Pediatric surgery. Bleeding from dilated veins of the esophagus with portal hypertension (lecture notes)

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Pediatric surgery. Bleeding from dilated veins of the esophagus with portal hypertension (lecture notes)

Lecture notes, cheat sheets

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LECTURE No. 6. Bleeding from dilated veins of the esophagus with portal hypertension

The most severe and frequent complication of portal hypertension syndrome is bleeding from esophageal varices.

The cause of bleeding is mainly an increase in pressure in the portal system, peptic factor, as well as disorders in the blood coagulation system. Bleeding from dilated veins of the esophagus may be the first clinical manifestation of portal hypertension.

clinical picture

The first indirect signs of incipient bleeding are the child's complaints of weakness, malaise, nausea, and lack of appetite.

The body temperature rises. Sudden profuse hematemesis explains the sharp deterioration in the general condition of the child.

Vomiting is repeated after a short period of time. The child turns pale, complains of headache, dizziness, becomes lethargic, drowsy. A tarry, fetid stool appears.

Blood pressure drops to 80/40-60/30 mmHg. Art. When examining the blood, an increasing anemia is detected. The volume of circulating blood decreases sharply. After 6-12 hours, the severity of the condition is aggravated by intoxication as a result of the absorption of blood decay products from the gastrointestinal tract.

Differential diagnosis

The symptom of bloody vomiting in children can be caused not only by bleeding from varicose veins of the esophagus. To determine the cause of bleeding, anamnestic data are of primary importance.

If the child is admitted to the surgical clinic again due to bleeding in the syndrome of portal hypertension or he underwent surgery for this disease, then the diagnosis should not be in doubt.

It is more difficult to make a differential diagnosis if bleeding was the first manifestation of portal hypertension, since similar clinical symptoms occur in children with a bleeding stomach ulcer, with a hernia of the esophageal opening of the diaphragm, after severe nosebleeds (in children with Werlhof's disease and hypoplastic anemia).

Children who bleed from chronic gastric ulcers usually have a characteristic and long-term "ulcerative" history. Profuse bleeding is extremely rare.

Acute ulceration in children receiving long-term hormone therapy is also rarely complicated by bleeding (perforation is more common), but with an appropriate history, the diagnosis is usually not difficult.

In children with a hernia of the esophageal opening of the diaphragm, intermittent hematemesis is not abundant, the presence of a "black" stool is not always observed.

The general condition of the child worsens slowly over many months.

Children usually come to the clinic for mild anemia of unknown etiology. Clinical and radiological examination establish the presence of a hernia of the esophageal opening of the diaphragm.

The cause of bloody vomiting that occurs after nosebleeds is clarified with a detailed history taking and examination of the patient.

Treatment

In all cases of bleeding, therapeutic measures should begin with complex therapy.

Conservative therapy in some cases leads to a stop of bleeding. After the diagnosis is established, the child is given a transfusion of blood products.

The amount of blood administered depends on the general condition of the child, hemoglobin levels, red blood cell count, hematocrit and blood pressure.

Sometimes 200-250 ml is required, and in case of severe unstoppable bleeding, 1,5-2 liters of blood products are transfused on the first day.

It is necessary to resort to direct transfusions more often, combining them with transfusion of conservative blood. With a hemostatic purpose, concentrated plasma, vikasol, pituitrin are administered; inside designate aminocaproic acid, adroxon, thrombin, hemostatic sponge.

The child is completely excluded from feeding by mouth, prescribing parenteral administration of an appropriate amount of liquid and vitamins (C and group B).

The infusion is carried out slowly, since a sharp overload of the vascular bed can lead to re-bleeding. An ice pack should be placed on the epigastric region.

All children are prescribed broad-spectrum antibiotics, detoxification therapy. To combat hypoxia, humidified oxygen is constantly given through nasal catheters. In case of severe non-stopping bleeding, hormone therapy is included (prednisolone 1-5 mg per 1 kg of body weight of the child per day).

Patients with an intrarenal form of portal hypertension for the prevention of liver failure are prescribed a 1% solution of glutamic acid. With successful conservative treatment after 4-6 hours, the general condition improves somewhat.

The pulse and blood pressure are aligned and become stable. The child becomes more contact and active. All this suggests that the bleeding has stopped, but despite the improvement in the general condition, therapeutic measures should be continued.

In the absence of repeated bloody vomiting, the drip infusion apparatus is removed after 24-36 hours. The child begins to drink chilled kefir, milk, and cream. Gradually, the diet is expanded, on the 3rd-4th day, mashed potatoes, 10% semolina porridge, broth are prescribed, from the 8th-9th day - a common table.

Blood transfusions are carried out 2-3 times a week, the administration of vitamins is continued. The course of antibiotics is completed on the 10-12th day. Hormonal drugs are canceled, gradually reducing their dosage.

After the child's general condition improves, a detailed biochemical blood test, splenoportography and tonometry are performed to determine the shape of the portal system block in order to choose a rational method for further treatment.

Along with the specified conservative therapy, resort to an attempt to mechanically stop bleeding. This is achieved by introducing into the esophagus an obturating Blackmore probe, the inflated cuff of which presses the varicose veins of the esophagus.

Sedatives are prescribed to reduce the anxiety associated with the presence of the probe in the esophagus. If during this period the conservative measures taken have not led to a stop of bleeding, the question of urgent surgical intervention should be raised.

The choice of the method of surgical treatment at the height of bleeding primarily depends on the general condition of the patient and on whether the child was operated on for portal hypertension earlier or bleeding occurred as one of the first manifestations of portal hypertension.

In children who have previously been operated on for portal hypertension (splenectomy, creation of organ anastomoses), the operation is reduced to direct ligation of varicose veins of the esophagus or the cardia of the stomach. In patients who have not previously been operated on for portal hypertension syndrome, surgery should be aimed at reducing blood pressure. portae by reducing blood flow to esophageal varices.

This operation cannot be considered radical, and, moreover, it has a number of disadvantages.

At the time of suturing varicose veins, severe bleeding may occur, esophagotomy is sometimes complicated by infection of the mediastinal space, the development of purulent mediastinitis and pleurisy.

In order to reduce blood flow to varicose veins of the esophagus, a modified Tanner operation is used - suturing the precordial veins without opening the lumen of the stomach. The latter significantly shortens the time of surgical intervention (which is especially important during surgery at the height of bleeding), reduces the risk of infection of the abdominal cavity and minimizes the possibility of gastric suture failure.

In children who have not previously been examined for portal hypertension, surgical splenoportography and splenometry are performed to resolve the issue of the form of the disease and the extent of intervention. If an intrahepatic block is detected, in addition to suturing the cardiac part of the stomach, it is rational to simultaneously create organoanastomoses: suturing the omentum to the decapsulated kidney and to the left lobe of the liver after its marginal resection. In the presence of pronounced hypersplenism, the spleen is removed. The abdominal cavity is then closed tightly after antibiotics are administered.

Postoperative treatment is a continuation of the activities carried out before the operation. A child needs parenteral nutrition for 2-3 days. Then the patient begins to drink, gradually expanding the diet (kefir, 5% semolina, broth, etc.). By the 8th day, the usual postoperative table is prescribed. Hormonal therapy is canceled on the 4-5th day, the administration of antibiotics is completed on the 7-10th day after surgery. Blood and plasma transfusions are prescribed daily (alternating) until anemia is eliminated.

With a smooth postoperative period on the 14-15th day, the children are transferred to a pediatric clinic for further treatment.

Authors: Drozdov A.A., Drozdova M.V.

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