The mainland is a large country with hepatitis B, with about 1 in 14 people infected with hepatitis B. However, many patients are not diagnosed and treated in a timely manner, which eventually leads to the development of cirrhosis.
According to incomplete statistics, the number of deaths due to liver cirrhosis in mainland China is as high as 400,000 every year.
However, the main cause of death in patients with cirrhosis is often their complication – esophageal and gastric variceal bleeding.
Cirrhosis is a chronic liver disease, often accompanied by esophageal and gastric varices in the late stage of the disease, which is prone to rupture and bleeding of esophageal and gastric varices, which poses a serious threat to the life of patients.
What are esophageal and gastric varices?
Esophageal and gastric varices are a common complication of advanced cirrhosis and are the thickening and tortuosity of the veins in the esophagus and gastric fundus.
In the early stage, it is earthworm-like, and as the disease progresses, serpentine blood vessels may slowly appear, and then develop into nodular changes, such as beads.
Esophageal and gastric varices tend to rupture after rupture, which can cause massive bleeding, which may induce shock and even lead to death.
Therefore, this disease is a more serious disease and needs to be paid attention to.
Normal esophagus VS esophageal and gastric varices
Among them, isolated gastric varices (IGV) are a relatively special type of gastric varices, which only exist in the stomach and are not accompanied by esophageal varices.
Large, isolated varicose veins in the fundus of the stomach
What are the manifestations of esophageal and gastric varices?
The main clinical manifestations are loss of appetite, abdominal distention, fatigue, pain in the liver area, jaundice, skin pigmentation, hepatosplenomegaly and ascites, etc., if esophageal and gastric variceal bleeding can occur a large amount of hematemesis, black stool or jam-like stool. Once the varicose veins rupture and bleed, the condition is dangerous, the mortality rate is high, and the prognosis is poor.
How to deal with the symptoms?
Esophageal and gastric varices are mainly treated with drugs to prevent ruptured bleeding and regular gastroscopy. Patients with mild disease can be treated with drugs to protect the liver and reduce portal venous pressure. Patients with moderate and severe esophageal varices need endoscopic examination and treatment to prevent bleeding from the first rupture and rebleeding and improve liver function. Bleeding that cannot be controlled by medical or endoscopic therapy should prompt surgery and other treatments.
How to choose endoscopic treatment?
1. Active bleeding: esophageal banding is mostly used for esophagus, and sandwich is used for gastric fundus.
2. Secondary prevention: esophageal ligation or combined sclerosis, and gastric fundus with sandwich tissue glue plugging.
3. Band ligation + sclerosis sequential treatment: this is the extension and expansion of the two treatment methods, the banding method acts on the varicose veins to ligate the mucosal layer and the submucosal layer of varicose veins, sclerosis can make up for the deficiency of banding, sclerosis can make the sclerosing agent enter the deep layer of the esophagus, eliminate the periesophageal, paraesophageal variceal veins and communicating veins, so the recurrence rate of varices is low.
4. Modified sandwich method: modified sandwich method for the treatment of gastric varicose veins (polylauricol + tissue gum + polylauricol (normal saline))
Case Study:
The patient was a male with a history of hepatitis B cirrhosis for 5 years and had 2 bloody stools within 1 month. No previous history of hypertension, diabetes, coronary heart disease, kidney disease, etc., no history of surgical trauma and drug allergy.
Diagnosis: decompensated cirrhosis of hepatitis (type B), upper gastrointestinal bleeding
Gastroscopic diagnosis: large isolated variceal bleeding in the gastric fundus (IGV1 type).
Treatment plan: nylon rope banding combined with tissue adhesive
Equipment: Aohua 4K ultra-high-definition endoscopic system AQ-300, therapeutic endoscope UHD-GT300T
First, a titanium clip is used for flow limiting, followed by a nylon rope snare, followed by endoscopic tissue glue injection.
During the intravariceal injection treatment, multi-point injection is carried out according to the condition of varicose veins, and the amount of tissue glue per point is 0.5~1.5 ml until the target blood vessel is fully occluded. When injecting glue, the latest hardener + tissue glue + hardener "sandwich" method is used to inject, and 2~4ml of hardener is flushed after each glue injection to avoid the hardening needle blocking the needle.
Is it cured after endoscopic treatment?
Will it not bleed again?
The answer is no.
Endoscopic treatment blocks the blood flow of esophageal and gastric varices, so as to achieve the purpose of preventing and/or treating bleeding, due to the continuous increase of portal venous pressure in liver cirrhosis, the regenerated capillaries of the esophageal and gastric fundus will gradually become thicker, so the patient is required to regularly recheck the gastroscopy and find that the thickened small blood vessels are treated in time, so as to avoid the risk of upper gastrointestinal bleeding.
Risk factors for esophageal and gastric variceal bleeding
- The incidence and recurrence of variceal bleeding is high (60%).
2. It is forbidden to eat coarse hard foods and crude fiber foods (such as nuts, whole grains, pancakes, etc.) in the daily diet.
3. Keep your stool smooth and do not exercise vigorously (playing ball, skipping rope, running, lifting heavy objects, etc.).
4. Actively cooperate with the treatment, maintain an optimistic mood, and ensure adequate sleep.
5. Follow the doctor's instructions to take the medicine, seek medical attention in time, and drink plenty of water after taking the medicine (avoid the medicine sticking to the esophageal wall).
Bibliography:
ZHANG Xiaobin, LIU Yingdi, WANG Juan, et al.Clinical diagnosis and treatment experience of isolated gastric varicose veins[J/CD].Chinese Journal of Gastrointestinal Endoscopy,2023,10(3): 167-172.