Aim. To determine prognostic criteria of variceal bleeding in patients with portal hypertension.Material and methods. There were 53 patients with portal hypertension and the threat of variceal bleeding from the esophagus and stomach without previous hemorrhage. Univariate and multivariate analysis was applied to determine prognostic criteria of the first bleeding. Patients with esophageal and gastroesophageal varices were analyzed separately. The following prognostic criteria were considered: dimensions of the veins, vasculopathy and gastropathy, liver function.Results. Incidence of hemorrhage was 72.7% in patients with esophageal varices grade 3, in case of vasculopathy — 80%. Child-Pugh class A was followed by incidence of hemorrhage near 12.5%, class B — 44%, C — 100%. MELD score < 9 was associated with bleeding rate 28.6%, 10—19 — 39.3%, over 20 scores — 100%. According to multivariate analysis consisting of Child—Pugh classification, in patients with < 11 scores 1-year incidence of bleeding was 13.3%, in case of MELD classification — 16.7%. The same values in patients with 11—16 scores were 77.8% and 31.3%, respectively. Analysis including both classifications (overall score over 16) was associated with incidence of hemorrhage up to 100%. Gastroesophageal varices grade 3 were associated with the risk of hemorrhage near 44.4% within 12 months, in case of vasculopathy — 60%, gastropathy — 37.5%. Incidence of hemorrhage in patients with Child-Pugh class A was 12.5%, class B — 44%, class C — 100%. In patients with MELD score < 9 bleeding rate was 28.6%, 10—19 scores — 39.3%, over 20 scores — 100%. According to multivariate analysis consisting of Child—Pugh classification, patients with gastroesophageal varices and less than 11 scores have the probability of hemorrhage near 15.4% within 12 months, in case of MELD score — 23%. The same values were 55.6% and 50%, respectively in case of 11—18 scores. In patients with more than 18 scores incidence of hemorrhage was 75% considering Child-Pugh classification and 100% for the MELD classification.Conclusion. The group of patients with threat of bleeding within 12 months was determined that makes possible a differentiated approach to patients who for need primary prevention of bleeding.
Äèàãíîñòèêà è ëå÷åíèå áîëüíûõ ñ ïîðòàëüíîé ãèïåðòåíçèåé Цель: улучшить результаты лечения больных с портальной гипертензией и кровотечением из варикозно расширенных вен пищевода и желудка совершенствованием лечебно-диагностической тактики. Материал и методы. Анализировали результаты лечения 440 пациентов с варикозно расширенными венами пищевода и желудка. У 367 больных портальная гипертензия была обусловлена циррозом печени и у 73-внепеченочным портальным блоком. Эндоскопическое лигирование вен пищевода выполнено 114 пациентам, склерозирование вен пищевода-196 больным, эндоскопическое лигирование вен желудка I типа-62, склерозирование вен желудка II типа-44. Спленэктомию выполнили 23 пациентам с изолированным варикозным расширением вен дна желудка. Результаты. Для остановки кровотечения из варикозно расширенных вен пищевода и желудка из эндоскопических вмешательств наиболее эффективной является склеротерапия. Применение отсроченного эндоскопического лигирования и склерозирования после первичного гемостаза зондом-обтуратором позволяет улучшить показатели применения методов и увеличить стойкий гемостатический эффект склеротерапии в пищеводе с 58,3 до 72,1%, в желудке-с 30 до 77,8%, лигирования в пищеводе-с 60 до 91,7%; в желудке-92,9%. В профилактике рецидива кровотечения из варикозно расширенных вен пищевода и желудка в плановом порядке гемостатический эффект склеротерапии в пищеводе составил 93,9%, в желудке-100%; лигирования в пищеводе-84,5%, в желудке-91,7%. Эндоскопическое лигирование имеет преимущества в профилактике первого кровотечения как в пищеводе, так и в желудке. У больных с изолированным варикозным расширением вен дна желудка преимуществом обладает спленэктомия. Выживаемость и гемостатический эффект в течение 3 лет составили 100%. Заключение. Результаты работы свидетельствуют о необходимости расширенной диагностики для принятия решения о возможности эндоскопических вмешательств при выявлении различных типов варикозно расширенных вен. Клю че вые сло ва: портальная гипертензия, варикозное расширение вен пищевода и желудка, эндоскопическое лигирование, эндоскопическое склерозирование.
Ten patients with cirrhosis and portal hypertension successfully underwent balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices. As an example, the paper presents a clinical observation demonstrating the use of a BRTO endovascular procedure. A spontaneous functioning gastrorenal shunt was distinctly observed during multidetector computed tomography in a patient with Child-Pugh А cirrhosis of alimentary-toxic and viral etiology, as well as portal hypertension and associated gastric varices (Type 2, Grade 3) with frequent recurrent bleeding. The presence of a shunt with no indications for TIPS procedure, as well as the inexpediency of a shunt surgery (taking positive immunoblot into account), enabled the formulation of indications for BRTO. This factor ensured regression of gastric varices, as well as eliminated the threat of recurrent gastric bleeding.
Clinical case demonstrates successful treatment of a pregnant woman, who had multiple giant splenic artery aneurysms with a high risk of spontaneous rupture. Pregnancy proceeded along with hereditary thrombophilia, thrombosis and cavernous transformation of the vena cava, extrahepatic portal hypertension, esophageal and gastric varices II–III. The surgical and obstetric tactics, surgical intervention, appropriate salvage and multidisciplinary pregnancy follow-up ensured a successful Cesarean delivery at 38 weeks, saving the life of the child and mother.
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