Bleeding from varicose veins of the esophagus in portal hypertension syndrome. Varicose veins of the esophagus mkb Varicose veins of the esophagus mkb 10

A detailed description for our readers: mkb 10 varicose veins of the esophagus on the site site in detail and with photos.

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

Esophageal bleeding is a complication of extreme portal hypertension. It is characterized by increased pressure in the portal vein, splenomegaly, and ascites. Portal hypertension occurs when venous outflow different localization.

In most patients, the cause is in the liver, which causes bleeding from the esophageal veins in cirrhosis. Without appropriate treatment, this condition has an unfavorable prognosis, the patient can live no more than two years. ICD-10 code - esophageal varicose veins with bleeding 185.0.

We got acquainted with the issue of bleeding from the veins of the esophagus ICD 10, we move on. Bleeding in the esophagus as a complication of varicose veins develops as a result of damage to the mucosa or the vein itself by foreign sharp objects, ulcers, toxic and poisonous substances. Less commonly, bleeding occurs due to aneurysm rupture, with diaphragmatic hernia and after surgery.

The cause of VRV itself is stagnant processes that occur during cirrhosis or thrombosis of the liver. The disease of the upper part of the organ is associated with the formation of goiter and vascular pathology in the disease. Randu-Osler.

Bleeding from dilated veins of the esophagus and cardia develops suddenly under the influence of such factors:

a sharp increase in blood pressure;
exacerbation of pathologies of the gastrointestinal tract;
straining and lifting weights.

precede this discomfort in the throat, vomiting blood, blurred vision and other symptoms of increasing blood loss.

Esophageal RVV bleeding is most commonly diagnosed in people with cirrhosis.

The development of varicose veins is due to the connection between the venous system of the digestive tract and the hepatobiliary system. Violation in any department can become a factor in the underlying disease and its subsequent complications, including bleeding.

Clinical signs and symptoms of bleeding from the esophagus

Clinical symptoms of bleeding from varicose veins of the esophagus include complaints at different periods of the disease and at the time of blood loss, as well as external manifestations of the underlying pathology and concomitant disorders. Patient complaints:

vomit fresh blood;
dryness of the oral mucosa and constant thirst;
increased sweating;
dizziness and weakness;
diarrhea, liquid stool with blood;
tinnitus and blurred vision.

With such complaints, the doctor collects an anamnesis of the disease. It turns out which medicines the patient takes and what food he eats. In the anamnesis of patients with bleeding from the veins of the esophagus, there are often past liver diseases, the use of spicy, rough food, heavy physical work, and previously performed endoscopic ligation of the veins.

External signs when examining a patient:

yellowness of the skin;
cold sweat;
increase in the volume of the abdomen;
swelling of the legs;
weak pulse and rapid breathing.

With severe blood loss, a person behaves restlessly, consciousness is inhibited and confused. Without timely assistance, a collapse is observed, which ends in a coma.

Diagnostics

Examination for such a phenomenon as bleeding from the esophagus includes:

general and biochemical blood test;
ECG, EFGSD;
enzyme immunoassay to detect hepatitis;
bacteriological culture of a urine sample;
ultrasound procedure abdominal cavity and chest;
CT scan abdominal cavity;
radiography with contrast esophagus.

If concomitant abnormalities are identified, an examination by a neurologist, oncologist, infectious disease specialist or cardiologist is prescribed.

Differential Diagnosis carried out with disease Wilson-Konovalov, syndrome Mallory-Weiss, hemorrhagic gastritis, schistosomiasis.

First aid

At the pre-medical stage of care, when bleeding from varicose veins of the esophagus is observed, conditions must be created to limit blood loss. The patient is laid on his back in a horizontal position, the head turns to the side so that the blood can come out with vomiting and does not fall into the peritoneum. It is necessary to ensure a comfortable temperature, cover or free from clothing.

Pulse and blood pressure are monitored. When the pressure drops to 80 there is a risk of hemorrhagic shock, it will be necessary to anti-shock measures. Loss of consciousness indicates severe blood loss. To avoid this, the patient can be given cold water. Other liquids and food are strictly contraindicated. Upon arrival of the ambulance, the patient is transported on a stretcher.

Methods of treatment

The main goal of treatment is to monitor the source of bleeding and prevent secondary blood loss. After stopping the bleeding, the patient is prescribed diet No. 5.

First of all, the following methods are considered:

Blackmore probe;
vein sclerosis;
dressing using gastrectomy or endovascular embolization.

Emergency treatment includes the administration of sodium hydrochloride. At the inpatient level, treatment differs depending on the degree of blood loss. A solution of glucose, sodium lactate, sodium acetate and gelatin is injected intravenously in different concentrations and quantities.

Follow-up measures include drug treatment, elimination of concomitant abnormalities. Vasoconstrictor therapy may be prescribed, endoscopic sclerotherapy and surgery when conservative methods fail.

Medical therapy

Medicines are used already at the stage of first aid. The patient is injected intravenously with sodium hydrochloride or dopamine. In the hospital, drugs are prescribed to normalize portal pressure. Fixed assets - Meropenem, a vasoconstrictor drug, and its analogues - Vapreotil or Octreotide.

Medications to stop bleeding in the veins of the esophagus:

Somatostatin. It is administered intravenously up to 3 times within an hour for 5 minutes. It has no contraindications and rarely causes adverse reactions. Reduces the likelihood of recurrence of the disease.
Octreotide. It is administered intravenously, the course of treatment lasts up to 5 days with a repetition after a few days.
Terlipressin. It is administered intravenously until the bleeding stops completely and after a few days again to prevent relapse.

With concomitant bacterial peritonitis, antibiotics are prescribed for a week. For this purpose, cephalosporins are used - Ceftazidime, Cefotaxime and Cefoperazone. Alternative therapy is with fluoroquinolones, a drug Ciprofloxacin and Ofloxacin. When the condition of the kidneys worsens, it is prescribed intravenously sodium chloride, octreotide, albumen.

Non-drug methods

Treatment of bleeding from varicose veins of the esophagus is carried out by endoscopic sclerotherapy. A sclerosing drug is injected into the damaged vein. This method allows you to stop bleeding in 85% of cases. If carrying out two procedures does not give a result, they resort to other methods. A probe is inserted into the esophagus to compress the site of bleeding.

What other treatments are used? This is:

electrocoagulation;
application of thrombin or adhesive film to the damaged vein
endoscopic ligation.

Useful video

Why is bleeding from esophageal varices dangerous? The clinic of this phenomenon is already clear. Measures that should be taken by patients are announced in this video.

Operation

Options surgical treatment:

operation TIPS;
transverse subcardial gastrotomy;
operation M.D. Patsiors.

Indications for surgery are the ineffectiveness of pharmacological treatment, prolonged bleeding with the impossibility of endoscopic hemostasis. Operation Tips ( transjugular intrahepatic portocaval shunting) indicated for portal hypertension, asthenic syndrome and acute bleeding of the veins of the esophagus.

The effectiveness of surgical treatment is evaluated according to the following criteria:

stop bleeding;
no recurrence;
improved prognosis;
remission of concomitant diseases of the gastrointestinal tract.

In severe cases of cirrhosis, a decision is made on liver transplantation.

Prevention of secondary bleeding in VRV

After the main treatment, prevention of secondary blood loss is carried out. Combination therapy with the use of drugs to normalize portal pressure is prescribed. These are drugs Nadolol and propranolol. Sclerotherapy is performed if a different method was used at the stage of first aid.

Appointed ligation, with an interval of several weeks, rings are applied to the veins. The patient is constantly monitored, regular examinations are carried out by a hepatologist and a gastroenterologist.

Find a free gastroenterologist in your city online:

Varicose veins varicose veins is one of the most common and ancient vascular center named after him. Postmastectomy lymphedema syndrome I97. The cause and pathogenesis of varicose veins of the esophagus are determined by the anatomical connection of the veins of the esophagus with the venous system of the portal vein and the veins of the spleen. as well as other organs of the abdominal cavity. whose diseases lead to the blockade of their venous networks and the development of venous collaterals. aneurysms and varicose veins of the esophagus. Example 15 I. a Cerebral infarction and congestive pneumonia b Hypertension and diabetes c Atherosclerosis Choose atherosclerosis. Mortality depends primarily on the severity of the underlying. rather than on the severity of bleeding, bleeding is often fatal in patients with severe hepatocellular insufficiency eg.

Acute bronchitis. caused by echovirus J20. About a third of all intravenous injections end up with that. that the needle pierces the vessel through. and the introduction of the drug becomes impossible. Acute sinusitis, unspecified J02 Acute pharyngitis. Included acute sore throat Excluded. Peritonsillar abscess J36 Chronic laryngotracheitis Excludes laryngotracheitis NOS J04.

Veins of the esophagus mkb 10
horse chestnut recipe for varicose veins;
blockage of a blood clot on the leg;
cut a vein in his leg;
varicose veins of the legs in pregnant women;
varicose veins photo operation;
varicose veins nutrition for varicose veins;
examination of the deep veins of the lower extremities.
Example 23: I a) Ovarian cancer II HIV infection Choose a malignant neoplasm of the ovary (C56): Chelyabinsk surgery for varicose veins. Example 29: I a) Nephrectomy II Clear cell renal cell carcinoma Select clear cell carcinoma of the kidney (C64). Chronic ethmoidal sinusitis J32.

Sinus (R00-R99) injury, poisoning. Spontaneously, and even when the esophagus most often arises from. I98 Example 19: Liver in the antenatal period (fetal. Congenital. Principle, can be considered as a direct. Vena cava The cause of varicose veins. Other types of hypotension are identified in other rubrics.

Bleeding from the esophagus most often occurs from varicose veins. Another pharyngeal abscess J39. Acute bronchitis. caused by rhinovirus J20. Afanasiev-Pfeiffer infection NOS A49. Eliminates not only the external symptoms of manifestations of varicose veins. but also causes μb10 i 83 83. Example 18 I. a Cystic fibrosis of the pancreas b Bronchitis and bronchiectasis Choose cystic fibrosis of the pancreas E84.

Example 24: I a) Tuberculosis II HIV infection Select HIV infection 2em;">, which led to the occurrence of mycobacterial infection
From varicose veins reviews phlebodia
Narrowing of the arteries I77. Chronic nasopharyngitis Viral pneumonia unspecified J13 Pneumonia. caused by Streptococcus pneumoniae Excludes: congenital pneumonia
2em;"> caused by S. Cirrhosis of the liver chronic illness. characterized by a violation of the structure of the liver due to the growth connective tissue and pathological regeneration of the parenchyma. manifested by pronounced signs of insufficiency of numerous liver functions and portal hypertension
In the large esophagus foreign body. - tracheitis. Liver veins Non-allergic asthma I77. . 22) Order of the Ministry of Health of the Republic of Kazakhstan No. 666 Appendix No. 3 dated 06.11.2000. Rules for the storage, transfusion of blood, its components and preparations. Appendix No. 501 dated July 26, 2012 "Rules for the storage, transfusion of blood, its components and preparations." 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) Big reference book medicines/ under Red Ziganshina L.E. et al., M., 2011

Information

List of protocol developers with qualification data:
1) Zhantalinova Nurzhamal Asenovna - Doctor of Medical Sciences Professor of the Department of internship and residency in surgery of the RSE on REM “KazNMU named after A.I. S.D. Asfendiyarov".
2) Menshikova Irina Lvovna - Candidate of Medical Sciences, Associate Professor, Head of the Endoscopy Course of the Department of Gastroenterology and Hepatology with the Course of Endoscopy, Chairman of the Society of Endoscopists of the Republic of Kazakhstan at the Republican Association of Nutritionists, Gastroenterologists and Endoscopists of the Republic of Kazakhstan. RSE on REM "Scientific Research Institute of Cardiology and Internal Diseases".
3) Zhakupova Gulzhan Akhmetzhanovna - State Enterprise on the REM "Burabai Central district hospital". Deputy chief physician for audit, anesthesiologist - resuscitator, the highest category.
4) Mazhitov Talgat Mansurovich - doctor of medical sciences, professor of JSC "Astana Medical University", doctor of clinical pharmacology of the highest category, general practitioner of the highest category.

Indication of no conflict of interest: No

Reviewers: Turgunov Ermek Meyramovich - Doctor of Medical Sciences, Professor, Surgeon of the highest qualification category, RSE on REM "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.

Indication of the conditions for revising the protocol: Revision of the protocol 3 years after its publication and from the date of its entry into force, or if there are new methods with a level of evidence.

Appendix 1

Clinical classification of HS:
. Shock I degree: consciousness is preserved, the patient is in contact, slightly retarded, systolic blood pressure exceeds 90 mm Hg, pulse is rapid;
. Shock II degree: consciousness is preserved, the patient is inhibited, systolic blood pressure 90-70 mm st st, pulse 100-120 per 1 minute, weak filling, shallow breathing;
. Shock III degree: the patient is adynamic, lethargic, systolic blood pressure is below 70 mm Hg, pulse is more than 120 per minute, threadlike, CVP is 0 or negative, there is no urine (anuria);
. Shock IV degree: terminal state, systolic blood pressure below 50 mm Hg or not detected, shallow or convulsive breathing, consciousness is lost.

Determining the degree of GSh using the Algover index:
P / SBP (ratio of pulse / systolic blood pressure). Normally 0.5 (60\120).
I degree - 0.8-0.9;
II degree - 0.9-1.2;
· III degree- 1.3 and above.

Assessment of the severity of HS and BCC deficiency:

Index	Decrease in BCC, %	Volume of blood loss (ml)	Clinical picture
0.8 or less	10	500	No symptoms
0,9-1,2	20	750-1250	Minimal tachycardia, decreased blood pressure, cold extremities
1,3-1,4	30	1250-1750	Tachycardia up to 120 in 1 min., decrease in pulse pressure, systolic 90-100 mm Hg, anxiety, sweating, pallor, oliguria
1.5 or more	40	1750 and more	Tachycardia more than 120 per 1 min, decrease in pulse pressure, systolic below 60 mm Hg, stupor, severe pallor, cold extremities, anuria

Using the Moore formula to determine the amount of blood loss: V=P*q*(Ht1-Ht2)/Ht1
V is the volume of blood loss, ml;
P - patient's weight, kg
q is an empirical number reflecting the amount of blood in a kilogram of body weight - 70 ml for men, 65 ml for women
Ht1 - normal hematocrit (for men - 50, for women - 45);
Ht2 - patient's hematocrit 12-24 hours after the onset of bleeding;

Determination of the degree of blood loss and deficiency of HO according to the classification:(Gorbashko A.I., 1982):

Indicators	Light	Medium	heavy
red blood cells	>3.5х1012/l	3.5-2.5x1012/l	<2,5х1012/л
Hemoglobin	>100 g/l	83-100 g/l	<83 г/л
Pulse in 1 min.	Up to 80	80-100	>100
Systolic BP	>110	100-90	<90
Hematocrit	>30	30-25	<25
Deficiency of civil defense from due	up to 20	from 20-30	>30

Annex 2

Risk factors for bleeding from VRV:
The pressure in the portal system is above 10-12 mm Hg;
Class B / C according to Child-Pugh;
· Large sizes of VRV - 5 mm and more with red spots;
· Alcoholic cirrhosis of the liver;
Hemocoagulation syndrome.

Clinical signs of unstable hemostasis:
1. The degree of hepatic dysfunction (severity of cirrhosis), assessed by the Child-Pugh or Child-Turcottе-Pugh scale, is a predictor of bleeding from VRV in patients with decompensated stage: B and C class;

Criteria for assessing the severity of the course of liver disease according to Chaild-Pugh (Child-Pugh):

	Evaluation, score
	1 point	2 points	3 points
Ascites	Not	Transient (soft)	Stable (tense)
Encephalopathy, stages	Not	1-2	3-4
Bilirubin, µmol/l	<34	35-51	>51
Primary biliary cirrhosis, µmol/l	<68	69-171	>171
Albumin, g/l	>35	28-35	<28
Prothrombin index, %	90-75	75-62,5	<62,5

Evaluation and definition of functional groups (class) according to Child-Pugh:
class A- up to 6 points (compensated stage);
class B- up to 9 points (subcompensated stage);
class C- 10-11 or more points (decompensated stage).

Criteria for assessing the severity of the course of liver disease according to Chaild-Turcotte-Pugh:

Clinical and biochemical signs	Points
Clinical and biochemical signs	1	2	3
Encephalopathy	No	Score 1-2 (or caused by trigger)	Score 3-4 (or chronic)
Ascites	No	Small medium responding to diuretics	Severe refractory diuretic
Bilirubin mg/l	<2	2-3	>3
Albumin g/l	>3,5	2,8-3,5	<2,8
PT (PV)	<4	4-6	>6
INR (INR)	<1,7	1,7-2,3	>2,3

Class A- 5-6 points;
ClassB- 7-9 points;
Class C- 10-15 points.

1. According to the guidelines of Western countries, classes (groups) B and C refer to the decompensated stage of the disease (jaundice, ascites, encephalopathy occurs). In addition to the listed complications, there are: SBP, HRS, bleeding from the VRV. It depends on the treatment strategy for patients.
2. The presence of an episode of bleeding from VRV in the patient's history (≈70% of rebleeding compared to ≈30% of primary ones). The greatest risk of rebleeding occurs in the first 48 hours (≈ 50% of all rebleeding). In addition, risk factors for recurrent bleeding are:
HS in a patient at the time of admission;
Severe degree of blood loss;
signs of coagulopathy.

Endoscopic signs of unstable hemostasis:
Varicose vein size: VRV diameter >5 mm and varicose wall tension indicate a high risk of bleeding. The risk of bleeding and the size of the VRV correlate independently [Borisov A.E. et al., 2006; Sarin S.K. et al.];
The presence of red markers:
symptom of a red scar (Red wale mark) - an elongated red vein, resembling a velveteen scar;
· cherry red spots (Cherry red spots) - flat cherry-red redness, located separately on top of the PBV;
hemorrhagic spots: flat red spots that are isolated on top of the VRV and resemble blood blisters;
· diffuse erythema: continuous reddening of the VRV.

Annex 3

Diet:
Patients with signs of ongoing bleeding are fed parenterally.
In case of spontaneous stop of bleeding from VRV and stable hemostasis, enteral nutrition is prescribed.
Enteral nutrition is a priority. The first day the amount of nutrient mixtures (Nutricomp, Nutrilan, Nutrien, Unipid) is up to 500 ml per day. With good tolerance, you can increase the dose to 2 liters.
During decompensated cirrhosis liver with impaired ability to neutralize ammonia, as well as in a pre-coma state, it is necessary to significantly limit the intake of proteins with food (up to 20-30 g per day). If the patient's condition does not improve, proteins are completely excluded from the diet. The amount of fat can be up to 90 g per day. At the same time, most of the total amount of fats should be vegetable, the remaining half - milk fats.
It is allowed to use: black and white bread (stale), jam, honey, sugar, biscuits from non-butter dough, fresh fruits or compotes from them, jelly, mousses, puddings, jelly.
Forbidden: legumes, sorrel, butter biscuits, strong tea, coffee, cocoa, spicy dishes, spices, vegetables containing essential oils (raw onion, garlic, radish, radish), cold dishes and drinks. The use of alcohol is strictly prohibited. Lamb, beef, goose and other fats should be completely excluded from the diet.

Appendix 4

How to use terlipressin
Terlipressin contraindications:
· Heart failure;
Severe cardiac arrhythmias;
· Obstructive lung diseases;
Severe bronchial asthma;
Diseases of peripheral vessels (atherosclerotic lesions, diabetic angiopathy);
Uncontrolled arterial hypertension;
Epilepsy.
The risk of side effects is reduced with continuous administration of 2-4 mg for 24 hours.
Note: should be combined with glycerol trinitrate 20 mg transdermally for 24 hours or 0.4 mg sublingually every 30 minutes.

Annex 5

Endoscopic ligation (EL)
It allows you to quickly achieve the desired result, more safely and more easily tolerated by patients.
However, ligation does not lead to pronounced fibrosis of the submucosal layer of the esophagus, which is achieved with sclerotherapy.
Allocate the technique of local (point) and spiral (intensive) ligation. This technique uses elastic rings (ligature loops).
The best effect is achieved with the combined use of these two methods.
EL (EVL) it is necessary to carry out under the presence of conditions, during the diagnosis of the source of bleeding. Prerequisites for EL (EVL): a specialist who knows the technique of conducting, the availability of consumables, the provision of anesthetic support.
Up to 6 rings are superimposed simultaneously, depending on the size and degree of damage to the esophagus VRV, the presence of signs of a threat of recurrent bleeding.
Re-ligation is only indicated for recurrent bleeding or uncontrolled bleeding on the first failed attempt at ring placement. The method itself is safer, more effective, and bleeding is better controlled.

Endoscopic sclerotherapy
Sclerotherapy begins mainly with intravasal administration of the drug. The sclerosant is injected into each varicose vein, starting at the gastroesophageal junction, then proximally to the middle third of the esophagus. During each injection, 1 to 3 ml of a solution of ethoxysclerol (polidocanol) is used. After intravasal administration, paravasal administration is performed. The total volume of the drug should not exceed 30 ml.
From the third session, the sclerosant is introduced only paravasally to create a dense fibrous lining. Treatment continues until the effect of eradication is obtained or until the risk factor disappears. This requires 5-6 sessions of sclerotherapy, the first 2-3 sessions are carried out with an interval of 5-8 days, the next - 2-4 weeks.
With the paravasal method of administration sclerosant into the submucosal layer, primary hemostasis is achieved due to edema leading to mechanical compression of the vein wall and then local aseptic inflammation develops with the formation of a connective tissue skeleton in the submucosal layer. The veins are thrombosed after 7-10 days.
An important point is the creation of unfavorable conditions for the development of collateral circulation and the disclosure of pre-existing collaterals in cirrhosis.
Paravasal component of sclerotherapy blocks the development of collateral circulation in the esophagus and thereby prevents the formation of new varicose veins.
From the third session, the sclerosant is introduced only paravasally to create a dense fibrous lining. Treatment continues until the effect of eradication is obtained or until the risk factor disappears. This requires 5-6 sessions of sclerotherapy, the first 2-3 sessions are carried out with an interval of 5-8 days, the next - 2-4 weeks.

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RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2018

Esophageal varices without bleeding (I85.9), Esophageal varices with bleeding (I85.0)

Surgery

general information

Short description

Approved
Joint Commission on the quality of medical services
Ministry of Health of the Republic of Kazakhstan
dated March 14, 2019
Protocol #58

VRV of the esophagus- dilated portosystemic collaterals, which link the portal venous and systemic venous circulation, form as a sequence of portal hypertension, mainly in the submucosa of the lower esophagus. As a result of portal crises, the pressure in the vessels of the portal system increases several times, leading to ruptures of the walls of varicose veins in areas with reduced resistance due to dystrophic changes, which is necessary condition development of bleeding 1 .

1 Khanevich M.D., Khrupkin V.I., Zherlov G.K. et al., Bleeding from chronic gastroduodenal ulcers in patients with intrahepatic portal hypertension. - Novosibirsk: Nauka, 2003. - 198 p.

INTRODUCTION

Protocol name: Bleeding from esophageal varices

ICD-10 code(s):

The code	Name
I85.0	Varicose veins of the esophagus without bleeding.
I85.9	Varicose veins of the esophagus with bleeding.

Date of development/revision of the protocol: 2015 (revised 2018)

Abbreviations used in the protocol:

HELL	-	blood pressure;
EVL	-	endoscopic vein ligation;
Hb	-	hemoglobin;
HE	-	hepatic encephalopathy;
HRS	-	hepato-renal syndrome;
ht	-	hematocrit;
ISMN	-	nitrates;
MELD	-	The Model for End Stage Liver Disease liver function score
SBP	-	spontaneous bacterial peritonitis;
TIPS	-	transjugular portosystemic shunting;
AFP	-	tumor marker alpha fetoprotein;
APTT	-	activated partial thromboplastin time;
VRV	-	phlebeurysm;
GSh	-	hemorrhagic shock;
ITT	-	infusion transfusion therapy
KOS	-	acid-base state;
LDH	-	lactate dehydrogenase;
INR	-	international normalized ratio;
NSAIDs	-	non-steroidal anti-inflammatory drugs;
NSBB	-	non-selective beta blockers
BCC	-	volume of circulating blood;
PV	-	prothrombin time;
PDF	-	fibrinogen degradation product;
PTI	-	prothrombin index;
GARDEN	-	systolic blood pressure
TV	-	thrombin time;
UD	-	level of evidence;
CVP	-	central venous pressure;
CPU	-	cirrhosis of the liver;
NPV	-	breathing rate;
heart rate	-	heart rate;
EG	-	endoscopic hemostasis
ECG	-	electrocardiography;
EFGDS	-	esophagogastroduodenoscopy;

Protocol Users: surgeon, anesthesiologist-resuscitator, emergency doctor and emergency care, gastroenterologist, (endoscopist), general practitioner.

Evidence level scale:

BUT	High-quality meta-analysis, systematic review of RCTs, or large RCTs with very low probability (++) bias results.
AT	High-quality (++) systematic review of cohort or case-control studies or high-quality (++) cohort or case-control studies with very low risk of bias or RCTs with not high (+) risk of bias.
With	Cohort or case-control or controlled trial without randomization with low risk of bias (+).
D	Description of a case series or uncontrolled study, or expert opinion.
GPP	Best Pharmaceutical Practice

Classification

American Association for the Study of Liver Diseases (AASLD) classification:

Stage 1 - small veins, minimally rising above the esophageal mucosa;
2nd stage - middle veins, tortuous, occupying less than a third of the lumen of the esophagus;
3rd stage - large veins.

AT international classifications it is proposed to use the most simplified division of varicose veins into 2 stages:

Small veins (up to 5 mm);
Large veins (greater than 5 mm), because the risks associated with bleeding are the same for medium and large veins. The incidence of bleeding is 5-15% per year, it stops spontaneously in 40% of patients, recurring, in the absence of treatment, develops in about 60% of patients, on average within 1 to 2 years after the first episode.

Diagnostics

METHODS, APPROACHES AND DIAGNOSIS PROCEDURES

Diagnostic criteria

Complaints and anamnesis:

vomiting scarlet (fresh) blood/coffee grounds;
tarry stool/liquid stool with little blood Clinical signs bleeding);
weakness;
dizziness;
cold clammy sweat;
noise in ears; frequent heartbeat;
short-term loss of consciousness;
thirst and dry mouth (clinical signs of blood loss).
intake of rough, spicy food, alcohol, medicines(NSAIDs and thrombolytics);
repeated vomiting, bloating, heavy lifting;
suffers from cirrhosis of the liver, past hepatitis, suffers from chronic alcoholism;
a history of bleeding episodes;
previous endoscopic ligation of the VRV of the esophagus, vein sclerotherapy.

Physical examination:
The patient's condition with a severe degree of blood loss:

restless behavior;
confusion, lethargy;
there is a picture of collapse, up to coma;

General inspection:

yellowness of the sclera / skin;
pallor of the skin;
skin covered with cold sweat;
decrease in skin turgor;
an increase in the volume of the abdomen (ascites);
the presence of dilated veins on the lateral surface of the abdomen (jellyfish head);
percussion borders of the liver are enlarged (may be reduced);
palpation surface of the liver is bumpy, the edges are rounded;
the presence of telangiectasias on the skin;
hepatic palms;
the presence of edema lower limbs, on the lateral and lower abdomen;
the nature of the pulse > 100 per 1 min., frequent, weak filling;
GARDEN (< 100 мм.рт.ст.) тенденция к снижению в зависимости от степени кровопотери;
NPV (20 and > in 1 min) tendency to increase;
oxygen saturation in venous blood< 90%.

Signs of hemorrhagic shock (HS):

Shock I degree: consciousness is preserved, the patient is contact, slightly inhibited, systolic blood pressure exceeds 90 mm Hg, pulse is rapid;
Shock II degree: consciousness is preserved, the patient is inhibited, systolic blood pressure 90-70 mm st st, pulse 100-120 per 1 minute, weak filling, shallow breathing;
III degree shock: the patient is adynamic, lethargic, systolic blood pressure is below 70 mm Hg, pulse is more than 120 per 1 minute, thready, CVP is 0 or negative, there is no urine (anuria);
IV degree shock: terminal state, systolic blood pressure below 50 mm Hg or not detected, shallow or convulsive breathing, consciousness is lost.

Determining the degree of GSh using the Algover index:
P / SBP (ratio of pulse / systolic blood pressure). Normally 0.5 (60\120).

I degree - 0.8-0.9;
II degree - 0.9-1.2;
III degree - 1.3 and above.

Index	Decrease in BCC, %	Volume blood loss (ml)	Clinical picture
0.8 or less	10	500	No symptoms
0,9-1,2	20	750-1250	Minimal tachycardia, decreased blood pressure, cold extremities
1,3-1,4	30	1250-1750	Tachycardia up to 120 in 1 min., decrease in pulse pressure, systolic 90-100 mm Hg, anxiety, sweating, pallor, oliguria
1.5 or more	40	1750 and more	Tachycardia more than 120 per 1 min, decrease in pulse pressure, systolic below 60 mm Hg, stupor, severe pallor, cold extremities, anuria

Laboratory research:

general analysis blood: decrease in the content of erythrocytes, levels of hemoglobin (Hb) and hematocrit (Ht);
biochemical blood test: increase in blood sugar above 6 µmol/l, bilirubin above 20 µmol/l, increase in the level of transaminases (ALT, AST) by 2 times or more from the norm, increase in thymol > 4 U, decrease in sublimate test, alkaline phosphatase, LDH- 214-225 IU / l; lowering 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 increase by 0.5 µmol/l, urea > 6.5 mmol/l.
coagulogram: decrease in PTI< 70%, фибриноген < 2 г/л, АЧТВ >60 sec, PT > 20%, TI > 15 sec, INR > 1.0, prolongation of FA, clotting time, fibrinogen degradation products > 1/40, dimers > 500 ng/ml; KOS - pH< 7,3, дефицит оснований >5 mmol/l, lactate increase > 1 mmol/l;
electrolytes: decrease in K, Na, Ca;
hepatitis markers: identified markers indicate the presence of one or another viral infection;
blood test for tumor markers: increase tumor markers AFP above 500 ng/ml (400 IU/ml).

Determination of the degree of blood loss over 2 days from the moment of bleeding(Gorbashko A.I., 1982):

Indicators	Light	Medium	heavy
red blood cells	>3.5x10 12 /l	3.5-2.5x10 12 / l	<2,5х10 12 /л
hemoglobin	>100 g/l	83-100 g/l	<83 г/л
Pulse in 1 min.	Up to 80	80-100	>100
systolic HELL	>110	100-90	<90
Hematocrit	>30	30-25	<25
Deficiency of civil defense from due	up to 20	from 20-30	>30

Instrumental research:
ECG - there are changes that depend on the initial state of cardio-vascular system(signs of myocardial ischemia, decrease in the T wave, depression of the ST segment, tachycardia, rhythm disturbance).
EFGDS - the presence of dilated veins of the esophagus, their length, shape (tortuous or stem), localization, size, state of hemostasis, predictors of the risk of bleeding (red markers).
EFGDS should be done as early as possible. The timing of this study is 12-24 hours from the moment the patient arrives ( UD-A) 1.
On EFGDS, the presence or absence of red marks on varicose veins of the esophagus and stomach should be noted ( UD-With) 2 .

Indications for consultation of narrow specialists:

consultation with a gastroenterologist to determine the tactics of treating the underlying disease as the cause of portal hypertension.
consultation with a nephrologist in case of suspected kidney pathology;
consultation with an oncologist in case of suspected oncopathology;
consultation of an infectious disease specialist in case of detection infectious diseases and development of toxic hepatitis;
consultation with a cardiologist in case of pathology of the cardiovascular system;
consultation of a neuropathologist in the detection of pathology from the side nervous system;
consultation of an obstetrician-gynecologist in the presence of pregnancy to resolve issues of treatment tactics.
consultation of an anesthesiologist-resuscitator to determine the volume of intensive care, preoperative preparation, choice of anesthesia.
Consultation with a transplantologist to determine indications and contraindications for liver transplantation.

Risk factors for bleeding from VRV:

The pressure in the portal system is above 10-12 mm Hg;
Large sizes of VRV - 5 mm and more;
Endoscopic stigmas: (gastropathy with portal hypertension; esophageal mucosa in the form of "snake skin", "cherry spots"; "hematocystic spots", a symptom of a red scar (Red wale mark), diffuse erythema - continuous redness of the VRV).
Cirrhosis of the liver Child B or C class (especially the presence of ascites);
Active alcohol intake - especially in the presence of chronic liver damage
Local changes in the mucosa of the distal esophagus (gastroesophageal reflux or other factors)
bacterial infection- translocation to the systemic circulation, disturbance in the hemostasis system, vasoconstriction

The degree of hepatic dysfunction (severity of cirrhosis), assessed by the Child-Pugh scale, is a predictor of bleeding from VRV in patients with decompensated stage: B and C class;

Criteria for assessing the severity of the course of liver disease according to Chaild-Pugh (Child-Pugh): ____

Clinical and biochemical signs	Evaluation, score
Clinical and biochemical signs	1 point	2 points	3 points
Ascites	Not	Transient (soft)	Stable (tense)
Encephalopathy, stages	Not	1-2	3-4
Bilirubin, µmol/l	<34	35-51	>51
Primary biliary cirrhosis, µmol/l	<68	69-171	>171
Albumin, g/l	>35	28-35	<28
Prothrombin index, %	90-75	75-62,5	<62,5

Evaluation and definition of functional groups (class) according to Child-Pugh:
class A - up to 6 points (compensated stage);
class B - up to 9 points (subcompensated stage);
class C - 10-11 or more points (decompensated stage).

Bleeding risk stratification (in points)
Varix size

Small - 8.7
Medium - 13.0
Large - 17.4

Red spots and other stigmas

No - 3.2
Lungs - 6.4
Average - 9.6
Heavy - 12.8

Child-Pugh stage

A-6.5
B-13.0
C-19.5

Risk classes:
1 (<20)
2 (20 to 25)
3 (25.1 to 30)
4 (30.1 to 35)
5 (35.1 to 40)
6 (>40)

Diagnostic algorithm:

1 Roberto de Franchis. Revising consensus in portal hypertension: Report of the Baveno V consensus workshop on methodology of diagnosis and therapy in port al hypertension. Journal of Hepatology 2010 vol. 53, P. 762-768.

2. Guideline Summary World Gastroenterology Organization (WGO). Esophageal varices. Milwaukee (WI): World Gastroenterology Organization (WGO); 2014. 14 p.

Differential Diagnosis

Differential diagnosis and rationale for additional studies

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

Diagnosis	Rationale for differential diagnosis	Survey	Diagnosis Exclusion Criteria
Bleeding from acute and chronic ulcers and erosions of the stomach and duodenum		FGDS.	History: stress, long-term use of drugs (NPS, thrombolytics), poisoning with alcohol surrogates, severe trauma, major surgery, diabetes, heart failure, the presence of an ulcer history. FGDS - the presence of an ulcer. Signs of bleeding according to the classification of J. Forrest. Ultrasound - no signs of portal hypertension (hepatosplenomegaly, ascites, expansion of the portal vein)
Hemorrhagic gastritis	Signs of bleeding from the upper GI tract	Ultrasound of the hepatopancreatoduodenal zone. FGDS.	Long term use drugs, alcohol, the presence of sepsis, acute renal failure and chronic renal failure, pregnancy toxicosis, acute pancreatitis, cholecystitis. FGDS - mucosa is edematous, hyperemic, abundantly covered with mucus, multiple erosions
Mallory-Weiss syndrome	Signs of bleeding from the upper GI tract	Ultrasound of the hepatopancreatoduodenal zone. FGDS.	More often the presence of longitudinal mucosal ruptures in the esophagus, gastric cardia of various lengths
Bleeding from decaying cancer of the esophagus, stomach	Signs of bleeding from the upper GI tract	Ultrasound of the hepatopancreatoduodenal zone. FGDS with biopsy. Oncologist's consultation	The presence of minor symptoms: increased fatigue, increasing weakness, weight loss, taste perversion, changes in the irradiation of pain FGDS - the presence of a large ulcerative mucosal defect, undermined edges, contact bleeding, signs of mucosal atrophy Ultrasound - no signs of portal hypertension
Budd-Chiari Syndrome	Presence of signs of portal hypertension and bleeding from the upper gastrointestinal tract	abdominal ultrasound Abdominal CT scan with vascular contrast FGDS	Thrombosis of large hepatic veins that develops after abdominal trauma, systemic lupus erythematosus, pancreatic tumor, liver tumor, in pregnant women and women taking contraceptives. Ultrasound - ascites, hepatosplenomegaly. FGDS-VRV of the esophagus. Bleeding from VRV is rare in these patients. CT - signs of thrombosis of the hepatic veins or inferior vena cava

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Treatment

Drugs ( active substances) used in the treatment

Groups of drugs according to ATC used in the treatment

Treatment (ambulatory)

TREATMENT TACTICS AT OUTPATIENT LEVEL: no.

Treatment (hospital)

TACTICS OF TREATMENT AT THE STATIONARY LEVEL

Urgent care:

resuscitation
Vasoactive drugs
Endoscopic hemostasis
Antibiotic prophylaxis

With no effect:
TIPS - trans-jugular intrahepatic porto-systemic shunt
If bleeding persists:
Balloon tamponade (Blackmore probe)
or
Stenting (Self-expanding metal mesh stent)
or
Surgical treatment (uncoupling operation)

Anti-shock intensive care

The purpose of resuscitation is to maintain tissue perfusion, initiate the restoration of circulating blood volume to stabilize hemodynamics.
Respiratory support (oxygen inhalation or mechanical ventilation), peripheral venous access, infusion of crystalloids and colloids.
Erythromass transfusions should be carried out cautiously when reaching a target hemoglobin level of 70-80 g/l, although individual management should take into account other factors: cardiovascular disease, age, hemodynamic status and the possibility of ongoing bleeding (LE-A).
Treatment recommendations for coagulopathy and thrombocytopenia cannot be made based on currently available information; prothrombin time and international normalized ratio are not reliable indicators of the state of coagulation in patients with cirrhosis (LE-A).

Indications for IVL are:

impaired consciousness (less than 10 points on the Glasgow scale);
lack of spontaneous breathing (apnea);
quickening of breathing more than 35-40 per minute, if this is not associated with hyperthermia (body temperature above 38.5 ° C) or severe uncorrected hypovolemia.
PaO 2< 60 мм рт ст при дыхании атмосферным воздухом или РаСО 2 >60 mm Hg in the absence of metabolic alkalosis;

Replenishment of the BCC
ITT for mild blood loss:

Blood loss 10-15% BCC (500-700 ml): intravenous transfusion of crystalloids (dextrose, sodium acetate, sodium lactate, sodium chloride 0.9%) in a volume of 200% of the volume of blood loss (1-1.4 l).

ITT with an average degree of blood loss:

Blood loss 15-30% BCC (750-1500 ml): intravenous crystalloids (glucose solution, sodium chloride 0.9%, sodium acetate, sodium lactate) and colloids (gelatin), in a ratio of 3:1 with a total volume of 300% from the volume of blood loss (2.5-4.5 liters); ITT for severe blood loss:
With blood loss of 30-40% of the BCC (1500-2000 ml): intravenous crystalloids (dextrose, sodium chloride 0.9%, sodium acetate, sodium lactate) and colloids (gelofusin) in a ratio of 2:1 with a total volume of 300% of volume of blood loss (3-6 liters). Transfusion of blood components is indicated (erythrocyte mass, FFP 30% of the transfused volume, platelet concentrate at the level of platelets< 50х10 9) и препарата крови - раствор альбумина при гипопротеинемии (общий белок < 60 г/л) и гипоальбуминемии (альбумин < 35 г/л).

When determining indications for replacement therapy focus only on tests taken from venous blood: Hb, Ht, erythrocytes, indicators
coagulograms: INR, PTI, fibrinogen.

The critical level of indicators is: hemoglobin - 70 g/l, hematocrit - 25-28%. It is necessary to maintain the hemoglobin level ~ 80 g/l ( UD-V).

With hemocoagulation syndrome and thrombocytopenia, the safest colloidal solution is succinylated gelatin. The rate of infusion is determined by the level of blood pressure. Until the bleeding stops, SBP should not exceed 90 mmHg. But the infusion rate should exceed the rate of blood loss - 200 ml / min in 1 or 2-3 veins.

Pharmacological therapy to reduce portal pressure:
The use of vasoactive drugs helps to stop bleeding in 75-80% ( UD-A).
The use is indicated immediately, as soon as bleeding from the VRV is established and even with suspicion ( UD-A).
Octreotide: 50 mcg/h IV bolus followed by continuous IV dosing at 50 mcg/h for 5 days or IV drip for 5 days. Or 0.025 mg/h is administered ( UD-A).
Terlipressin: patient's weight<50 кг - 1 мг; 50-70 кг - 1,5 мг; вес >70 kg - 2 mg. Then intravenous bolus 2 mg every 4 hours for 48 hours, from day 3, 1 mg every 4 hours up to 5 days. Or 1000 mcg every 4-6 hours for 3-5 days until stopping and for another 2-3 days to prevent rebleeding ( UD-A).
Somatostatin: 250 mcg IV bolus over 5 minutes and may be repeated 3 times within 1 hour. Then continuous administration of 6 mg (=250 µg) for 24 hours. The dose may be increased up to 500 mcg/h. Side effects are rare and have no contraindications. Compared to terlipressin, the effect is the same (reduces relapse and controls bleeding) 1 .With absence this drug showing it synthetic analogues- octreotide or vapreotide.

Prevention of hepatic encephalopathy:

Lactulose and rifaximin prevent the development of hepatic encephalopathy in patients with cirrhosis and upper gastrointestinal bleeding (LE-A).
Episodes of hepatic encephalopathy should be treated with lactulose (25 ml every 12 hours until soft stools appear 2-3 times, followed by titration of the dose of lactulose to maintain soft stools at a frequency of 2-3 times a day.
Prognostic factors routinely used to assess 6-week mortality are: Child-Pugh class C, The Model for End-Stage Liver Disease (MELD) score, and homeostatic therapy failure (UD-B).
If bleeding from varicose veins is suspected, treatment with vasoactive drugs should be started as soon as possible before endoscopy (LE-A).
Treatment with vasoactive drugs (terlipressin, somatostatin, octreotide) should be combined with endoscopic therapy and continued for up to 5 days (LE-A).
When using terlipressin, hyponatremia may develop, especially in patients with preserved liver function. Therefore, monitoring of sodium levels (UD-A) is necessary.
After carrying out resuscitation measures to stabilize hemodynamics, patients with bleeding from the upper gastrointestinal tract and signs of cirrhosis should undergo endoscopy within 12 hours from the moment of admission.
In the absence of contraindications (prolongation of the QT interval), a pre-endoscopic infusion of erythromycin (250 mg IV 30–120 min before endoscopy) should be given (LE-A).
It is recommended that an EGD hemostasis specialist and support staff with experience in working with endoscopic equipment be called in 24 hours a day, 7 days a week.
The need to place a patient with bleeding from varicose veins in the intensive care unit should be considered.
In patients with impaired consciousness, endoscopy should be performed while respecting airway protection measures.
For the treatment of acute variceal bleeding, endoscopic ligation (LEA) is recommended.
Endoscopic tissue adhesion therapy (eg, using N-butylcyanoacrylate) is recommended for the treatment of acute bleeding from isolated gastric veins (UD-A) and type 2 esophageal and gastric varices extending beyond the cardiac region.
To prevent recurrence of bleeding from gastric varices, one should keep in mind the additional administration of glue (after 2-4 weeks), the use of beta-blockers, a combination of the first and second, or the imposition of a transjugular intrahepatic portosystemic shunt (TIPS) (UD-A). More data is needed in this area.
Endoscopic ligation or tissue adhesion can be used for bleeding from type 1 gastroesophageal varices.
Early placement of TIPS using PTFE-coated stents within 72 (ideally within 24) hours should be considered in patients with bleeding from esophageal veins, type 1 and 2 gastroesophageal veins at high risk of failure. treatment (e.g. Child-Pugh class C< 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.
Balloon tamponade, which has a high rate of serious complications, should only be used in cases of refractory esophageal vein bleeding as a temporary "bridge" (up to a maximum of 24 hours) until appropriate treatment is initiated; intensive monitoring and readiness to intubate if required.
Evidence suggests that self-expanding coated metal esophageal stents are equally effective, but safer, in the treatment of refractory esophageal vein bleeding than balloon tamponade (LE-C).
If bleeding continues despite combined medical and endoscopic therapy, TIPS using polytetrafluoroethylene (UD-B) coated stents is the best option.
Rebleeding during the first 5 days may be managed with a second attempt at endoscopic therapy. If bleeding is heavy, TIPS using polytetrafluoroethylene (UD-B) coated stents should be considered the best method.

Antibiotic prophylaxis

Antibiotic prophylaxis is an integral part of the management of patients with cirrhosis and upper gastrointestinal bleeding and should be initiated as soon as the patient is admitted (LE-A).
The risk of bacterial infection and mortality is very low in patients with Child-Pugh A (UD-B) cirrhosis, but more prospective studies are needed to evaluate whether antibiotic prophylaxis is needed in this subset of patients.
When choosing a first-line drug for antibiotic prophylaxis in acute bleeding from varicose veins, it is necessary to take into account the individual risk factors of each patient and the local pattern of antibiotic resistance in each center.
Ceftriaxone intravenously at a dose of 1 g/24 hours is recommended for severe liver cirrhosis (UD-A) when the patient is in a hospital where quinolone-resistant infections predominate, as well as in patients who have previously received quinolone prophylaxis.

Patient follow-up card, patient routing (schemes, algorithms): no

Non-drug treatment(mode - 1, diet - 0);

Medical treatment

List of Essential Medicines(having a 100% cast chance)

medicinal group	Medicines	Mode of application	Level of Evidence
Vasoactive drugs	Octreotide Or Terlipressin Or Somatostatin	50 mcg/h IV bolus followed by 50 mcg/h continuous IV dosing for 5 days or IV drip for 5 days Patient's weight<50 кг - 1 мг; 50-70 кг - 1,5 мг; вес >70 kg - 2 mg. Then intravenous bolus 2 mg every 4 hours for 48 hours, from day 3, 1 mg every 4 hours up to 5 days. Or 1000 mcg every 4-6 hours for 3-5 days until stopping and for 2-3 more days to prevent rebleeding Bolus IV 250 mcg over 5 minutes and can be repeated 3 times within 1 hour. Then continuous administration of 6 mg (=250 µg) for 24 hours. The dose may be increased up to 500 mcg/h.	BUT
Antibiotics	Ceftriaxone or	intravenously at a dose of 1 g / 24 hours	A
Antibiotics	Ciprofloxacin	intravenously at a dose of 250 mg 1-2 times a day	A
Solutions for infusion	Sodium chloride solution 0.9%	400-800 ml/day 3-10 IV 5-10 days	BUT
Solutions for infusion	Dextrose 5%	400-800 ml/day IV for 5-10 days	BUT
Solutions for infusion	Potassium chloride solution 10%	10-30 ml/day 2-6 IV 5-10 days	BUT
Solutions for infusion	Succinylated gelatin solution 4%	500-1000 ml 2 times / in 3-5 days	BUT

List of additional medicines(less than 100% chance of application)

medicinal group	Medicines	Mode of application	Level of Evidence
Antibiotics	erythromycin	250 mg IV 30-120 minutes before endoscopy to improve gastric emptying	BUT
Drugs that promote healing (scarring) of wounds	N-butyl cyanoacrylate	Endoscopic application to bleeding veins of the esophagus and stomach	BUT
Antisecretory drugs	Omeprazole	2 tablets / day for 10 days	BUT
Laxatives	Lactulose	25 ml every 12 hours until softened stools appear 2-3 times a day, followed by titrating the dose of lactulose to maintain soft stools at a frequency of 2-3 times a day
Solutions for infusion	Complex solutions for parenteral nutrition	1-2 sachets per day 3-5 sachets IV 3-5 days	BUT
Blood components	erythrocyte mass		BUT
Blood components	Thromboconcentrate		BUT
Blood components	Fresh frozen plasma		BUT
Blood products	cryoprecipitate		BUT
Blood products	Albumin 5% or 10%		BUT

Surgical intervention:
- endoscopic hemostasis (EG)- ligation or sclerosis of the veins of the esophagus and stomach (UD-A) .
Indications:

ongoing and/or stopped bleeding from the esophageal varices. Contraindications:

- installation of the Sengstaken-Blakemore probe(UD-B).
Indications:

ongoing bleeding from the esophageal RV, as a temporary procedure before performing the EG

Monitoring the effectiveness of hemostasis is carried out by dissolving the cuff of the probe 4 hours after its installation. When the bleeding stops, the cuffs are deflated. The duration of the probe is up to 24 hours.

- installation of a self-expanding stent
Indications:

temporary procedure, the stent is installed during endoscopy for no more than 1 week (removed endoscopically).

Contraindications:

agonal state of the patient;
anatomical defects of the esophagus (strictures).

- transjugular portosystemic shunting (TIPS)
Indication: in case of failure of pharmacological therapy and EG in Child-Pugh class A patients ( UD-C).
Contraindication to TIPS - the severity of the disease class B / C according to Child-Pugh (decompensated stage).

Laparotomy, separation of the veins of the esophagus and stomach in combination with devascularization of the stomach and splenectomy or without them (operations Paciora and Sugiura and their modifications).
Indications: failure or impossibility of endoscopic hemostasis

- liver transplant
Liver transplantation has been and remains the most effective treatment for end-stage patients. Patients with cirrhosis of the liver should be referred for liver transplantation in the following cases:

with the development of hepatocellular insufficiency (Child-Pugh scale ≥ 7 and MELD ≥ 15);
the first serious complication (ascites, bleeding from varicose veins of the esophagus, hepatic encephalopathy);
type I hepatorenal syndrome (it is recommended to refer such patients for transplantation immediately), hepatopulmonary syndrome.

After transplantation, the survival rate of recipients during the year reaches 90%, five years - 75%, ten years - 60%, twenty years - 40% 2 .

Further management:

Treatment of the underlying disease. After stopping the bleeding and discharge from the hospital, the patient is referred to a gastroenterologist or hepatologist;
Selection and referral for liver transplantation (transplantologist).
prevention and treatment of SBP, HRS, HE;
prevention of secondary bleeding from VRV.

Prevention of secondary bleeding:

First-line therapy for all patients is a combination of NSBB (propranolol or nadolol) and endoscopic vein ligation (UD-A). Propranolol at a dose of 20 mg 2 times a day or nadolol 20-40 mg 1-2 times a day 3 . Dose adjustment by decreasing heart rate (bring 55-60 in 1 min);
Endoscopic vein ligation should not be used in isolation unless there is a contraindication to NSBB (LE-A). Apply up to 6 rings to the veins every 1-2 weeks. The first control EFGDS after 1-3 months and thereafter every 6-12 months to monitor the recurrence of VRV (LE-C).
In liver cirrhosis, NSBB monotherapy should be used in patients who do not want ligation or are unable to do so (LE-A).
If first-line therapy (NSBB + ligation) fails, TIPS with coated stents (UD-A) is the treatment of choice.
Since there are no comparative studies of carvedilol with current standards of care, its use cannot be recommended in the prevention of rebleeding.

Secondary prevention in patients with refractory ascites

In patients with cirrhosis and refractory ascites, NSBB (propranolol, nadolol) should be used with caution and with careful monitoring of blood pressure, sodium and serum creatinine (UD-C).
Until the results of randomized trials are available, the dose of NSBB should be reduced or these drugs should be discontinued if a patient with refractory ascites develops one of the following complications:
1) decrease in SBP to a level of less than 90 mm Hg. Art.;
2) hyponatremia< 130 мэкв/л;
3) there are signs of acute renal disease (it is understood that other drugs that can cause these phenomena (for example, NSAIDs, diuretics) have been canceled).
The consequences of discontinuing NSBB in terms of secondary prevention are unknown.
If the listed events were triggered by any specific factor (eg, spontaneous bacterial peritonitis, bleeding), resumption of NSBB treatment is possible only after the listed parameters return to baseline after the precipitating factor has ceased.
When resuming NSBB therapy, the dose should be titrated again starting from its minimum value.
If the patient remains intolerant to NSBB and is a suitable candidate for TIPS, then this technique should be performed using coated stents.

Second line therapy:

if NSBB+ EVL was not effective, then TIPS or bypass surgery is indicated, but only in class A patients according to the severity of cirrhosis. Class B and C, these operations are not indicated, as they lead to the development of encephalopathy. Alternative therapy:
NSBB (β-blockers) + nitrates in tablet form);
NSBB+ISMN+EVL. This combination of pharmacological (NSBB+ISMN) and ligation (EVL) PBV is associated with a lower rate of rebleeding and is the method of choice 4 .

If a patient has rebleeding from a VRV despite a combination of pharmacological and endoscopic treatment, TIPS or bypass surgery is recommended in such cases (subject to local conditions and experience with their use. ( UD-A). Candidates for liver transplantation should be referred to a transplant center ( UD-C) 5 .

Indicators of treatment efficacy and safety of diagnostic and treatment methods described in the protocol:

stop bleeding from the VRV of the esophagus and stomach;
achievement of target indicators of CVP (10-12 cm of water column);
hourly diuresis not less than 30 ml/hour;
clinical criteria for the restoration of BCC (elimination of hypovolemia):
increase in blood saturation;
warming and discoloration of the skin (from pale to pink).
prevention of recurrent bleeding;
prevention and relief of HRS, SBP, HE;

Minutes of the meetings of the Joint Commission on the quality of medical services of the Ministry of Health of the Republic of Kazakhstan, 2018
1. .Khanevich M.D., Khrupkin V.I., Zherlov G.K. et al., Bleeding from chronic gastroduodenal ulcers in patients with intrahepatic portal hypertension. - Novosibirsk: Nauka, 2003. - 198 p. . Robert de Franchis. Revising consensus in portal hypertension: Report of the Baveno V consensus workshop on methodology of diagnosis and therapy in port al hypertension. Journal of Hepatology 2010 vol. 53, pp. 762–768. . Guideline Summary World Gastroenterology Organization (WGO). Esophageal varices. Milwaukee (WI): World Gastroenterology Organization (WGO); 2014. 14 p. .Bosch J, Abraldes JG, Berzigotti A, Garcia-Pagan JC. Portal hypertension and gastrointestinal bleeding. Semin Liver Dis. 2008; 28:3-25. . National clinical guidelines "Liver transplantation". "Russian Transplant Society" 2013. 42 p. . WGO Practice Guideline Esophageal Varices, 2014 7. Gonzalez R, Zamora J, Gomez-Camarero J, Molinero LM, Banares R, Albillos A. Meta-analysis: Combination endoscopic and drug therapy to prevent variceal rebleeding in cirrhosis. Ann Intern Med. 2008;149:109-122. . Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010; 362:823-832.

Information

ORGANIZATIONAL ASPECTS OF THE PROTOCOL

List of protocol developers with qualification data:

Turgunov Ermek Meyramovich - doctor of medical sciences, professor, surgeon of the highest qualification category, head of the Department of Surgical Diseases No. 2 of the Republican State Enterprise on the REM "Karaganda State Medical University" of the Ministry of Health of the Republic of Kazakhstan;
Zhantalinova Nurzhamal Assenovna - Doctor of Medical Sciences, Professor of the Department of Internship and Residency in Surgery, RSE on REM "Kazakh National Medical University. S.D. Asfendiyarov".
Medeubekov Ulugbek Shalkharovich - doctor of medical sciences, professor, surgeon of the highest qualification category, deputy chairman of the board of JSC "National Scientific Center for Surgery named after. A.N. Syzganov".
Clinical pharmacologist: Kalieva Mira Maratovna - Candidate of Medical Sciences, Clinical Pharmacologist of JSC "National Scientific Center for Surgery named after N.N. A.N. Syzganov".

Indication of no conflict of interest: No

Reviewers:

Shakenov Ablai Duysenovich - Doctor of Medical Sciences, Professor, Head of the Department of Surgical Diseases No. 1 of NJSC "Astana Medical University";
Proshin Andrey Vladimirovich - Doctor of Medical Sciences, Professor of the Department of Hospital Surgery, Novgorod State University named after I.I. Yaroslava Mudrova (Russian Federation).

Indication of the conditions for revising the protocol: revision of the protocol 5 years after its publication and from the date of its entry into force or in the presence of new methods with a level of evidence.

Attached files

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