Bleeding from the esophagus. Symptoms of acute hemorrhage. Endoscopic ligation of VRV of the esophagus

The veins of the esophagus are very thin-walled vessels. With an increase in portal pressure, they stretch and change varicose.

Symptoms of bleeding from varicose veins of the esophagus

The clinical picture depends on the volume and rate of blood loss. In patients with prolonged (hidden) minor blood loss, the disease manifests itself as weakness and iron deficiency. Given the chronic nature of the process, with latent blood loss, the patient may experience a significant deterioration in the condition. On physical examination, the patient appears tired and pale. Arterial pressure, due to the absence of acute bleeding, remains normal. More often, manifestations of bleeding from varicose veins of the esophagus are more pronounced, accompanied by bloody vomiting, bloody stool indicating massive bleeding.

With portal hypertension, the source of bleeding can be localized in almost any part of the gastrointestinal tract. However, more often the cause of massive blood loss is the rupture of the veins of the esophagus, stomach, or both of these organs. In case of blood loss caused by portal hypertension from sources of other localizations, similar resuscitation measures, assessment of severity and timely treatment should be carried out.

Patient examination

The first and foremost thing when examining a patient with suspected variceal bleeding is a comprehensive clinical evaluation. Pay attention to signs of ascites, encephalopathy and limb atrophy. The presence of any of the signs is indicative of severe cirrhosis and poor liver reserve. Often there are arachnids on the skin and palmar erythema, signs of increased cardiac output and low peripheral vascular resistance and other manifestations of severe progressive cirrhosis.

At general examination the severity of the patient's condition must be assessed quickly. Severe hematemesis, melena with symptoms hemorrhagic shock indicate severe bleeding and the need for appropriate treatment. life parameters, mental status and the intensity of ongoing bleeding determine the conduction emergency care according to the ABC scheme (airway patency, bleeding control, hemodynamic maintenance). Protecting the airways and preventing aspiration of blood into the tracheobronchial tree is essential, especially in the presence of liver-related encephalopathy. Patients with low respiratory reserve or failure to protect the airway should be intubated prior to any intervention to avoid blood aspiration. Immediately after mechanical ventilation, it is necessary to replace intravascular volume and stop bleeding as soon as possible.

In patients with bleeding from esophageal varices, severe hematological abnormalities are often observed. Anemia can be the result of both acute and chronic blood loss. In the latter case, there may be Iron-deficiency anemia. Violations of hemostasis may occur due to ongoing blood loss, impaired synthetic ability of the liver, or. In patients with bleeding, it is imperative to correct clotting disorders with fresh frozen plasma and parenteral administration vitamin K. Sequestration of platelets in the spleen in patients with portal hypertension often leads to thrombocytopenia. At the same time, platelet transfusion is ineffective due to their quick removal from the bloodstream.

Numerous deviations of the results may also be observed. laboratory research. Electrolyte imbalance can be the result of taking diuretics, alcohol abuse, redistribution of fluid in the body, acute blood loss or resuscitation. Serum albumin, bilirubin and cholesterol levels, prothrombin time should be used to assess liver function and determine the need for replacement of clotting factors.

Evaluation of patients with bleeding from esophageal varices should include screening for hepatitis and HIV. Hepatitis screening can determine the cause of cirrhosis and also provide information for appropriate etiotropic therapy. Treatment of patients with severe viral load may differ from that of patients with long-term existing hepatitis in terminal stage cirrhosis without it. It is also necessary to look for signs of HIV infection. The choice of treatment for portal hypertension may depend on life expectancy with HIV infection and AIDS.

Allows you to establish the final diagnosis, possible etiology and morphological features cirrhosis. Biopsy-determined degree of hepatitis activity may not match clinical picture hepatic reserve. AT emergency situations a biopsy is usually not performed due to its riskiness and duration of the study.

After completion of the physical examination and receipt of laboratory results, each patient should be assessed according to the Child and Child-Pugh classification, as well as taking into account the MLSP. In spite of known limitations these evaluation systems, they remain the best way determine the prognosis and help in the appointment of appropriate treatment.

Treatment of bleeding from varicose veins of the esophagus

Early Intensive Care

Once adequate respiration is achieved, intravascular volume replacement should begin. When planning resuscitation, it is important to assess the magnitude and severity of blood loss. At minor bleeding a transfusion of isotonic crystalloid solutions such as Ringer's lactate may be sufficient. With severe bleeding, early transfusion of red blood cells is necessary. Adequate hemoglobin levels should be maintained. The introduction of fresh frozen plasma reduces the initial coagulopathy and helps to stop bleeding.

Because successful resuscitation often requires transfusion of large volumes of fluid, catheterization is important. central vein and monitoring of central venous or intravenous pressure pulmonary artery. Usually the best access is provided by the internal jugular vein, since in this area it is easier to control the formation of a hematoma than with a complication of catheterization of the subclavian vein. It is also important not to exceed the volume of the transfused liquid. If a infusion therapy leads to an excessive increase in central venous pressure (for example, up to 20 mm Hg), there is a significant increase in portal venous pressure (for example, up to 40 mm Hg), leading to severe stretching of varicose veins and continued bleeding. The purpose of resuscitation is to normalize blood pressure and intravascular volume with restoration of adequate urine production.

Immediately after the patient's arrival at the hospital, treatment should be started to stop bleeding from esophageal varices even before a final diagnosis is established. Treatment prior to diagnosis is not entirely optimal, but in severe varicose bleeding it is carried out according to vital indications.

Pharmacotherapy

The initial treatment, with the exception of resuscitation, is pharmacotherapy. It usually starts before endoscopic methods, because it is readily available, relatively non-toxic and quite effective. Pharmacotherapy does not increase gastrointestinal bleeding unrelated to portal hypertension and may be beneficial.

The main drugs for pharmacotherapy are vasopressin and octreotide. Vasopressin has been the mainstay of treatment for bleeding patients with portal hypertension for several decades. Its intravenous administration should begin with a dosage of up to 1.0 U / min (do not inject more than 20 IU in 20 minutes), and then gradually reduce to 0.4 IU / min. Vasopressin has relative contraindications in defeat coronary arteries, because they reduce blood flow in the myocardium, causing spasm coronary vessels. In the treatment of elderly patients or patients with diagnosed coronary artery disease, treatment with vasopressin should be combined with intravenous administration nitroglycerin. In addition, vasopressin contributes to fluid retention in the body and an increase in ascites, so the duration of its administration should not exceed 72 hours.

AT recent times octreotide is increasingly being used instead of vasopressin. Octreotide does not negative impact on coronary blood flow and does not contribute to fluid retention with the accumulation of ascites. In randomized trials comparing octreotide and vasopressin, they were found to be equivalent in the treatment of bleeding and in terms of 30-day mortality. Octreotide is administered as an intravenous bolus of 50 to 100 units followed by 50 to 100 units/hour. Treatment with these drugs is usually continued for 2 to 4 days, more specific treatment is planned and carried out.

Endoscopic and dressing

Emergency is of exceptional importance in the diagnosis and treatment of bleeding from varicose veins of the esophagus. In the management of these patients, it is indicated early holding endoscopic examination upper divisions GIT. It may also be required to exclude a source of bleeding in the lower gastrointestinal tract. Before endoscopic examination In such circumstances, there are three main challenges.

- The first task is to determine the cause and localization of bleeding. This is sometimes easy to do, but sometimes almost impossible, for example, when filling the esophagus, stomach, duodenum with clotted blood, or when filling the colon stool and blood clots. It is important to distinguish bleeding from portal hypertension from other etiologies (eg, peptic ulcers, Mallory-Weiss syndrome, esophagitis, or cancer).
- The second task is to determine the size and localization of varicose vessels for treatment planning. For example, if the bleeding is associated with small varices located in the esophagus, without signs of gastric varices, the chances of success with endoscopic treatment exceed 90%.
“The third task and ultimate goal of emergency endoscopy is treatment.

With the help of endoscopy, it is possible to directly control bleeding from varicose veins. The dilated veins of the esophagus, as well as, can be endoscopically ligated or sclerosed by injecting a special solution into them, without adversely affecting liver function. Large dilated veins are less amenable to endoscopic treatment and may be a source of rebleeding. Excessively enlarged varicose veins are very difficult to bandage, since the node can only consist of the anterior wall of the varicose vein. Ligation of the anterior wall does not lead to obliteration of the varicose vein. It can increase bleeding due to necrosis of the wall itself. Such patients are often prescribed sclerotherapy. In the US, the most commonly used sclerosing agents are sodium tetradecyl sulfate and sodium morrhuate. Sclerosing agents are usually injected directly into the varicose vein, although some endoscopists prefer to inject the sclerosing agent along the walls of the varicose vein (paravaricose injection). A number of studies failed to establish the advantage of either of these two methods. Gastric varices are not amenable to endoscopic treatment and usually require portal decompression. They are also not amenable to sclerotherapy or ligation because the thin wall of the stomach is easily perforated.

Endoscopic sclerotherapy and ligation has many potential complications, although serious complications meet infrequently. Severe bleeding from esophageal varices is a treatment complication that is characteristic of paravaricose sclerotherapy or inadequate ligation. Bleeding from an untreated area usually occurs as a result of refusal to endoscopic treatment and is not considered a complication. With repeated bleeding from varicose veins of the esophagus, regardless of whether they arose after an unsuccessful treatment or due to refusal of it, endoscopic sclerotherapy or ligation is also used.

Perforation of the esophagus is rare, but formidable complication sclerotherapy. More often there is ulceration of the mucosa of the esophagus in the area of injection of the sclerosing agent or the site of ligation of the nodes. Ulcers can occur within 1 week after treatment, sometimes being a source of significant rebleeding. Healing of severe ulceration may subsequently lead to the formation of strictures.

Endoscopic treatment of bleeding from varicose veins of the esophagus is accompanied by low mortality (l-2%). When dressing, there are fewer complications, strictures and ulcers are less likely to form. This treatment method is more effective in stopping bleeding from esophageal varices than sclerotherapy. In some circumstances, re-endoscopic intervention may be considered as the definitive treatment in patients with bleeding from esophageal varices. For the finality of the treatment, several sessions are required over a long period of time in order to obliterate varicose veins. However, repeat endoscopic procedures are not always applicable. Some patients are unable to tolerate the treatment regimen, while others live in rural areas remote from centers of care medical services. Patients with gastric or intestinal varicose veins are not suitable for long-term endoscopic therapy.

Balloon tamponade

In patients with ongoing bleeding who cannot be treated with endoscopic interventions (or who fail to similar treatment), uncontrolled reception pharmaceuticals, the next stage of treatment should be balloon tamponade using a Sengstaken-Blakemore probe. In parallel, preparation for portal decompression or other types of radical treatment should be carried out.

A double-balloon probe is inserted through the mouth into the stomach. To prevent aspiration, an aspirator is attached to the probe proximal to the esophageal balloon. In this case, the secretion or blood is removed to prevent their aspiration into the tracheobronchial tree. After the introduction of the probe, the presence of its tip in the stomach is confirmed radiographically. Then the gastric balloon is filled with 250-300 ml of air, and the position of the probe tip is checked radiographically again. After confirming the position of the probe, a thrust of 0.5-1.0 kg is applied to it. It ensures the position of the balloon in the area of the esophageal-gastric junction and compression of the fundic and cardiac varicose veins. If bleeding continues, air is pumped into the esophageal balloon, usually up to a pressure of 30 mm Hg. After correct placement of the Sengstaken-Blakemore probe, the channel of the gastric tube and the nasoesophageal tube are connected to a vacuum aspirator for periodic evacuation of the secret of the esophagus and stomach. You should carefully monitor the condition of the mucous lips of the patient in order to avoid the formation of bedsores.

The probe with inflated balloons should not be left for more than 48 hours. Within 48 hours, the patient's condition usually stabilizes and the coagulopathy is corrected. After 48 hours, the risk of ulcers or decubitus ulcers associated with inflated balloons is significantly increased.

The article was prepared and edited by: surgeon

Bleeding from these veins is usually insidious, difficult to control, and usually occurs in association with coagulopathy, thrombocytopenia, and sepsis.

Drugs that cause mucosal erosion, such as salicylates and other NSAIDs, can also cause bleeding. Varicose veins in other areas become a source of bleeding relatively rarely.

Bleeding from varicose veins of the esophagus: diagnosis

History taking and general examination suggest VRV as the cause of gastrointestinal bleeding. In 30% of patients with cirrhosis, another source of bleeding is identified. If a disease is suspected, it is necessary to perform fibrogastroduodenoscopy as soon as possible. Along with rupture of varicose veins of the stomach and esophagus, the cause of bleeding in rare cases is hypertensive gastropathy.

Bleeding from varicose veins of the esophagus: conservative therapy

Transfusion of blood, fresh frozen plasma and platelets, depending on hematological parameters. Vitamin K is administered at a dose of 10 mg intravenously once in order to exclude its deficiency. Avoid excess transfusion.

20 mg of metoclopramide is injected intravenously. This drug allows for a short-term increase in pressure in lower section esophagus and thereby reduce blood flow in the system v. azy-gos.

Antibacterial therapy. Take a sample of blood, urine and ascitic fluid for culture and microscopy. Several studies have found an association of the disease with sepsis. Antibiotics are prescribed. Duration antibiotic therapy should be 5 days.

Terlipressin causes vasospasm in the basin of the celiac trunk, due to which it allows to stop bleeding from the esophagus esophagus (decrease in mortality by about 34%). Serious side effects occur in 4% of cases and include myocardial ischemia, spasm peripheral vessels which may be accompanied by serious arterial hypertension skin ischemia and circulatory disorders internal organs. Nitrates may reverse the peripheral effect of vasopressin but are not usually prescribed to treat the side effects of terlipressin. Octreotide is a synthetic analogue of somatostatin. It does not have a side effect on the heart, and therefore the appointment of nitrates with its introduction is not required. According to latest research from the Cochrane database, octreotide has no effect on disease mortality and minimal effect on the need for transfusion therapy.

Endoscopic injection of sclerosing agents into the VRV and surrounding tissues can stop acute bleeding. Side effects(severe - in 7%) include the occurrence of pain behind the sternum and fever immediately after injection, the formation of ulcers on the mucosa, late strictures of the esophagus. In the future, the introduction of sclerosing substances should be continued until complete obliteration of the veins. The greatest difficulties arise when injecting into the gastric this case thrombin should be used.

Varicose vein ligation is used frequently.

Balloon tamponade with a Sengstaken-Blakemore or Linton probe. Usually this alone is enough to stop the bleeding. The probe should not be used for more than 12 hours due to the risk of ischemia, the risk of which increases with the simultaneous administration of terlipressin.

Treatment liver failure: for the prevention of encephalopathy, lactulose 10-15 ml every 8 hours, as well as thiamine and multivitamin preparations, should be administered orally or through a tube. Patients with severe encephalopathy are prescribed enemas with magnesium sulfate and phosphates.

Critical to acute bleeding from varicose veins of the esophagus has a correction of hemodynamic disorders (infusion of blood and plasma products), since under conditions of hemorrhagic shock, blood flow in the liver decreases, which causes a further deterioration in its functions. Even in patients with confirmed varicose veins veins of the esophagus, it is necessary to establish the localization of bleeding using FEGDS, since other sources of bleeding are detected in 20% of patients.

Local treatment

To stop bleeding from varicose veins of the esophagus, endoscopic techniques, balloon tamponade, and open dissection of the esophagus are used.

Esophageal vein ligation and sclerotherapy

These are the most commonly used initial treatments. Ligation is a more complex procedure than sclerotherapy. In the presence of active bleeding, endoscopic procedures may be difficult. In such cases, balloon tamponade should be performed.

Balloon tamponade

Use a Sengstaken-Blakemore probe with 2 tamponade balloons. There are modified versions of the probe (for example, the Minnesota tube) that allow aspiration of the contents of the stomach and esophagus. The probe is inserted through the mouth, its penetration into the stomach is controlled by auscultation epigastric region during balloon inflation or radiographically. Light traction is needed to compress the varicose veins. The first step is to fill with air (200-250 ml) only the gastric balloon - this event is usually enough to stop the bleeding. The filling of the gastric balloon should be stopped if the patient experiences pain, because if the balloon is incorrectly placed in the esophagus, it may rupture during filling. If gastric tamponade is not enough to stop bleeding and esophageal tamponade has to be resorted to, the esophageal balloon should be lowered for 10 minutes every 3 hours. The pressure in the esophageal balloon is controlled using a sphygmomanometer. Special attention when setting the probe, attention should be paid to preventing aspiration of gastric contents (if necessary, the patient is intubated).

Dissection of the esophagus

Varicose vein ligation can be performed with a stapler, although there is a risk of developing esophageal stenosis in the future; The operation is usually combined with a splenectomy. This procedure usually used if there is no effect from all the other therapies listed above and the impossibility of performing a transjugular intra-hepatic porto-caval bypass. Operations are associated with frequent complications and high mortality.

X-ray vascular methods of therapy

AT specialized centers transvenous intrahepatic portosystemic shunting is possible. Access through the jugular or femoral vein produces catheterization of the hepatic veins and between them (system low pressure) and portal venous system (high pressure) introduce an expanding stent. The pressure in the portal vein should decrease to 12 mm or less.

Surgery

Urgent porto-caval shunting allows to stop bleeding in more than 95% of cases, but is characterized by high (>50%) intraoperative mortality and does not affect long-term survival. This method of treatment is currently used only in isolated cases.

Prognosis for varicose veins of the esophagus

Mortality in general is 30%. It is higher in patients with severe liver disease.

The effectiveness of therapy aimed at stopping bleeding from the esophageal varicose veins

Injection of sclerosing drugs or vein ligation - 70-85%.

Balloon tamponade - 80%.

Terlipressin - 70%.

Octreotide - 70%.

Vasopressin and nitrates - 65%.

Bleeding from varicose veins (hereinafter VRV) of the esophagus. Long-term therapy

Injection of a sclerosing drug in a volume of 0.5-1 ml into the tissue around the VRV or 1-5 ml into varicose veins every week until complete obliteration of the veins; then at intervals of 3-6 months.

Ligation is carried out in the same mode as sclerosing therapy, while obliteration of varicose veins occurs faster (39 days versus 72 days).

The appointment of propranolol reduces the frequency of relapses. No decrease in mortality was noted.

Transvenous intrahepatic portosystemic shunting and other shunting procedures are considered to be more reliable in preventing rebleeding, which can only occur if the shunt is blocked. However, when they are carried out, the incidence of chronic hepatic encephalopathy increases.

Prevention of rebleeding

During endoscopic ligation, varicose veins are aspirated into the lumen of a special endoscopic instrument and tied with elastic bands. The ligated vein is subsequently obliterated. The procedure is repeated every 1-2 weeks until the obliteration of the veins. In the future, regular endoscopic monitoring is necessary for timely treatment recurrence of varicose veins. Endoscopic ligation generally more effective than sclerotherapy. To prevent secondary bleeding due to ulceration induced by ligatures, antisecretory therapy with inhibitors of Na +, K + -ATPase (proton pump) is prescribed.

Sclerotherapy

Sclerotherapy is the introduction of sclerosing agents into varicose veins. After the introduction of endoscopic ligation this method used relatively rarely. Sclerosing therapy is not without drawbacks, as it may be accompanied by transient pain, fever, temporary dysphagia, and sometimes perforation of the esophagus. It is also possible to develop esophageal strictures.

Transjugular intrahepatic portocaval shunting

The operation consists in placing an intrahepatic stent between the portal and hepatic veins, which provides a porto-caval bypass and reduces pressure. The procedure is performed under x-ray control. Before the operation, it is necessary to confirm the patency portal vein angiography and prescribe prophylactic antibiotic therapy. The occurrence of rebleeding is usually associated with narrowing or occlusion of the shunt (appropriate examination and treatment, such as angioplasty, is necessary). Transjugular intrahepatic porto-caval shunting can provoke the development of hepatic encephalopathy, for its relief it is necessary to reduce the diameter of the shunt.

Porto-caval shunt surgery

Portocaval bypass surgery can prevent rebleeding. The imposition of non-selective porto-caval shunts leads to an excessive decrease in the flow of portal blood to the liver. With this in mind, selective bypass surgery has been developed, in which the risk of developing postoperative hepatic encephalopathy is lower. However, over time, hepatic portal blood flow decreases.

Antagonists of p-adrenergic receptors (p-blockers)

Propranolol or nadolol lower blood pressure. They can be used to prevent recurrent bleeding. However, for secondary preventionβ-blockers are rarely used. Treatment compliance with these drugs may be low.

Mallory-Weiss syndrome

Rupture of the mucosa in the region of the esophageal-gastric anastomosis, resulting from strong vomiting movements and especially often observed with excessive alcohol consumption. Initially, the vomit is of a normal color, and then blood appears in them.

Treatment

In most cases, bleeding stops spontaneously. Packing with a Sengstaken-Blakemore tube may be required.
In some cases, it is required to surgical operation with stitching of a bleeding vessel or selective angiography with embolization of the feeding artery.
The Child Score can effectively determine the severity of liver disease in a patient with cirrhosis of the liver. It should not be used in patients with primary biliary cirrhosis or sclerosing cholangitis.
Group A<6 баллов.

Bleeding with varicose veins is the most dangerous complication that requires immediate hospitalization of the victim. The causes of the disease and the methods of helping the patient with bleeding from varicose veins in the lower extremities will be discussed in this article.

Possible causes of bleeding

Varicose veins most often affect women (in 75% of cases) older than 30 years of age. Very often, varicose veins occur in women during pregnancy and after childbirth. There are also varicose veins in men, especially those who are at risk (leading a sedentary lifestyle, experiencing excessive stress on the legs, having a genetic predisposition, etc.). It is extremely rare, but still there are varicose veins in children.

If varicose veins do not receive the necessary treatment, they continue to thin out, and sooner or later there comes a critical moment when the vessel ruptures under the influence of blood that has stagnated in it. Most often, the rupture occurs in the lower leg. Bleeding is very profuse, and the loss of blood is so great that the consequence of this can be fatal.

Provoking factors for the occurrence of bleeding can be:

mechanical impacts (impacts, cuts, bruises, punctures);
weight lifting;
significant physical activity;
coughing;
prolonged stay on the legs;
constant squeezing of the veins with uncomfortable clothes or shoes;
hypertensive crisis.

At the initial stage, the disease very often proceeds secretly, however, with its exacerbation, the risk of bleeding increases sharply due to the weakness of the veins. Bleeding is localized in the lower third of the lower leg and in the ankle. Areas with pronounced venousness are especially vulnerable.

There is a classification of bleeding based on their causes and intensity:

Spontaneous. They arise as a result of neglected varicose veins, when the patient did not seek qualified help in time. The veins in such patients are clearly expressed, their pattern is clearly visible under the skin. Venous nodes and trophic ulcers are often noted. Usually not only veins are torn, but also nearby tissues.
Traumatic. Occur as a result of mechanical action on the vein. Even with minor injuries (for example, a small cut), blood flows in a powerful stream, although the victim may not feel it right away. It will not be possible to stop the loss of blood in an upright position. As a rule, the patient loses a lot of blood.
Subcutaneous. They can be either spontaneous or resulting from trauma. Depending on the site on which the affected vein is located, blood loss may be mild or significant. Subcutaneous bleeding is visually indicated by hematomas. The most potentially dangerous type of bleeding is from a vein in the area of the ulcerative bottom. The cause of such an outpouring can be a purulent infectious process or autoimmune aggression, which led to tissue and venous necrosis.
Outdoor. Bleeding begins as a result of damage to the surface of the skin. Due to a cut or puncture of the dermis, the vascular walls are destroyed, and blood begins to leave a nearby vein.

For all types of bleeding from the dilated veins of the legs, the absence of pain in the patient is characteristic, even when it comes to traumatic injury. External blood loss is much more common than subcutaneous effusions.

Bleeding from the lower extremities is characterized by moderate or intense blood loss of dark blood from the damaged area. If a hematoma occurs, then a pain syndrome appears, entailing temporary disability.

Danger of bleeding

Since the victim most often does not experience pain at the time of bleeding, it is very likely that he will not notice the beginning of the process. As a result, patients often lose a lot of blood. In addition, when the patient becomes aware of blood loss, he may fall into a panic state, which excludes the adoption of reasonable decisions and only aggravates the situation. The consequence of panic is an increase in blood pressure, an acceleration of the heart rate and blood flow, which leads to even more intense blood loss.

It is impossible to predict the amount of blood loss in advance, but it is clear that the situation must be brought under control in order to prevent shock and death. To prevent the dangerous consequences of rupture of the veins, the patient must receive first aid.

emergency measures

If a vein in your leg bursts, you need to force yourself to remain calm. If done correctly, the bleeding can be stopped.

You need to take the following actions:

A hemostatic sponge is placed at the site of the ruptured vein. If a sponge is not available, you can use a clean piece of cloth folded several times.
A sterile gauze pad is placed on a sponge or piece of cloth. It must be folded several times.
An elastic bandage is applied on top.
When the bandage is applied, a very cold object (ice) should be applied to the affected area for 20-30 minutes.
Immediately after applying the bandage, you need to take a supine position with your legs raised up. If the bleeding started on the street, you don’t need to run around in search of a cold object yourself, but it’s better to ask the people around you about it.

The next step is to call for emergency medical assistance. If we are talking about an external rupture with varicose veins, doctors can apply finger pressure, applying a tight bandage. In cases with ruptures in ulcerated areas of the skin, a vein will need to be sutured to rule out septicopyemia and thromboembolism. If necessary and technically feasible, sclerotherapy with compression can be performed.
If the blood loss is large, antibiotics are given to prevent infection. In the case of internal ruptures, external ointment formulations, painkillers and non-steroidal anti-inflammatory drugs are used. Phlebotonics and phleboprotectors must be used.

Steps to take after bleeding has stopped

First of all, you need to make sure that the bleeding has stopped. This can be done as follows: we are located on a horizontal surface and lie with our leg raised for about half an hour, watching the bandage to see if the blood stain is increasing on it. If the spot does not change in size, it can be concluded that the bleeding has stopped. After that, you can lower the lower limb to the level of the body. For the rest of the day, strict bed rest should be observed. The bandage can not be removed until the morning.

During the day after the bleeding stops, you can not take drugs that thin the blood. You also need to pay special attention to the level of blood pressure.

In the morning you can not abruptly get out of bed. Too much activity can cause bleeding to resume.

So, getting out of bed should be done in several stages:

At first they sit on the bed, but the legs do not hang down - they are on the bed.
They sit on the bed for about 2-3 minutes, after which they lower their legs to the floor.
Again they wait a little and slowly rise to their feet.

The bandage during the time he was on the leg, firmly dries to the wound. It is categorically not recommended to tear it off by force, since in this case the bleeding will begin again. To avoid this, the bandage is moistened in a weak solution of potassium permanganate, furatsilina or plain water. The lower limb is lowered into a container with liquid for several minutes. When the bandage gets wet, it is removed, and a bactericidal patch is applied to the wound, which is worn for 2-3 days.

Rules of behavior

With a sudden rupture of a vein, it is important to adhere to several rules:

In the presence of varicose veins, carry with you the simplest set of medical supplies for first aid.
Don't panic.
Do everything possible to stop or stop the bleeding until the doctors arrive.
Do not use a tourniquet to stop bleeding. This method of stopping bleeding can only be used by experienced doctors. The fact is that stagnation in veins affected by varicose veins can cause bleeding from nearby vessels. If the blood loss is very intense, you can use finger compression of the vessels through a napkin.
When the bleeding is stopped, it is important to observe a calm mode of behavior during the day (or even more), avoiding physical exertion and stress.
In no case in the coming days, do not go to the bathhouse and do not take hot baths. As a result of a sharp expansion of blood vessels, blood loss can resume.

Prevention

Bleeding with varicose veins is a very dangerous complication of this disease. To prevent such a development of events, it is necessary to take a number of preventive measures:

Do not lift too heavy objects, avoid sports with jerky loads.
Maintain physical activity (with the help of therapeutic exercises, swimming).
Monitor body weight.
Avoid prolonged stay in an upright position.
Monitor blood pressure levels.
Avoid injury.
Wear comfortable, non-constricting clothing and shoes.
Do not delay with the treatment of varicose veins.

Thus, prevention is based on the prevention of those factors that can provoke bleeding. However, if nevertheless an unpleasant event has occurred, it is necessary to take all the measures described above to stop the bleeding and immediately call an ambulance.

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- pathology of esophageal veins, characterized by their tortuosity and saccular expansion due to the formation of phleboectases. The cause of this disease can be damage to the liver, heart and other organs. Most often, varicose veins of the esophagus do not manifest themselves in any way until the most formidable complication occurs - bleeding. The main method for diagnosing varicose veins is endoscopy, during which therapeutic hemostasis is performed. Also, the treatment includes conservative measures: therapy of the underlying disease, drug control of bleeding. With the ineffectiveness of therapeutic measures, a bypass operation is performed.

Treatment of VRV of the esophagus

Depending on the symptoms of the disease, the patient may be under observation in the department of gastroenterology or surgery. The task of the gastroenterologist is to treat the underlying disease and prevent the development of bleeding. For this, the patient receives hemostatic drugs, antacids, vitamins. Prevention of esophageal reflux is mandatory. Recommend strict adherence to proper diet, rest and exercise.

With the development of bleeding, hemostatic therapy is carried out - calcium preparations, vitamin K, fresh frozen plasma are prescribed. An emergency esophagoscopy is performed to determine the source of hemorrhage and endoscopic clipping of the bleeding vein, application of an adhesive film and thrombin, electrocoagulation of the vessel. To stop bleeding, the introduction of a Blackmore probe is used - it has special balloons that, when inflated, block the lumen of the esophagus and squeeze the vessels. However, even after these manipulations, in 40-60% of cases, a positive effect is not achieved.

After stopping the bleeding and stabilizing the condition, surgical methods of treatment are used - their effectiveness is much higher than that of conservative methods. Usually, surgical treatment consists of shunting between the portal vein and the systemic circulation, due to which the pressure in the portal vein is reduced and the likelihood of bleeding becomes minimal. The safest and most popular method is the endovascular transjugular method of shunting (access through the jugular vein), porto-caval and splenorenal anastomoses are also applied, the removal of the spleen, ligation of the unpaired and portal veins, splenic artery and stitching or removal of the veins of the esophagus are practiced.

Forecast and prevention of VRV of the esophagus

The prognosis of the disease is unfavorable - varicose veins of the esophagus are incurable, when this disease appears, all measures must be taken to prevent the progression of the pathology and fatal bleeding. Even for the first time, bleeding significantly aggravates the prognosis, reducing life expectancy to 3-5 years.

The only method of preventing esophageal varicose veins is the prevention and timely treatment of diseases that provoke this pathology. If there is a history of liver disease that can lead to cirrhosis and increased pressure in the portal vein, the patient should be regularly examined by a gastroenterologist to detect esophageal vasodilation in a timely manner.

When varicose veins have formed, a strict diet should be followed: food should be steamed or cooked, it is advisable to wipe the food and not eat dense foods in the form of large pieces. You should not take dishes too cold or hot, rough and hard food to prevent injury to the esophageal mucosa. To prevent reflux of stomach contents into the esophagus, the head of the bed is raised during sleep. To avoid bleeding, it is recommended to exclude heavy physical exertion and heavy lifting.