The first days of nutrition after doping the veins of the esophagus. Endoscopic ligation of varicose veins of the esophagus. Complications and rehabilitation

The operation on the esophagus undoubtedly belongs to the category of complex, therefore, during the recovery period, it is extremely important to ensure that the patient eats properly. The diet should be limited to any chemical and mechanical irritants of the mucous membrane of the stomach and esophagus. It is also important to exclude from the menu all extractive nitrogenous substances, refractory fats and too strong bile stimulants. In addition, you should definitely reduce your salt intake.

What should be the diet after esophageal surgery?

An example menu might look like this:

breakfast - steamed omelette, or mashed buckwheat without added sugar;
lunch - grated pearl barley soup with carrots, steamed meat cutlets, a glass of dried fruit compote;
afternoon snack - cottage cheese unsweetened pudding;
dinner - boiled fish with mashed potatoes, a cup of tea.

This diet food is often prescribed for 4 months. If there are no complications after the operation, then the patient can be transferred to the usual diet of standard diet food. If chemotherapy has been given, doctors usually advise switching to a high-protein diet.

Table salt is limited in the diet to 5-6 grams per day.

After surgery on the esophagus in the diet allowed food like this:

yesterday's or dried wheat bread, wheat bread crackers, unbread biscuits (not particularly sweet);
soups cooked on cereal or vegetable broths (mashed and without the addition of white cabbage and millet);
lean beef, turkey, chicken, rabbit and veal dishes, as well as fish dishes (mashed potatoes, meatballs, cutlets, rolls, soufflé);
eggs and egg products (no more than one egg per day), egg white omelet;
dairy products and milk, after 2.5-3 months kefir is allowed, a little sour cream (as a dressing for a dish), non-acidic fresh cottage cheese;
greens and vegetables (boiled, grated or mashed);
fruits, berries and sweets (sugar, honey and jam - in limited quantities);
cereals and pasta;
butter, melted, refined, sunflower oil (use not for frying, but as a dressing for salads and other dishes);
sauces prepared on vegetable broths;
unsweetened fruit, vegetable and berry juices, weak tea, tea with milk, weak coffee, rosehip broth.

Forbidden dishes and products:

any products from sweet and hot dough;
liver, kidneys, brains, lungs;
borscht, cabbage soup, soups cooked in fish, meat or mushroom broths;
smoked meats, pickles, marinades, spicy seasonings, any salty and spicy dishes;
carbonated and cold drinks;
cocoa, ice cream, chocolate;
any alcoholic drinks;
white cabbage, legumes, spinach, mushrooms, radish, radish, sorrel, swede, onion, garlic, all spices;
products that contain a lot of organic acids (cranberries, gooseberries, cherries, lemons, sour apples, red and black currants).

first breakfast - steamed egg white omelette, buckwheat porridge (mashed, without added sugar), a cup of tea with milk;
second breakfast - a baked apple (do not add sugar), lean meat meatballs;
lunch - a plate of pearl barley soup with the addition of grated carrots, steamed lean meat cutlets, carrot puree, a glass of dried fruit compote;
afternoon snack - cottage cheese pudding without added sugar;
dinner - boiled fish with mashed potatoes, steamed meatloaf, a cup of tea;
during the day - 300 grams of bread and 40 grams of sugar.

What can you eat after heart surgery? Nutrition…
Sports nutrition for boxers - the right ...

The ligation of esophageal veins, which turned out to be varicose, is an endoscopic operation. It is the most important component of complex treatment of patients with portal hypertension. This intervention in the area of the veins of the esophagus makes it possible to prevent the subsequent formation of bleeding from the presented area, which very often has fatal consequences. About how to prepare for the event and about all other features, further.

Preparation and conduct of the operation

Before prescribing doping, the specialist must necessarily indicate the need for certain procedures. In particular, we are talking about an initial examination, a blood test and a correct check of the patient for any contraindications. It is also important to take into account that before the procedure in the area of the veins of the esophagus, it is unacceptable to eat for 12 hours, in some cases the presented period of time is even longer.

In addition, it is very important to stop using anti-inflammatory drugs and drugs that are designed to thin the blood. Before the operation itself, the patient is given a dose of local anesthesia, and sedative and sedative components can also be administered. Speaking about the operation in the area of the esophageal veins, it should be noted that it always goes through the following successive stages:

the patient must be laid on his left side and in order for the oral cavity to be open, an expander is placed in it;
indicators of heartbeat and respiration should be under the constant control of assistants;
in order to drain saliva, a special tube is inserted into the mouth. In addition, if there is such a need, oxygen supply through the nose is prescribed.

Intervention in the region of the veins of the esophagus also consists in the fact that an endoscope is inserted into the problematic organ through the oral region.

It is equipped with a microscopic camera and a lamp to film and illuminate the internal organs at the same time.

Speaking about the expansion of the body, it should be noted that it occurs due to the supply of air. It is also important to consider that loops are always placed around the problem area. As a result of such manipulations, the pathological tissue area will be sucked into the tube.

The presented procedure, carried out in the region of the veins of the esophagus, can last no more than 60 minutes. This intervention is one of the least traumatic in its field, and therefore is the most in demand today. About how rehabilitation is carried out and what other, additional, information about alloying, further.

rehabilitation period

Immediately after the doping, the patient is transferred to a specially equipped ward. After at least 60 minutes, the effect of the medicinal components ends and the patient can go home, but the subsequent stay in the hospital is not excluded. If the patient nevertheless decided to go home, it is necessary to discuss this with a specialist in advance in order to determine the measures that must be observed in this particular case.

In general, home-based rehabilitation consists of maintaining a certain diet, not driving for the next 24 hours. It is also very important to avoid the use of alcoholic components and smoking, which can provoke numerous complications, including in the veins of the esophagus. An equally important condition for rehabilitation should be considered the longest possible rest. About what are the indications and contraindications for the presented intervention, further.

Main indications and contraindications

The main indication, of course, should be considered varicose veins in the esophagus.

Moreover, the more neglected this pathological condition is, the longer the further operation will be.

The purpose of this method may also be noted in other situations that should be discussed with a specialist in a separate order.

Like any intervention, this operation has certain contraindications that must be observed in order to avoid complications and other critical consequences:

excessive drinking - even if it was observed earlier, in the patient's medical history;
violation of the degree of blood clotting;
age of 60 years or more - in connection with other concomitant medical indicators.

The list of contraindications also includes violations of the activity of the heart muscle and lung parenchyma. In addition, close attention must be paid to problems such as active bleeding if it occurs spontaneously, the use of certain medications, and nicotine addiction. The list can be supplemented, especially in the presence of concomitant chronic or pathological conditions.

Experts point out that it is very important to take into account all contraindications, because this is what will make it possible to cope with such a serious problem as the expansion of the veins in the esophagus. In addition, if all contraindications and mandatory norms of the procedure are observed, it will be possible to exclude the subsequent development of complications.

List of complications

The most probable complications after doping include damage to the problematic organ, pain during swallowing (most often due to incorrect insertion of the endoscope). In addition, the patient may experience bleeding, bouts of nausea, dizziness.

Significantly less often, the operation leads to complications such as the appearance of blood in the feces and the introduction of infection. The latter processes are formed due to improper intervention or non-compliance with contraindications. That is why it is very important to consult a specialist before intervention to improve the condition of the veins of the esophagus.

As noted earlier, the presented operation is necessary to restore the normal functioning of the human digestive system.

However, it must be taken into account that there will be a need for special preparation for the procedure, as well as a rehabilitation period. It is equally important in this case to take into account the main indications and contraindications. All this will allow a person to maintain 100% activity and vitality, as well as the excellent condition of the gastrointestinal system.

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1. Can cancer be prevented?
The occurrence of a disease such as cancer depends on many factors. No one can be completely safe. But everyone can significantly reduce the chances of a malignant tumor.

2. How does smoking affect the development of cancer?
Absolutely, categorically ban yourself from smoking. This truth is already tired of everyone. But quitting smoking reduces the risk of developing all types of cancer. Smoking is associated with 30% of cancer deaths. In Russia, lung tumors kill more people than tumors of all other organs.
Eliminating tobacco from your life is the best prevention. Even if you smoke not a pack a day, but only half, the risk of lung cancer is already reduced by 27%, as the American Medical Association found.

3. Does excess weight affect the development of cancer?
Keep your eyes on the scales! Extra pounds will affect not only the waist. The American Institute for Cancer Research has found that obesity contributes to the development of tumors in the esophagus, kidneys, and gallbladder. The fact is that adipose tissue serves not only to store energy reserves, it also has a secretory function: fat produces proteins that affect the development of a chronic inflammatory process in the body. And oncological diseases just appear against the background of inflammation. In Russia, 26% of all cancer cases are associated with obesity.

4. Does exercise help reduce the risk of cancer?
Set aside at least half an hour a week for exercise. Sport is on the same level as proper nutrition when it comes to cancer prevention. In the US, a third of all deaths are attributed to the fact that patients did not follow any diet and did not pay attention to physical education. The American Cancer Society recommends exercising 150 minutes a week at a moderate pace or half as much but more vigorously. However, a study published in the journal Nutrition and Cancer in 2010 proves that even 30 minutes is enough to reduce the risk of breast cancer (which affects one in eight women in the world) by 35%.

5.How does alcohol affect cancer cells?
Less alcohol! Alcohol is blamed for causing tumors in the mouth, larynx, liver, rectum, and mammary glands. Ethyl alcohol breaks down in the body to acetaldehyde, which then, under the action of enzymes, turns into acetic acid. Acetaldehyde is the strongest carcinogen. Alcohol is especially harmful to women, as it stimulates the production of estrogen - hormones that affect the growth of breast tissue. Excess estrogen leads to the formation of breast tumors, which means that every extra sip of alcohol increases the risk of getting sick.

6. Which cabbage helps fight cancer?
Love broccoli. Vegetables are not only part of a healthy diet, they also help fight cancer. This is also why recommendations for healthy eating contain the rule: half of the daily diet should be vegetables and fruits. Especially useful are cruciferous vegetables, which contain glucosinolates - substances that, when processed, acquire anti-cancer properties. These vegetables include cabbage: ordinary white cabbage, Brussels sprouts and broccoli.

7. Which organ cancer is affected by red meat?
The more vegetables you eat, the less red meat you put on your plate. Studies have confirmed that people who eat more than 500 grams of red meat per week have a higher risk of developing colon cancer.

8. Which of the proposed remedies protect against skin cancer?
Stock up on sunscreen! Women aged 18-36 are particularly susceptible to melanoma, the deadliest form of skin cancer. In Russia, in just 10 years, the incidence of melanoma has increased by 26%, world statistics show an even greater increase. Both artificial tanning equipment and the sun's rays are blamed for this. The danger can be minimized with a simple tube of sunscreen. A study published in the Journal of Clinical Oncology in 2010 confirmed that people who regularly apply a special cream get melanoma half as often as those who neglect such cosmetics.
The cream should be chosen with a protection factor SPF 15, apply it even in winter and even in cloudy weather (the procedure should turn into the same habit as brushing your teeth), and also do not expose yourself to the sun's rays from 10 to 16 hours.

9. Do you think stress affects the development of cancer?
By itself, stress does not cause cancer, but it weakens the entire body and creates conditions for the development of this disease. Research has shown that constant worry alters the activity of the immune cells responsible for turning on the fight-and-flight mechanism. As a result, a large amount of cortisol, monocytes and neutrophils, which are responsible for inflammatory processes, constantly circulate in the blood. And as already mentioned, chronic inflammatory processes can lead to the formation of cancer cells.

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Cirrhosis is one of the most dangerous diseases of the liver, when, due to reasons not fully understood, normal liver tissue is replaced by connective tissue, which disrupts the structure of the organ and its function. Rough connective tissue inhibits blood flow in the portal venous system, the pressure in it rises, and portal hypertension (PH) occurs.

When the pressure reaches a critical value, the blood, through the system of gastric and esophageal veins, flows into the systemic circulation. Not adapted to such a volume and pressure of blood, the veins of the esophagus expand, lengthen, their walls protrude like a bag. The mucous membrane of the esophagus over the dilated veins and venous nodes becomes thinner. There is a risk of bleeding. Bleeding is the most severe complication of PH, which is why there is so much interest in all new methods to stop and prevent it.

Endoscopic ligation of the veins of the esophagus in practice

All abdominal surgeries proposed for relief and prevention of subsequent bleeding from esophageal varicose veins (EVV) are very traumatic, require long-term rehabilitation, and are often accompanied by severe complications. With cirrhosis, such operations can not be performed by all patients due to the risk of death.

Therefore, endoscopic techniques, introduced into clinical practice relatively recently, immediately became widespread.

Advantages of endoscopic ligation of esophageal varices:

these are non-invasive techniques;
they are easy to perform;
well tolerated by patients;
have few contraindications;
relatively safe;
the recovery period is short.

Currently, three methods and their modifications are mainly used:

Endoscopic ligation of RVV. The method is based on strangulation (compression) of varicose veins with latex ligatures. Compressed varicose veins are ischemic and necrotic, forming a scar.
Endoscopic sclerosis. Only paravasal (perivascular) administration of sclerosing drugs is used; intravascular administration of a sclerosant is not currently used due to the risk of injury to the esophagus. The main goal with this technique is to create a massive submucosal edema, which compresses the bleeding vessel, stopping the bleeding. The outcome of endoscopic sclerosis is the formation of a scar frame in the submucosa of the esophagus.
Endoscopic application of adhesive compositions. The method is based on the fact that cyanoacrylate compounds, getting into the blood, quickly form high-molecular compounds that obliterate the bleeding vessel.

Esophageal vein ligation - what is it?

is an endoscopic minimally invasive operation based on constriction of the EVV with the help of elastic latex rings. As a result, dilated veins and nodes are ischemic, necrotic, and are excluded from the blood circuit. The number of strangulation rings can be different, it is determined by the size and condition of the varicose veins.

Of the unpleasant consequences, mechanical damage to the esophagus and bleeding should be indicated, but in practice they are extremely rare. This is all the more important because this simple technique prolongs the life of patients with cirrhosis of the liver.

Indications

The indication for endoscopic ligation of the EVV is both the primary prevention of bleeding (before a bleeding episode) and the prevention of rebleeding.

So far, there is no single indication for this technique. Usually, RVRP is carried out:

with active cirrhosis of the liver;
the presence of varicose veins of the II degree (veins expand, become tortuous, moderately enlarged varicose nodes appear) and III degree (the lumen of the vessel is narrowed, the veins take on a serpentine shape, the first angioectasias appear).

Ligation of the veins of the esophagus can also be performed at earlier stages of phlebectasia, which improves the prognosis of the disease.

How is the operation for the ligation of the veins of the esophagus

The condition of patients with cirrhosis of the liver, especially during the onset of complications, is severe. Therefore, all interventions should be low-traumatic, fast, using a minimum amount of anesthetics. All these requirements are met by LRVP.

The operation is usually performed under local anesthesia, the procedure takes no more than an hour.

Operation progress

Surgical manipulation is carried out on an empty stomach, after premedication (promedol, metacin, relanium), irrigation of the pharynx with lidocaine is used as local anesthesia.

Operation progress:

An endoscope with a special nozzle is inserted through the pharyngeal ring.
In the case of bleeding prevention, ligation is started from the distal esophagus. When the intervention is carried out against the background of bleeding, the bleeding knot is first tied up, and only then they go down to the distal section. Ligature rings are applied along the esophagus in a spiral to prevent dysphagia.
The selected varicose node is sucked into the cylinder of the endoscopic nozzle, and then a ligature (latex ring or nylon loop) is dropped onto it.
Up to a dozen ligatures are applied in one session.

Ligation rings (ligators) are just a strangulation material for “squeezing” the esophageal veins. Apply latex rings, and with varicose veins of the stomach - nylon loops.

Preparation

Before the procedure for ligation of the veins of the esophagus with cirrhosis of the liver, the following are examined:

analysis of peripheral blood;
venous blood analysis (AST, ALT, alkaline phosphatase, amylase, blood sugar, total protein);
coagulogram;

Attention! A week before the operation, all anti-inflammatory drugs and drugs that reduce blood clotting (anticoagulants, antiaggregants) are canceled.

On the eve of the procedure, the patient is examined, he is informed about the essence of the operation, he is warned that the procedure is carried out strictly on an empty stomach so that he does not take food.

Consequences

Complications during ligation of the veins of the esophagus are rare, therefore, in some clinics, the patient is discharged on the same day that the manipulation was performed, with which academic science categorically disagrees. Any procedure for cirrhosis of the liver can give a complication and have various consequences.

The most severe, requiring immediate attention, is bleeding from ligated veins.

In addition, patients had:

allergy to latex;
hyperthermia;
pain in the retrosternal region;
transient dysphagia;
perforation of the esophagus;
formation of varices in the stomach.

Therefore, after such an intervention, patients with portal hypertension require a hospital stay for up to 7-10 days.

Recovery period

The patient is allowed to get out of bed and walk around the ward a few hours after the operation, at this time the patient can only drink, he does not eat any food.

Nutrition after ligation of varicose veins of the esophagus

From the second day, the patient is transferred to table No. 1 according to Pevzner. Food should be soft, mashed, cool. If the pain bothers, the patient is given Almagel A, if the pain does not subside, painkillers are prescribed. The pain goes away on its own, usually after three days.

On the 4th–5th day, the ligated varix begins to be rejected, superficial ulcers form in their place. Diet at this time, as with an exacerbation of erosive esophagitis, is one of the main methods of treatment during this period.

Patients should accustom themselves to eat regularly, in small portions, avoiding hyperphagia. Food must be boiled or steamed.

A sample menu during this period may be as follows:

After three weeks, the ulcers heal, leaving star-shaped scars.

If the patient does not have complications, new varixes, then the further course of the disease and the patient's ability to work determines the course of the cirrhotic process.

(ligation) of a thread (ligature) circled around the vessel and tightened is used as a means of finally stopping bleeding or preventing it, less often in order to change the direction of blood flow in a given area of the vascular bed (for example, from superficial veins to deep ones). For ligation of blood vessels, silk is usually used: when ligating large vessels - silk No. 4-7, small ones - No. 1-2 (see). For ligation of small muscle vessels, as well as medium-sized vessels in an infected wound, catgut is used (one number thicker than silk).

Ligation of blood vessels is performed in the wound or along the vessel (upstream of the blood stream). Bandaging of a vessel in a wound is the most reliable way of a final stop of bleeding (see). The ends of the vessel are grasped with clamps (Kocher, Pean, etc.), slightly tightened and separated from the tissues with anatomical tweezers. At 2-10 mm, from the end of the vessel (the farther, the larger the vessel), it is surrounded by a thread (the length of the thread is 20-35 cm - the longer the deeper the vessel lies) and its ends are tightened with a sea knot (see). Having tightened the first cross of the knot, remove the clamp and tighten the second cross, making sure that the first does not weaken. At the ends of very large vessels (femoral, axillary and larger), two ligatures are often applied at a short distance from one another. The ends of the threads are cut off the farther from the node, the thicker the thread (when ligating blood vessels with silk - by 2-4 mm, with catgut - by 4-8 mm). Small vessels of fiber and muscles are ligated without being isolated from the surrounding tissue. On hard-to-reach vessels (especially on vessels of a brain) instead of bandaging apply clipping of vessels (see). Sometimes a large damaged vessel is visible in a wide gaping wound, which is easy to capture with a clamp. In this case, if the delivery of the wounded to the doctor takes more than 2-2.5 hours (a period that is safe for constriction with a tourniquet), an experienced paramedic can also apply a ligature. The thread must be tightened tightly, but so that it does not cut through the wall of the vessel. The wounded person is evacuated by circling a provisional (not tightened) tourniquet around the limb.

The ligation of blood vessels throughout is carried out through a specially made. Having exposed the vascular bundle, the vessel to be ligated is separated and surrounded by a ligature (usually the thread is carried out with a Deschamp needle). The thread must be threaded into the eye so that its short end lies on the outer (curved) side of the needle and has a length of about 10 cm (it is difficult to pull the end out of the eye too long, the short one can slip out). To apply two ligatures, the length of both ends of the thread is equalized and, having passed them under the vessel, they are cut near the eye. Then, spreading the threads, tighten the ligatures.

The surgical wound is usually sewn up tightly.

Ligation of the main arteries (femoral, brachial and especially popliteal) is resorted to involuntarily, if it is impossible (see), since it threatens with gangrene of the limb. Before non-urgent operations on these vessels, training of collaterals is necessary, which can provide in case of inevitability of ligation of blood vessels. Training is carried out by pressing the artery (finger or by means of a special apparatus - a compressor) at the root of the limb - in, in - until the pulse disappears on the wrist. Pressing sessions are repeated 8-10 times a day, first for 10 minutes, then adjusted to 20-25 minutes. The effectiveness of training is checked in various ways - by capillaroscopy, by measuring capillary pressure,. The simplest way is a fatigue test: if the shutdown of the main artery does not cause a quick and cessation of movement of the foot (flexion - extension) or hand (compression - unclenching) and the patient can continue them for about 2 minutes, therefore, the collaterals have developed enough. It usually takes about 3-4 weeks to train the collateral circulation.

If urgent ligation of the main artery is necessary (mainly in military field conditions) and there is no time to train collaterals, ligation of the corresponding vein is also performed (according to indications). The difficulty of outflow of blood arising at the same time partly compensates for its insufficient inflow, the so-called reduced blood circulation is created. Another way is to the peripheral end of the ligated artery, causing expansion of the collateral vasculature.

In case of circulatory failure caused by persistent spasm of collaterals, it is possible to prevent by producing a lumbar or cervicothoracic novocaine blockade (see Novocaine blockade) or (see).

Esophageal vein ligation - what is it? This term refers to the procedure by which the prevention of bleeding from the esophageal veins occurs. The development of gastric varicose veins is characterized by pathologically thin walls of blood vessels and an increase in pressure.

It is these factors that can provoke a break. As part of the gastrointestinal endoscopy of the upper gastrointestinal tract, a special elastic band is attached to the dilated veins.

Types of varicose changes

The esophageal veins have four degrees of changes that are used in medical practice when making a diagnosis:

Main reasons

There are several causes of dilated veins of the esophagus, which include:

liver diseases: cirrhosis, viral hepatitis, tuberculosis;
development of thrombosis;
high blood pressure;
constriction of the portal vein.

Treatment

For the treatment of this pathology, an integrated approach is required: conservative and operative. As a conservative treatment are drugs that lower the pressure in the portal system. Doctors also aim to treat the disease that provoked this ailment.

Surgical intervention on the esophageal veins can be different:

endoscopic;
X-ray endovascular;
open.

Thanks to a special device - a fibroesophagogastroscope - doctors conduct sclerosing and ligation of esophageal varices. A ligator of varicose veins of the esophagus is necessarily used.

The main indication for such a procedure as endoscopic ligation of varicose veins of the esophagus is the development of the disease to the 2nd and 3rd stages. You can read about the first stage of esophageal varicose veins (EVV) in this article.

Like any other surgical intervention, ligation has certain contraindications:

serious disorders in the work of the cardiovascular system or blood circulation in the brain;
chronic diseases in the period of exacerbation;
eating less than 12 hours before the procedure;
the presence of active bleeding.

There are also factors that can affect the development of complications:

Immediately before the operation, the patient must undergo a medical examination, take blood tests:

general blood analysis;
general urine analysis;
biochemical analysis of urine;
coagulogram;
HIV, hepatitis.

It is best to refrain from taking any medications, but if the patient is taking medications that are necessary for the normal functioning of the body (for example, in case of diabetes), additional consultation may be required.

Carrying out the procedure

Immediately before the procedure, the patient is prescribed atropine and a sedative. The operation itself must be performed on an empty stomach. Local or general anesthesia may be used.

After the patient is placed on his left side and he clamps the mouthpiece, endoscopist begins to insert the device with a nozzle. Thanks to a special nozzle, it is possible to see changes in the vessels. After selecting a target, suction is turned on, which tightens the damaged area, thereby allowing you to put on an enlarged vein, latex ring.

The constricted areas become similar to cyanotic balls located in the lumen of the esophagus. During one session, the specialist can place from 3 to 10 rings. The procedure lasts about an hour, if there are no complications.

For seven days, necrosis of the separated areas occurs and their fibrins are covered. This whole process ends with the falling off of the sites and the withdrawal from the body in a natural way. At the site of detachment, ulcers form, which turn into scars after 2-3 weeks.

The number of procedures performed is strictly individual, because one session will be enough for someone.

After the operation, the patient is required to follow a diet. For a month it is not recommended to play sports. On the first day, it is best to observe bed rest and not drive.

Useful video

A lot of useful information about the esophageal vein ligation procedure can be found in this video.

Possible Complications

Any surgical intervention can cause certain complications, and endoscopic ligation of the veins of the esophagus is no exception.

So, after the operation can:

It is very important to observe the patient after the operation, on the first day he should not have: severe weakness, bloody vomiting, black stools, lump in the throat. Any of these symptoms is a dangerous bell about possible complications.