congestive heart failure with defects, complication of extensive infarction, myocardial dystrophy, heart disease;
- hereditary diseases with metabolic alterations (galactosemia, hepatocerebral dystrophy, hemochromatosis);
- fetal hepatitis in newborns 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 the collaterals can cause tumors of the intestine and liver, peritonitis, any enlargement of the spleen, lymph nodes.
Bunty 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 internal organs with a tendency to bleed. 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 necessary to treat the cause of the disease.
There are several proposed classifications of the disease. The 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, located 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 the venous vessels, the diameter is more than 10 mm, side by side, on the surface there are characteristic red markers of 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 - the veins become tortuous, gnarled, 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 in 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 against the background of pathologies of unknown origin;
- acquired - caused by various diseases.
How do esophageal varicose veins manifest?
Symptoms of the disease depend on the pathology that caused the esophageal varicose veins. The initial period proceeds without clinical manifestations, patients are unaware of the development of pathology. But cases of progressive course with sudden bleeding are not uncommon.
The deterioration of the condition occurs in 4-5 days. Patients feel the increasing heaviness behind the breastbone, compression. This sign is considered a harbinger of massive bleeding and requires urgent measures, as surgeons' observations 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 assigned blood, the body gradually weakens. Hypochromic anemia develops. The patient is pale, loses weight, moves with difficulty, worries about shortness of breath. Sometimes there is a black liquid stool.
Precursors of bleeding and initial signs of varicose veins can be:
- vague chest pain;
- 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", sweat, a salty taste in the mouth before the bleeding starts.
With acute bleeding appear:
- increased paleness of the skin;
- vomiting of blood ("coffee grounds");
- constant dizziness;
- liquid tarry stools;
- darkening in the eyes;
- severe weakness.
Bleeding is caused by weight lifting, physical work, high body temperature, taking blood thinners, and the fibrogastroscopy procedure. But sometimes it occurs spontaneously against the background of general health. It is necessary to differentiate hemorrhage from a decaying tumor of the esophagus and stomach, the germination of the tumor into a large vessel and its breakthrough, injury to the vessels by a foreign body.
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 gastric varicose veins are detected at the same time.
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 rupture. It is almost impossible to conduct research during bleeding.
In a scheduled way, a contrast radiograph of the esophagus is prescribed; before the image, the patient is given a barium mixture to drink. According to a series of radiographs, the movement of the contrast and its diffusion into the lumen of the esophagus is monitored.
- it is necessary to establish the presence of anemia by the content of erythrocytes, platelets, color index;
- in acute bleeding, the hematocrit is calculated;
- be sure to do an analysis of clotting indicators;
- determine the function of the liver by enzyme tests, the level of proteins, glucose, bilirubin, deviations of the results allow to suspect the influence of liver pathology on changes in the venous system of the esophagus;
- if there are signs of bleeding, the blood group and Rh factor are determined in case of a necessary blood transfusion.
Even the slightest excretion of blood in the stool 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 emergency problem, life-threatening bleeding.
In the absence of massive bleeding, the patient needs therapy for the underlying disease, increased administration of hemostatic agents. The patient must be admitted to a specialized ward. Mode - bed, the head of the bed is raised.
Therapeutic nutrition includes the absence of irritating foods (hot spices, fried and smoked meat products, coarse vegetables, whole fruit, bread crusts, bones, carbonated water). Alcohol and chocolate are strictly prohibited.
The diet consists of sufficiently high-calorie, but liquid and cooled food. Slightly warm broths, boiled liquid porridges, milk pasta, cottage cheese, sweet fruit jelly, cooled tea, white bread pulp, meat in the form of boiled minced meat are recommended.
In order to reduce the activity of cirrhotic changes in the liver, the treatment regimen includes:
- antiviral drugs (with slow 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;
- high-dose vitamin preparations 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 reduced coagulation is detected in a patient, a transfusion of fresh frozen single 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 in the blood that dilate blood vessels. A calcium chloride solution is administered intravenously.
Care should be taken with drugs that increase blood pressure, increase bleeding.
If the bleeding continues, the following is used: wash the esophagus with warm water (40–45 degrees) through a probe, install a rubber balloon probe - there are standard corrugated products (obturator probes) to press the vessel bleeding in the esophagus and in the stomach ulcer.
How does surgery help?
An unfavorable clinical course is an indication for endoscopic ligation. The technique consists in sewing the veins of the esophagus using an endoscope. Surgeons consider it more effective than sclerosing agents (sclerotherapy) injected into the veins, which require 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 the pressure in the portal vein by creating shunts and discharging into the inferior vena cava.
Creating an artificial anastomosis (installation of a metal stent) between the portal and hepatic veins is called a transjugular intrahepatic portosystemic shunt. 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 early relapses of bleeding, inflammation. Reinstallation is required in 1/3 of patients, as the stent thromboses rapidly, 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 left splenic and renal veins. The surgical technique is complicated and risky for the patient, accompanied by high mortality. The devascularization operation consists in the excision and removal of the affected veins and in 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 root 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;
- rowan fruits;
- Wild rose.
In the initial stages of esophageal varicose veins with constant treatment, sufficient functional state of the liver, adherence to the 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. I am constantly at high risk. Survival of people with severe cirrhosis is low.
Varicose veins of the esophagus refer to diseases-complications. In itself it is already a sign of serious damage to the body. Support can only be provided through timely detection using the endoscopic method and observation of the patient.