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Bleeding from the varicose-expanded veins of the esophagus, the treatment of which should be timely, is the life-threatening state, the consequence of the disease or damage to Vienna by various factors.

Esophageal bleeding is complicated by the portal hypertension of extreme severity. It is characterized by an increase in pressure in a portal vein, splenomegaly and ascite. Portal hypertension appears in violation of venous outflow of different location.

In most patients, the reason is in the liver, which causes bleeding from the veins of the esophagus during the cirrhosis of the liver. Without appropriate treatment, such a state has an unfavorable prognosis, a patient can live no more than two years. Code of the ICD-10 - varicose veins of the esophagus with bleeding 185.0.

With the question of bleeding from the veins of the esophagus of the ICD 10, we got acquainted, go on. Bleeding in the esophagus as a complication varicose expansion veins develop due to damage to the mucous membrane or veins itself by foreign acute objects, ulcer, toxic and poisonous substances. It takes better bleeding due to the ripper of the aneurysm, with a diaphragmal hernia and after the operation.

The reason for directly VRV (varicose veins of the esophagus) becoming stagnant processes arising from cirrhosis or liver thrombosis. The disease of the upper body of the organ is associated with the formation of goiter and vascular pathology for the disease Randy Osler.

Bleeding from the extended veins of the esophagus and cardia develops suddenly under the action of such factors:

• sharp increase in blood pressure;
• exacerbation of tract pathologies;
• singing and raising gravity.

Preceded by this unpleasant feeling in the throat, vomiting with blood, turbidity in the eyes and other symptoms of the increasing blood loss.

Bleeding VRV esophagus is most often diagnosed with people with cirrhosis.

The development of varicose expansion is due to the bond of the venous system of the gastrointestinal and hepatobiliary system. Violation in any department can be a factor in the main disease and subsequent complications, including bleeding.

Clinical signs and symptoms of bleeding from the esophagus

Clinical symptoms of bleeding from varicose-extended veins of the esophagus include complaints in a different period of the disease and at the time of bloodstures, as well as external manifestations of basic pathology and related violations. Patient complaints:

• vomot fresh blood;
• dry mucosa and constant thirst;
• reinforced sweating;
• dizziness and weakness;
• diarrhea, liquid stool with blood;
• noise in the ears and darkening in the eyes.

With such complaints, the doctor collects anamnesis of the disease. It turns out what medicines is taking a patient, and what food eats. In the history of patients with bleeding from the veins of the esophagus, there is often transferred liver diseases, use of acute, coarse food, severe physical work, previously conducted endoscopic veins.

Exterior signs When examining the patient:

• the jaggility of the skin;
• cold sweat;
• an increase in abdomen;
• legume of legs;
• weak pulse and frequent breathing.

With severe blood loss, man behaves uneasily, the consciousness of the inhibited and confused. Without timely assistance, a collapse is observed, which ends with a coma.

Diagnostics

An examination with such a phenomenon, like bleeding from the esophagus, includes:

• general I. biochemical analysis blood;
• ECG, EFGSD;
• immunoassay analysis to identify hepatitis;
• bacteriological sowing of urin sample;
• ultrasound examination of the esophagus, abdominal cavity and chest;
• cT scan abdominal cavity;
• radiography with contrasting esophagus.

When identifying concomitant deviations, an examination is appointed by a neurologist, oncologist, an infectious source or cardiologist.

Differential diagnosis is carried out with the disease Wilson Konovalova, syndrome Mellory Weis., hemorrhagic gastritis, shistosomoz.

First aid

On a prefiguration stage of help, when bleeding from the varicose veins of the esophagus is observed, it is necessary to create conditions for limiting bloodstures. The patient is stacked on the back in horizontal positionThe head turns to the side so that the blood can go along with vomit and did not fall into the peritoneum. It is necessary to provide a comfortable temperature, cover or free from clothing.

The control of the pulse and hell is carried out. With a decrease in pressure to 80 there is a risk of hemorrhagic shock, it will be necessary anti-shock events. The loss of consciousness indicates a serious blood loss. To avoid this, the patient can be given cold water. Other liquids and food are strictly contraindicated. Upon arrival of ambulance, the patient on stretcher is transported.

Methods of treatment

The main purpose of treatment is monitoring the source of bleeding and the prevention of secondary blood loss. After stopping bleeding, diet number 5 is prescribed to the patient.

First of all, the use of such techniques is considered:

• probe Blackmore;
• sklerosation of veins;
• binding using gastrectomy or endovascular embolization.

Emergency treatment includes the introduction of sodium hydrochloride. At the stationary level, treatment is different, depending on the degree of blood loss. Intravenously introduced a solution of glucose, sodium lactate, sodium acetate and gelatin in different concentrations and quantities.

Subsequent activities include medicia treatmentelimination of concomitant deviations. Vesseloring therapy may be assigned, endoscopic sclerotherapy and the operation in the ineffectiveness of conservative methods.

Medical therapy

Drugs are applied already at the first aid stage. The patient is introduced intravenously drip sodium hydrochloride or Dopamine. In the hospital, drugs are prescribed to normalize portal pressure. Fixed assets - Meropem, vasoconducting drug, and its analogs - Vapreotil or Octreotide.

Medicines for stopping the bleeding of the veins of the esophagus:

1. Somatostatin. It is introduced intravenously to 3 times within an hour to 5 minutes. No contraindications and extremely rarely causes adverse reactions. Reduces the likelihood of recurrence of the disease.
2. Octreotide. Intravenously introduced, the course of treatment continues up to 5 days with a repetition after a few days.
3. Terlimipressin. It is introduced intravenously until a complete stopping of bleeding and in a few days reused with the aim of preventing relapse.

With accompanying bacterial peritonitis assigned antibacterial drugs in a week. For this purpose, cephalosparins are used - Ceftazidim, Cefotaxim and Cefoperason. Alternative therapy conducted by fluoroquinolones, drug Ciprofloxacin and Offloxacin. With the deterioration of the kidney state, intravenously is appointed sodium chloride, octreotide, albumen.

Non-media methods

The treatment of bleeding from varicose veins of the esophagus is carried out by endoscopic sclerotherapy. The sclerosing drug is introduced into a damaged vein. This method allows you to stop the bleeding in 85% of cases. If the holding of two procedures does not give results, resort to other methods. It is introduced into the esophagus probe for squeezing the bleeding section.

What other treatment methods are used? It:

• electro-generation;
• application on a damaged vein thrombin or adhesive film
• endoscopic ligation.

Useful video

What is dangerous bleeding from the varicose extended veins of the esophagus? The clinic of this phenomenon is already clear. Measures that should be taken to patients are voiced in this video.

Operation

Options surgical treatment:

• operation Tips.;
• cross subcardial gastrotomy;
• operation Ppm Patients.

Indications for the operation serve the ineffectiveness of pharmacological treatment, prolonged bleeding at the impossibility of endoscopic hemostasis. TIPS operation ( trashlight intrahepatic portrait It is shown in portal hypertension, asthenic syndrome and acute bleeding of the esophagus.

The effectiveness of surgical treatment is estimated at such criteria:

• stop bleeding;
• lack of relapse;
• improving the forecast;
• remissance of related gastrointestinal diseases.

In severe cases, the cirrhosis decides on liver transplantation.

Prevention of secondary bleeding at VRV

After the main treatment, the prevention of secondary blood loss is carried out. Combined therapy is prescribed using drugs to normalize portal pressure. These are drugs Osolol and Propranolol. Sclerotherapy is carried out if another method was applied at the first aid phase.

Assign ligation, with an interval of a few weeks, rings are superimposed on veins. The patient is constantly monitoring, a regular examination is carried out at the hepatologist and the gastroenterologist.

Choose a free gastroenterologist's doctor in your city online:

Bleeding from the varicose-expanded veins of the esophagus, the treatment of which should be timely, is the life-threatening state, the consequence of the disease or damage to Vienna by various factors.

Esophageal bleeding is complicated by the portal hypertension of extreme severity. It is characterized by an increase in pressure in a portal vein, splenomegaly and ascite. Portal hypertension appears in violation of venous outflow of different location.

In most patients, the reason is in the liver, which causes bleeding from the veins of the esophagus during the cirrhosis of the liver. Without appropriate treatment, such a state has an unfavorable prognosis, a patient can live no more than two years. Code of the ICD-10 - varicose veins of the esophagus with bleeding 185.0.

With the question of bleeding from the veins of the esophagus of the ICD 10, we got acquainted, go on. Bleeding in the esophagus as a complication of varicose veins develops due to damage to the mucous membrane or veins itself by foreign acute objects, ulcers, toxic and poisonous substances. Less often bleeding due to the aneurysm break, and after surgery.

The reason for directly VRV () becomes stagnant processes arising from cirrhosis or liver thrombosis. The disease of the upper body of the organ is associated with the formation of goiter and vascular pathology for the disease Randy Osler.

Bleeding from the extended veins of the esophagus and cardia develops suddenly under the action of such factors:

• sharp increase in blood pressure;
• exacerbation of tract pathologies;
• singing and raising gravity.

Preceded by this unpleasant feeling in the throat, vomiting with blood, turbidity in the eyes and other symptoms of the increasing blood loss.

Bleeding VRV esophagus is most often diagnosed with people with cirrhosis.

The development of varicose expansion is due to the bond of the venous system of the gastrointestinal and hepatobiliary system. Violation in any department can be a factor in the main disease and subsequent complications, including bleeding.

Clinical signs and symptoms of bleeding from the esophagus

Clinical symptoms of bleeding from varicose-extended veins of the esophagus include complaints in a different period of the disease and at the time of bloodstures, as well as external manifestations of basic pathology and related violations. Patient complaints:

With such complaints, the doctor collects anamnesis of the disease. It turns out what medicines is taking a patient, and what food eats. In the history of patients with bleeding from the veins of the esophagus, there are often transferred liver diseases, drinking acute, coarse food, severe physical work, previously spent.

External signs when examining the patient:

• the jaggility of the skin;
• cold sweat;
• an increase in abdomen;
• legume of legs;
• weak pulse and frequent breathing.

With severe blood loss, man behaves uneasily, the consciousness of the inhibited and confused. Without timely assistance, a collapse is observed, which ends with a coma.

Diagnostics

An examination with such a phenomenon, like bleeding from the esophagus, includes:

When identifying concomitant deviations, an examination is appointed by a neurologist, oncologist, an infectious source or cardiologist.

Differential diagnosis is carried out with the disease Wilson Konovalova, syndrome Mellory Weis., shistosomoz.

First aid

On a prefiguration stage of help, when bleeding from the varicose veins of the esophagus is observed, it is necessary to create conditions for limiting bloodstures. The patient is stacked on the back in a horizontal position, the head turns to the side so that the blood can go out with the vomit and did not fall into the peritoneum. It is necessary to provide a comfortable temperature, cover or free from clothing.

The control of the pulse and hell is carried out. When the pressure drop is reduced to 80, there is a risk of hemorrhagic shock, anti-shock events will be required. The loss of consciousness indicates a serious blood loss. To avoid this, the patient can be cold water. Other liquids and food are strictly contraindicated. Upon arrival of ambulance, the patient on stretcher is transported.

Methods of treatment

The main purpose of treatment is monitoring the source of bleeding and the prevention of secondary blood loss. After stopping bleeding, diet number 5 is prescribed to the patient.

First of all, the use of such techniques is considered:

• probe Blackmore;
• sklerosation of veins;
• binding using gastrectomy or endovascular embolization.

Emergency treatment includes the introduction of sodium hydrochloride. At the stationary level, treatment is different, depending on the degree of blood loss. Intravenously introduced a solution of glucose, sodium lactate, sodium acetate and gelatin in different concentrations and quantities.

Subsequent activities include drug treatment, eliminating concomitant deviations. Vesseloring therapy may be assigned, endoscopic sclerotherapy and the operation in the ineffectiveness of conservative methods.

Medical therapy

Drugs are applied already at the first aid stage. The patient is introduced intravenously drip sodium hydrochloride or Dopamine. In the hospital, drugs are prescribed to normalize portal pressure. Fixed assets - Meropem, vasoconducting drug, and its analogs - Vapreotil or Octreotide.

Medicines for stopping the bleeding of the veins of the esophagus:

With accompanying bacterial peritonitis, antibacterial drugs are prescribed during the week. For this purpose, cephalosparins are used - Ceftazidim, Cefotaxim and Cefoperason. Alternative therapy is carried out by fluoroquinolones, preparation Ciprofloxacin and Offloxacin. With the deterioration of the kidney state, intravenously is appointed sodium chloride, octreotide, albumen.

Non-media methods

The treatment of bleeding from varicose veins of the esophagus is carried out by endoscopic sclerotherapy. The sclerosing drug is introduced into a damaged vein. This method allows you to stop the bleeding in 85% of cases. If the holding of two procedures does not give results, resort to other methods. It is introduced into the esophagus probe for squeezing the bleeding section.

What other treatment methods are used? It:

• electro-generation;
• application on a damaged vein thrombin or adhesive film
• endoscopic ligation.

Useful video

What is dangerous bleeding from the varicose extended veins of the esophagus? The clinic of this phenomenon is already clear. Measures that should be taken to patients are voiced in this video.

Operation

Options for surgical treatment:

• operation Tips.;
• cross subcardial gastrotomy;
• operation Ppm Patients.

Indications for the operation serve the ineffectiveness of pharmacological treatment, prolonged bleeding at the impossibility of endoscopic hemostasis. TIPS operation ( trashlight intrahepatic portrait It is shown in portal hypertension, asthenic syndrome and acute bleeding of the esophagus.

The effectiveness of surgical treatment is estimated at such criteria:

• stop bleeding;
• lack of relapse;
• improving the forecast;
• remissance of related gastrointestinal diseases.

In severe cases, the cirrhosis decides on liver transplantation.

Prevention of secondary bleeding at VRV

After the main treatment, the prevention of secondary blood loss is carried out. Combined therapy is prescribed using drugs to normalize portal pressure. These are drugs Osolol and Propranolol. Sclerotherapy is carried out if another method was applied at the first aid phase.

Assign ligation, with an interval of a few weeks, rings are superimposed on veins. The patient is constantly monitoring, a regular examination is carried out at the hepatologist and the gastroenterologist.

RCRZ (Republican Center for Health Development MD RK)
Version: Clinical Protocols MOR RK - 2015

Gastrointestinal dish-hemorrhagic syndrome (K22.6), portal hypertension (K76.6)

Gastroenterology, Surgery

general information

Short description

Recommended
Expert Council
RSP on PVC "Republican Center for Health Development"
Ministry of Health
and social development
from September 30, 2015
Protocol No. 10.

Bleeding out varicose-extended veins esophagus It is a complication of portal hypertension syndrome. The VRV of the esophagus is portoysystem collaterals that bind portal venous and systemic venous blood circulation. They are formed as a sequence of development of portal hypertension, mainly in the submucosal shell of the lower part of the esophagus. As a result of portal crises, the pressure in the vessels of the portal system increases several times, leading to the ruptures of the walls of varicose veins in areas with reduced resistance due to dystrophic changes, which is a prerequisite for the development of bleeding.

Protocol code:

Code (s) μb-10:
K22 Other Food Diseases
K22.6 Gastrointestinal Broken-Hemorrhagic Syndrome
K76.6 Portal Hypertension

Abbreviations used in the protocol:
Blood pressure;
Alat - Alanineotransferase;
AST - Aspartataminotransferase;
ACTV - activated partial thromboplastin time;
AFP - oncomarker alpha fetoprotein;
VRV - varicose veins;
GSH - hemorrhagic shock;
DVS - Disseminated intravascular coagulation;
ITT - infusion-transfusion therapy;
CT - computed tomography;
LDH - lactate dehydrogenase;
Many - international normalized relationship;
NSAID - non-steroidal anti-inflammatory drugs;
OCC - the volume of circulating blood;
PV - prothrombin time;
PD - portal pressure;
PDF - fibrinogen degradation product;
PH - prothrombin index;
Garden - systolic blood pressure
LNG - portal hypertension syndrome;
TV - thrombin time;
UD - level of evidence;
Ultrasound - ultrasound examination;
F - fibrinolytic activity;
FVD - central venous pressure;
CPU - liver cirrhosis;
Chdd - respiratory frequency;
Heart rate - cardiac frequency;
SHF - alkaline phosphatase;
EG - endoscopic hemostasis
ECG - electrocardiography;
EFGDS - Ezophagogastroduodenoscopy;
D-dimer - fibrin decay product;
EVL - endoscopic veins;
HB - hemoglobin;
HT - hematocrit;
ISMN - nitrates;
NBSS - non-selective β-blockers;
HRS - hepato-renal syndrome;
SBP - spontaneous bacterial peritonitis;
HE - hepatic encephalopathy;
Kos is an acid-base state;
ELISA - immunoferment analysis;
APF - alpha-ketoprotein;
TIPS - transiugular portoysystem shunting;
Pon - polyorgan deficiency;
Mar is a secondary blood pressure.

Date of development / revision of the Protocol:2015 year.

Protocol users: Surgeon, anesthesiologist resuscitator, doctor ambulance and emergency care, Feldsher, doctor of functional diagnostics (endoscopist), gastroenterologist, therapist, general practitioner.

Classification

Clinical classification:

Classification of the VRV of esophagus and stomach by Paquet (1983):
1 degree - single ectasia veins;
2 degree - single well-drawn veins trunks, mainly in the N / s of esophagus, which during air insufflation remain clearly expressed. The form of the veins is represented, there is no narrowing of the enlightenment of the esophagus, there is no thinning of the epithelium on the veins and there are no red wall markers;
3 degree - A distinct narrowing of the enlightenment of the esophagus of the VRV trunks located in C / s and N / s of the esophagus, which are only partially reduced by air insufflation. There is a nodal form of veins, on the tops of the veins - "red markers".
4 degree - The clearance of the esophagus is fully completed, the extension of the veins affects the / s of the esophagus. The epithelium over the veins is thinned, the many "red markers" walls are determined.

Three-particle classification (Soehendra N., Bimoeller K., 1997):
VRV esophagus:
I degree - the diameter of the veins does not exceed 5 mm, elongated and are located only in the N / s of the esophagus;
II degree - VRRs with a diameter of 5 to 10 mm, convoluted, spread to the middle third of the esophagus inclusive;
III degree - the size of the veins is more than 10 mm, the shape is noded, strained with a thin wall, are located close to each other, on the surface of the veins "Red Markers".
VRV stomach:
I degree - the diameter of the veins is not more than 5 mm, barely distinguishable over the gastric mucosa;
II degree - VRV from 5 to 10 mm, solitary polypoid;
III degree - Vienna with a diameter of more than 10 mm, represent an extensive conglomerate of nodes, thin-walled, polypoids. For practical purposes, it is important to take into account the reprehensive form of the veins (II degree - moderate risk of bleeding) and a nodal (III degree - the high risk of bleeding).

Classification of VRV stomach:
RVW is classified depending on localization.
Gastroesophageal veins (Gastroesophal veins, gov) - VRV, moving from the esophagus in the stomach, are divided into 2 types:
· 1st type (GOV1) - pass along the small curvature of the stomach (the principles of treatment comply with the principles of treatment of the VRRP);
· 2nd type (GOV2) - located in the day of the stomach, longer and convoluted.
· Isolated veins of the stomach (Isolated Gastric Veins, IGV) are developing in the absence of an extension of the veins of the esophagus, are divided into 2 types:
· 1st Type (IGV1) - located in the bottom of the stomach, convinced (found at thrombosis of the spleen vein);
· 2nd type (IGV2) - pass in the body of the stomach, Antrume or around the gatekeeper. The greatest danger represents the veins located in the day of the stomach (Foundal Vienna). Other risk factors are the size of the nodes, the CPU class, the presence of a symptom of the Red Spot.
The division to the degree of VRF is based on the same parameter as the division of the VRPP, on the size of the nodes:
· 1st degree - diameter VRV no more than 5 mm, veins are barely distinguishable over the gastric mucosa;
· 2nd degree - diameter VRV 5-10 mm, veins have a solitar-polypoid;
· 3rd degree - diameter VRV more than 10 mm, veins of thin-walled, polypoid character, are an extensive conglomerate of nodes.

The classification of the American Association for the Study of Liver Diseases (AASLD) allocates 3 stages of VRV):
· 1st stage - small veins, minimally towering over the mucosa of the esophagus;
· 2nd stage - medium veins, convolutions that occupy less than a third of the enlightenment of the esophagus;
· 3rd stage - Large veins.
IN international Classifications It is proposed to use the maximum simplified division of varicose veins into 2 stages:
· Small Viennes (up to 5 mm);
· Large veins (more than 5 mm), since the risks associated with bleeding are the same for medium and large veins. The frequency of bleeding is 5-15% per year, it is spontaneously terminated in 40% of patients, repeatedly, in the absence of treatment, develops approximately 60% of patients, on average within 1 to 2 years after the first episode.

Clinical picture

Cymptoms, flow

Diagnostic criteria for diagnosis:

Complaints and history:

Complaints:
· In vomiting of the scarlet (fresh) blood / coffee grounding;
· Degte-shaped chair / liquid stools with low-change blood ( clinical signs bleeding);
· Weakness;
· dizziness;
· Cold sticky sweat;
· noise in ears;
· Frequent heartbeat;
· Short-term loss of consciousness;
· Thirst and dry mouth (clinical signs of blood loss).

Anamnesis of the disease:
· Reception rough, acute food, alcohol, medicinal preparations (NSAID and thrombolytic);
· Repeated vomiting, bloating, lifting weight;
· It suffers from cirrhosis of the liver, transferred hepatitis, suffers from chronic alcoholism;
· The presence of episodes of bleeding in history;
· Previously transferred endoscopic ligation of the VRV of the esophagus, the sclerotherapy of the veins.

Physical examination(Appendix 1, 2):
condition Patient with severe blood loss:
· restless behavior;
· Connection confusion, inhibition;
· There is a picture of the collapse, up to coma;
General inspection:
· The jaundice of scler / skin cover;
· Pallor of skin cover;
· The skin is covered with cold later;
· Reducing the leather turgor;
· Increase in abdomen in volume (ascites);
· The presence of extended veins on the side surface of the abdomen (head of jellyfish);
· Percussively borders of the liver are increased (may be reduced);
· Palpatormo the surface of the liver is buggy, edges rounded;
· The presence of teleangioectasis on the skin;
· Hepatic palms;
· The presence of edema on the lower limbs, on the side and lower stomach departments;
· Pulse character\u003e 100 in 1 min., Frequent, weak filling;
· Garden (< 100 мм.рт.ст.) тенденция к снижению в зависимости от степени кровопотери;
· Chdd (20 and\u003e in 1 min) trend towards participation;
· Oxygen saturation in venous blood < 90%.

Diagnostics

List of basic and additional diagnostic measures:

Main (mandatory) diagnostic surveys conducted on an outpatient level: not carried out.

Additional diagnostic surveys conducted on an outpatient level: not carried out.

The minimum list of the survey, which must be carried out in the direction of the planned hospitalization: is not conducted

Main (mandatory) diagnostic surveys conducted at the stationary level (in emergency hospitalization, diagnostic surveys are conducted on an outpatient level):

· Physical examination (calculation of the pulse, calculation of the CDD, measuring blood pressure, measurement of saturation, finger study of the rectum);
· general blood analysis;
· general urine analysis;
· Biochemical blood test (total protein and its fractions, bilirubin, alt, asthikes, alkaline phosphatase, LDH, cholesterol, creatinine, urea, residual nitrogen, blood sugar),
· Kos;
· Determination of blood type on the AVO system;
· Determination of blood reserves;
· Coagulogram (PH, MNA, TV, APTTV, Fibrinogen, coagulation time);
· D-dimer;
· PDF;
· ECG;
· EFGDS remove previously marked level of evidence

Additional diagnostic surveys conducted at the stationary level (for emergency hospitalization, diagnostic surveys are conducted on an outpatient level):
· Determination of hepatitis markers by the IFA method;
· Definition of oncomarcker (AFP) by the IFA method;
· Bacteriological sowing urine;
· Ultrasound of the abdominal organs;
· Uzi kidney;
· CT abdominal cavity;
· X-ray examination of the esophagus and stomach with contrasting (double contrast);
· Splinoportography.

Diagnostic measures carried out at the emergency stage:
· Collection of complaints, anamnesis of disease and life;
· Physical examination (calculation of the pulse, heart rate, CDD counting, DC measurement).

Tools:
ECG - There are changes that depend on the initial state of the cardiovascular system (signs of myocardial ischemia decreased to the teeth, depression of ST segment, tachycardia, rhythm violation).
EFGDS -the presence of an extended veins of the esophagus, their length, shape (convolve or stem), localization, size, hemostasis state, bleeding risk predictors (red markers).
EFGDS must be carried out as early as possible. The timing of this study is 12-24 hours from the date of the patient's receipt (UD-Class I, level A).
The EFGDS should note the presence or absence of red signs on varicosely extended esophageal veins and stomach (UD-Class IIa, level C).

Indications for the consultation of narrow specialists:
· Consultation of the nephrologist in suspected kidney pathology;
· Consultation of an oncologist with suspicion of oncopathology;
· Consultation of infectious diseases in identifying infectious diseases and development of toxic hepatitis;
· Consultation of the cardiologist in the pathology of the cardiovascular system;
· Consultation of a neuropathologist when identifying pathology from nervous system;
· Consultation of the obstetrician-gynecologist in the presence of pregnancy to solve the issues of therapeutic tactics.

Laboratory diagnostics

Laboratory research:
· general blood analysis: Reducing the content of erythrocytes, hemoglobin levels (HB) and hematocrit (HT);
· blood chemistry: The increase in blood sugar is higher than 6 μmol / l, bilirubine above 20 μmol / l, increasing the level of transaminase (ALT, AST) by 2 times or more of the norm, increase thymol\u003e 4 units, reduction of the sulea test, alkaline phosphatase, LDG-214- 225 U / L; Reduced cholesterol< 3,6 ммоль/л, снижение общего белка < 60 г/л, альбумина < 35 г/л, снижение альбумин/глобулинового коэффициента ниже 1,5, повышение креатинина > 105 μmol / l or an increase in it with 0.5 μmol / l, urea\u003e 6.5 mmol / l.
· coagulogram: Reducing the bird< 70%, фибриноген < 2 г/л, АЧТВ > 60 sec., PV\u003e 20%, TV\u003e 15 sec., MN\u003e 1.0, FA elongation, coagulation time, fibrinogen degradation products\u003e 1/40, dimers\u003e 500 ng / ml; Kos RN.< 7,3, дефицит оснований ≥ 5 ммоль/л, повышение уровня лактата > 1 mmol / l;
· electrolytes: Reduced to, Na, Ca;
· gepatitis markers: Revealed markers indicate the presence of one or another viral infection;
· blood test to oncomarkers: Increased oncomarckers AFP higher than 500 ng / ml (400 me / ml).

Differential diagnosis

Differential diagnosis:

Table - 1. Differential diagnosis of bleeding from varicose-expanded veins of the esophagus during portal hypertension syndrome.

Treatment abroad

Treat treatment in Korea, Israel, Germany, USA

Get advice on medical examination

Treatment

Treats of treatment:

· Control of the source of bleeding;
· Prevention and treatment of SBP, HRS. He;
· Prevention of secondary bleeding from VRV.

Tactics of treatment:

Non-drug treatment:
Mode- I.II;
Diet - Table number 5 (Appendix 3).

Medical treatment:

At the outpatient level, urgently:
Sodium solution chloride 0.9% 400.

Inpatient treatment:
Fill the OCC.
ITT at easy blood loss:
· Blood lodge 10-15% BCC (500-700 ml): intravenous transfusions of crystalloids (dextrose, sodium acetate, sodium lactate, sodium chloride 0.9%) in the amount of 200% of blood loss (1-1.4 l).
ITT middle degree Bloodstocks:
· Blood lodge 15-30% BCC (750-1500 ml): V / in crystalloids (glucose solution, sodium chloride 0.9%, sodium acetate, sodium lactate) and colloids (gelatin), in a 300 ratio with a total volume of 300 % of blood loss (2.5-4.5 liters);
ITT with severe blood loss:
· In the blood loss 30-40% of the BCC (1500-2000 ml): B / in crystalloids (dextrose, sodium chloride 0.9%, sodium acetate, sodium lactat) and colloids (geloofusion) in a 2: 1 ratio with a total volume of 300% from the volume of blood loss (3-6 liters). The transfusion of blood components (erythrocyte weight, 30% of the overflow volume, thromboconcentrate in the level of platelet content< 50х10 9) и препарата крови - раствор альбумина при гипопротеинемии (общий белок < 60 г/л) и гипоальбуминемии (альбумин < 35 г/л).
When determining the testimony to substitution therapy, only for tests taken from venous blood:HB., HT, erythrocytes, coagulogram indicators: MN, PH, Fibrinogen.
Critical level Indicators are: hemoglobin - 70 g / l, hematocrit - 25-28%. . It is necessary to preserve the level of hemoglobin ~ 80 g / l (UD-Class I, level B).
· In the hemokoagulatory syndrome and thrombocytopenia, the most safe colloidal solution is recommended succinylated gelatin. The rate of infusion conducted is determined by the level of blood pressure. Behind the bleeding, the garden should not exceed 90 mm.rt.st. But the rate of infusion should exceed the speed of blood loss - 200 ml / min in 1 or in 2-3 veins.
Criteria for adequacy of ITT:
· Increased FVD (10-12 cm. Body.);
· Hourly diuresis (at least 30 ml / hour);
· While the CCD will not reach 10-12 cm. and hourly diuresis 30 ml / hour ITT must continue.
· With a rapid increase in the FLA above 15 cm. It is necessary to reduce the pace of transfusion and revise the amount of infusion;
· Clinical criteria for restoring OCC (elimination of hypovolemia):
· Increased blood pressure;
· Reduction of heart rate;
· Increased pulse pressure;
· Increase in blood saturation;
· Warming and changing the color of the skin (with pale to pink).
Preparations of vitamin K:
Menadion sodium bisulfite 2 ml 3 times in / intravenously.
Protelyolis inhibitors (Adrotinin / Analogues: Contrickle, Aprotinin) Reduce the need for substitution therapy and reduce blood loss. It is recommended that the use of 50,000 units of conflict, then 10,000-20,000 every 4-6 hours. The initial dose of aprotinin in hemorrhagic shock is 500 thousand kie. The rate of administration is no more than 5 ml / min, then in / in drip 50 thousand per hour (UD - D).
Pharmacological therapy to reduce portal pressure:
The use of vasoactive drugs contribute to the stopping of bleeding in 75-80%. (UD-Class I, level A).
Of vesseloring drugs (To reduce PD) used in the treatment of bleeding from VRVs, have the advantage of Meropenem and its analogues: octreotide and vapreotide, as they have a low side effect. The application is possible immediately as soon as bleeding from VRV and even if suspicion (UD-Class I, level A). .
Otreotide: Bolus intravenously is introduced 50 μg / h, followed by continuous V / in the introduction through a dispenser 50 μg / h for 5 days or drip / in 5 days (UD-5D). Or 0.025 mg / h is introduced (UD - a).
Terlimipressin: Patient weight<50 кг - 1 мг; 50-70 кг - 1,5 мг; вес >70 kg - 2 mg. Next, intravenously bolus 2 mg every 4 hours for 48 hours, from 3 days 1 mg every 4 hours to 5 days (Appendix 4). Or 1000 μg every 4-6 hours 3-5 days before stopping and for another 2-3 days to prevent bleeding recurrences.
Somatostatin: Bolus in / in 250 μg for 5 minutes and can be repeated 3 times for 1 hour. Next, continuous administration of 6 mg (\u003d 250 μg) within 24 hours. The dose can be increased to 500 μg / h. Side effects Rare and no contraindications. In comparison with the terminressin, the effect is the same (reduces recurrence and bleeding is carried out). With absence this drug It shows its synthetic analogs - octreotide or vapreotide.

Treatment of spontaneous bacterial peritonitis (SBP.):
Antibiotic therapy (for 7-8 days):
Cephalosporins III of generation (cefotaxim, ceftriaxone, cefoperasazon, ceftazidim):
· Cefotaxim 2 g 2 times a day in / c, ceftazidim 1 g 2 times a day in / in;
· Amoxicillin / Clavulanate 1G / 3 times a day;
· Ampicillin / sulbactam 1 g / 3 times a day.

Alternative therapy with antibiotics in the absence of kidney dysfunction and encephalopathy:
Fluoroquinolones:
· Offlsacin PER OS 400 mg per day;
· Ciprofloxacin PER OS 200 mg 2 times a day.
Carbapenes:
· Meropenem 500 mg 2 times or 1 g 1 time per day in / in;
· Imipenem500 mg 2 times or 1 g 1 time per day in / in;
· Doripenem 500 mg 2 times in / in;
· Meropenem 1 g 1 time in / in;

With nosocomial SBP as an empirical antibacterial therapy It is recommended to Piperillalin / Tazobactam 2 g 1 time per day in / c. In its absence - the cephalosporins III of generation (cefotaxim, ceftriaxone, cefoperasazon, ceftazidim).
Albumin 1.5 g / kg Weight of the patient during the first 6 hours, then enter the patient's weight per day at the rate of 1 g / kg.
Contraindications:
· Application in the acute period of diuretics;
· Application of aminoglycocyids.

Treatment of hepatic encephalopathy:
· Reducing the daily use of protein 20-30 g;
· Reception of lactulose 30-50 ml every 1-2 hours (before the start of the defecation). After defecation (2-3 soft stools), the dose of lactulose is 15-30 ml 2 times a day.
Alternative therapy:
· Neomycin per OS + magnesium / sorbitol;
· Rifaximine 400 mg per OS;
· Ornithine Aspartate and benzoate.

Treatment of hepato-renal syndrome:
With the deterioration of the kidney function (the increase in creatinine):
· Cancel diuretics;
· Albumin V / in 1 g / kg weight;
· Sodium solution of chloride 0.9% 400 ml in / Venidly drip. If creatinine does not decrease, then to perform ultrasound kidneys, take urine bacteriological sowing.
Main treatment:
· Terliminsyn 0.5 - 1.0 mg in / every 4-6 hours. If creatinine is not reduced by more than 25% for 2 days, the dose must be increased to 2 mg every 4-6 hours. If creatinine is not reduced by 50% for 7 days, the treatment stops. If there is a response, then continue treatment up to 14 days;
· Octreotide 100 mg 3 times subcutaneously + Midodrine 5-7.5 mg 3 times / day Per OS, if necessary, the dose of Midodrina increases to 12.5-15 mg;
· Or octreotide 100 mg 3 times subcutaneously + terlyressin 0.5-0 mg every 4-6 hours V / VENSO;
· Albumin 50-100 g / day at the rate of 1 g / kg patient weight for 7 days. Conduct control for hell. The purpose of treatment will increase the MAP by 15 mm. RT. Art.

Medical treatment rendered at the stage of ambulance:
· Sodium solution chloride 0.9% 400 ml V / in drip;
· Dopamine 4% or 0.5% solution of 5 ml in / in drip.

Other types of treatment:

Other types of treatment rendered on an outpatient level
· Inhalation of oxygen.

Other species rendered at the stationary level:
· Inhalation of oxygen;
· Catheterization 2 peripheral veins or 1 central Vienna;
· Endotracheal intubation (readings, mode).
IVL is shown to severe patients (with massive bleeding of severe and violation of the level of consciousness), must be performed by patients before EFHDs.

Indications to the IVL are:
· Violation of consciousness (on the scale of Glasgow less than 10 points) (Appendix 2);
· Lack of self-breathing (apnea);
· Respiratory gain is more than 35-40 per minute, if this is not associated with hyperthermia (body temperature above 38.5 ° C) or severely displeased hypovolemia.

Gaza arterial blood:
· PAO 2.< 60 мм рт ст при дыхании атмосферным воздухом или PaСО 2 > 60 mm RT in the absence of metabolic alcohol;

Control of bleeding with the help of obtasters: (UD-Class I, level B).
Sengstachen-Blakemor probe:
Indications:
· Continuing bleeding from VRV esophagus
Contraindications:
Stopped bleeding from VRV esophagus.
Hemostasis efficiency control is carried out by dissolving the casing of the probe after 4 hours from the moment of its installation. When stopping bleeding cuffs descend. The duration of the probe is up to 24 hours.

Tube Linton
Indications:
· Gastric Localization of VRV;
Contraindications:
· Stopped bleeding from VRV stomach.

Stant Danisha(self-resisting):
Indications:
· Continuing bleeding from VRV esophagus.
The stent is installed during an endoscopy for no more than 1 week (endoscopically removed).
Contraindications:

Endoscopic hemostasis(UD-Class I, level A). (Appendix 5) :
Endoscopic ligation(EVL) :
Indications:

Contraindications:
· The agonal state of the patient;
· Anatomical esophageal defects (stricture).

(It is carried out intravasal and paravazally):
Indications:
· Continuing and / or stopped bleeding from VRV esophagus.
Contraindications:
· The agonal state of the patient;
· Anatomical esophageal defects (stricture).

Cleaning enema:
Indications:
· The presence of blood in the lumen of the intestine.

Physicu with lactulose:
Indications:

300 ml of lactulose by 1 liter of water, introduce every 4-6 hours.

Using the system "MaRS. - Molecular AdSorben Recirculating System » - albumin Dialysis:
Indications:
· Hepatical encephalopathy.

Sumorizing therapy (bridge therapy) for patients waiting for liver transplantation :
Indications:
· Hepato-renal syndrome.

Other types of treatment rendered at the stage medical care:
· Inhalation of oxygen;
· Translation to IVL according to the testimony during critical condition;
· Catheterization of peripheral veins.

Surgical intervention:

Surgical intervention rendered on outpatient conditions: not carried out.

Surgical intervention provided in stationary conditions:
OperationTips.
Indications:
· With ineffectiveness of pharmacological therapy and EG.
TIPS and shunt operations are shown in child-drink patients (UD-Class I, level C).
Contraindications:
· The severity of the disease class in / s in Child-Pugh (decompensated stage).
Liver transplantation:
Indications:
· cirrhosis of the liver;
· Some forms chronic hepatitis;
· Some forms of malignant liver neoplasms.
Contraindications:
· Chronic infections;
· HIV virus availability,
· Mycobacterium tuberculosis,
· Syphilis;
· Viral hepatitis.

Paper operation (transverse subcardial gastrotomy):
Indications:
· Continuing bleeding from VRV cardiosezophageal transition and stomach in the absence of conditions for conducting endoscopic hemostasis and other stop methods
Contraindications:
· The agonal state of the patient;
Pon.

Treatment Efficiency Indicators:
· Stop bleeding from VRV esophagus and stomach;
· Prevent the recurrence of bleeding;
· Warning and relief HRS, SBP, HE;
· Reducing mortality rates.

Preparations ( active substances) applied in the treatment

Hospitalization

Indications for hospitalization indicating the type of hospitalization:

Indications for emergency hospitalization:
· Bleeding from VRV esophagus and stomach.

Indications for planned hospitalization: not.

Prevention

Preventive actions:

Prevention of secondary bleeding:(UD-Class I, level A).
· NSBB should be started immediately as soon as the introduction of vasoactive drugs (terminressin, octreotide or vapreotide) is terminated;
· NSBB significantly reduces the risk of re-bleeding.
For the prevention of secondary bleeding from the VRV of the esophagus and the stomach shown :

First line therapy Combined therapy: (UD-Class I, level A).
· Application of non-selective β-blockers (NSBB) to reduce portal pressure: propranolol at a dose of 20 mg 2 times a day or supolyas 20-40 mg 1-2 times a day. Correction of the dose on the cutting of heart rate (bring 55-60 in 1 min);
· + VRV ligation (EVL). Above 6 rings on veins every 1-2 weeks. The first control EFGDS in 1-3 months and later every 6-12 months to control the recurrence of VRV. (UD-Class I, Level C).

Second line therapy:
· If NSBB + EVL was not effective, then the TIPS operation is shown or shunting, but only class A patients in gravity of the CPU flow. Class B and with these operations are not shown, as they lead to the development of encephalopathy.

Alternative therapy:
· NSBB ( β-blockers) + ISMN (nitrates in tablet form);
· NSBB + ISMN + EVL. This combination of pharmacological (NSBB + ISMN) and ligation (EVL) VRV is associated with more low level Recycle bleeding and is a choice method.
If the patient has re-bleeding from VRV despite combinations of pharmacological and endoscopic treatment, in such cases the use of TIPS or shunt operations is recommended (if there are local conditions and experience of their use. (UD-Class I, level a). Liver transplant candidates must To be sent to the Transplantology Center (UD-Class I, Level C).

For the secondary prevention of bleeding from VRV not shown:
· NSBB + sclerotherapy;
· EVL + sclerotherapy.

Antibacterial prevention of spontaneous bacterial peritonitis (SBP.):
The use of quinolones for 7 days: (UD-Class I, level A).
· Norfloxacin 400 mg 2 times a day per OS 7 days;
· Or Ciprofloxacin 400 mg V / in drip 1 time for 7 days;
· Or ceftriaxone 1 g per / every 1 time per day to 7 days. This drug is more effective in patients with ascites, encephalopathy, as well as preceding therapy with quinolon. Especially in centers with high resistance to quinolones (UD-Class I, level B).

Further maintenance:
· Treatment of the main disease. After stopping bleeding and discharge from the hospital, the patient is sent to a gastroenterologist or hepatologist;
· Selection and direction on the liver transplant (transplantologist).

Information

Sources and literature

1. Protocols of the meetings of the Expert Council RCRs MZSR RK, 2015
   1. List of used literature (References Valid studies are needed to listed sources in the text of the Protocol): 1) Khanevich MD, Trackkin V.I., Zherev G.K. et al., bleeding from chronic gastroduodenal ulcers in patients with intrahepatic portal hypertension. - Novosibirsk: Science, 2003. - 198 p. 2) Guideline Summary World Gastroenterology ORGANISATION (WGO). Esophageal Varices. MILWAUKEE (WI): World Gastroenterology Organization (WGO); 2014. 14 p. 3) De Franchis R. Evolving Consensus in Portal Hypertension Report of the Baveno IV Consensus Workshop on Methodology of Diagnosis and Therapy in Portal Hypertension. J Hepatol 2005; 43: 167 - 76. 4) Garcia-TSAO G, Sanyal AJ, GRACE ND E T Al. Prevention and Management of Gastroesophadle Varices and Variceal Hemorrhage in Cirrhosis. Hepatology 2007; 46: 922 - 38. 5) Garcia-Tsao G, Sanyal AJ, GRACE ND E T Al. Prevention and Management of Gastroesophadle Varices and Variceal Hemorrhage in Cirrhosis. Am j Gastroenterol 2007; 102: 2086 - 102. 6) Longacre AV, Imaeda A, Garcia-Tsao G, Fraenkel L. A Pilot Project Examining The Predicted Preferences of Patients and Physicians of the Variceal Hemorrhage. Hepatology. 2008; 47: 169-176. 7) Gluud LL, Klingenberg S, Nikolova D, Gluud C. Banding Ligation Versus β-Blockers As Primary Prophylaxis in Esophageal Varices: Systematic Review Of Randomized Trials. Am j gastroenterol. 2007; 102: 2842-2848; Quiz 2841, 2849. 8) Bosch J, Ablades JG, Berzigotti A, Garcia-Pagan JC. Portal Hypertension and Gastrointestinal Bleeding.semin Liver Dis. 2008; 28: 3-25. 9) Ablades JG, Tarantino I, Turnes J, Garcia-Pagan JC, Rodés J, Bosch J. Hemodynamic Response to Pharmacological Treatment of Portal Hypertension and Long-Term Prognosis of Cirrhosis. Hepatology. 2003; 37: 902-908. 10) Villanueva C, Aracil C, Colomo A, Hernández-Gea V, López-Balaguer JM, Alvarez-urturi C, Torras X, Balanzó J, Guarner C. Acute Hemodynamic Response to β-Blockers and Prediction of Long-Term Outcome in PRIMARY PROPHYLAXIS OF VARICEAL BLEEDING. Gastroenterology. 2009; 137: 119-128. 11) Fernández J, Ruiz del Arbol L, Gómez C, Durandez R, Serradilla R, Guarner C, Planas R, Arroyo V, Navasa M. Norfloxacin VS Ceftriaxone In The Prophylaxis of Infections in Patients with Advanced Cirrhosis and Hemorrhage. Gastroenterology. 2006; 131: 1049-1056; Quiz 1285. 12) Bernard B, Lebrec D, Mathurin P, Opolon P, Poynard T. B-Adrenergic Antagonists In The Prevention of Gastrointestinal Rebleding in Patients with Cirrhosis: A Meta-Analysis. Hepatology. 1997; 25: 63-70. 13) Gonzalez R, Zamora J, Gomez-Camarero J, Molinero LM, Bañares R, Albillos A. Meta-Analysis: Combination Endoscopic and Drug Therapy to Prevent Variceal Rebleding in Cirrhosis. Ann Intern Med. 2008; 149: 109-122. 14) Garcia-Tsao G, Bosch J. Management of Varices and Variceal Hemorrhage in Cirrhosis. N engl j med. 2010; 362: 823-832. 15) LUCA A, D "AMICO G, La Galla R, Midiri M, Morabito A, Pagliaro L. Tips for Prevention of Recurrent Bleeding in Patients with Cirrhosis: Meta-Analysis of Randomized Clinical Trials. Radiology. 1999; 212: 411- 421. 16) Henderson JM, Boyer TD, Kutner MH, Galloway JR, Rikkers LF, Jeffers LJ, Abu-Elmagd K, Connor J. Distal Splenorenal Shunt Versus Transjugular Intrahepatic Portal Systematic Shunt for Variceal Bleeding: A Randomized Trial. Gastroenterology. 2006 ; 130: 1643-1651. 17) Khurram Bari and Guadalupe Garci-Cao. Treatment of Portal Hypertension. World J Gastroenterol. 2012 March 21; 18 (11): 1166-1175. 18) De Franchis R. Evolving Consensus in Portal Hypertension . REPORT OF THE BAVENO IV CONSENSUS WORKSHOP ON METHODOLOGY OF DIAGNOSIS AND THERAPY IN PORTAL HYPERTENSION. J. HEPATOL., 2005, 43: 167-176. 19) Garcia-Tsao G., Bosch J. Management of Varices and Variceal Hem-Orrhage In Cirrhosis. N. engl. J. Med., 2010, 362: 823-832. 20) De Franchis R., Revising Consensus in Portal Hypertensio N: Report of the Baveno V Consensus Workshop on Methodology of Diagnosis and Therapy in Portal Hypertension. J. Hepatol., 2010, 53: 762-7682010. 21) WGO Practice Guideline Esophageal Varicses, 2014]. 22) Order of the Ministry of Health of Kazakhstan No. 666 Appendix No. 3 of 06.11.2000. "Storage rules, blood transfusions, its components and drugs." Appendix No. 501 dated July 26, 2012 "Rules for storage, blood transfusion, its components and drugs." 23) Evidence-based Gastroenterology and Hepatology, Third Edition John WD McDonald, Andrew K Burroughs, Brian G Feagan and M BRIAN FENNERTY, 2010 BlackWell Publishing Ltd. 24) Great Directory of Medicines / Ed Ziganshina L.E. et al., M., 2011

Information

List of protocol developers with qualifying data:
1) Zhantalinova Nurzhamal Asenovna - D.M. Professor of the Department of Internship and Residency on RSP Surgery on PCV "KazNMU. S.D. Asphendiyarova. "
2) Menshikova Irina Lvovna - Ph.D., Associate Professor, Head of Endoscopy of the Department of Gastroenterology and Hepatology with Endoscopy Course, Chairman of the Endoscopic Society of the Republic of Kazakhstan at the Republican Association of Nutriciologists, Gastroenterologists and Endoscopists of the Republic of Kazakhstan. RGP on PFV "Research Institute of Cardiology and Internal Diseases."
3) Zhakupova Guljan Akhmetzhanovna - GKP on PVV "Burabayan Central District Hospital". Deputy Chief Doctor for Audit, Anesthesiologist - Resuscitator, Higher Categories.
4) Majitov Talgat Mansurovich - Doctor of Medical Sciences, Professor JSC "Medical University Astana" doctor clinical pharmacology Higher Categories, therapist of the highest category.

Indication for the absence of conflict of interest: not

Reviewers:Turgunov Ermek Maeramovich - Doctor of Medical Sciences, Professor, Surgeon of the Higher Qualification Category, RGP at PCB "Karaganda State Medical University" of the Ministry of Health of the Republic of Kazakhstan, Head of the Department of Surgical Diseases No. 2, an independent accredited expert of the Ministry of Health of the Republic of Kazakhstan.

Note Protocol Review Conditions: The revision of the Protocol 3 years after its publication and from the date of its entry into force or in the presence of new methods with the level of evidence.

Attachment 1

Appendix 2.

Appendix 3.

Appendix 4.

Appendix 5.

Attached files

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RCRZ (Republican Center for Health Development MD RK)
Version: Clinical Protocols MOR RK - 2018

Varicose veins of the veins of the esophagus without bleeding (i85.9), varicose veins of the veins of the esophagus with bleeding (i85.0)

Surgery

general information

Short description

Approved
Joint Commission for Medical Services
Ministry of Health of the Republic of Kazakhstan
from March 14, 2019
Protocol No. 58.

VRR FoodsHowel Expanded portoysystem collaterals that bind portal venous and systemic venous blood circulation are formed as a sequence of the development of portal hypertension, mainly in the submucosal shell of the lower part of the esophagus. As a result of portal crises, the pressure in the vessels of the portal system increases several times, leading to the ruptures of the walls of varicose veins in areas with reduced resistance due to dystrophic changes, which is a necessary condition for the development of bleeding 1.

1 Khanevich MD, KRUPKIN VI, Zherelov G.K. et al., bleeding from chronic gastroduodenal ulcers in patients with intrahepatic portal hypertension. - Novosibirsk: Science, 2003. - 198 p.

Input part

Protocol name: Bleeding from varicose-expanded veins of the esophagus

Code (s) μb-10:

Classification

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Differential diagnosis

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Treatment abroad

Treat treatment in Korea, Israel, Germany, USA

Get advice on medical examination

Treatment

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3. Endoscopic hemostasis
4. {!LANG-0bcf62c5e002d944fb734503e11bd120!}

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• {!LANG-bc45a0a87311f2f7494949a5711ea652!}< 60 мм рт ст при дыхании атмосферным воздухом или РаСО 2 >{!LANG-8888e92bad3310deadcd103fe4faaee8!}

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• {!LANG-9284d837b770223451eedeb44a9449be!}
• {!LANG-2c73d8d741bd8bc0c3b5bd195304ff3c!}< 14 баллов или класс В по Чайлду-Пью с активным кровотечением) после проведенной лекарственной или эндоскопической терапии (УД-A). Критерии для выявления пациентов высокого риска следует уточнить.
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  {!LANG-bfa4d1bd2051015ebec924dda586483c!}
  {!LANG-893cf35db67f00c549acd0e25464c977!}< 130 мэкв/л;
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1. {!LANG-200eadf938e5cc993c8dc827f26c9b50!}
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Information

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3. {!LANG-af713f6da0fd6a8490412dec710a6cfe!}
4. {!LANG-cbdab59af7bbba97da6ad7db081c334c!}

Indication for the absence of conflict of interest:{!LANG-df28b6f9df132e3be4db5b102433d3b1!}

Reviewers:

1. {!LANG-f90b042782c5774014d8935e9de34687!}
2. {!LANG-ec5520000cf4a4b71d448245d9b1d809!}

Note Protocol Review Conditions:{!LANG-64d77e9bb6518611ff2f685408d4d047!}

Attached files

Attention!

• By self-medication, you can apply irreparable harm to your health.
• The information posted on the MedElement website and in MEDElement mobile applications, "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Directory", cannot and should not replace a full-time doctor consultation. Be sure to contact medical facilities in the presence of any diseases or disturbing symptoms.
• The choice of medicines and their dosages should be stated with a specialist. Only a doctor can prescribe the necessary medicine and its dosage, taking into account the disease and the state of the patient's body.
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