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Comparative efficacy emergency endoscopic sclerotherapy in the treatment of bleeding from the varices of esophagus...
11. Wikstrand J., Wedel H., Castagno D., McMur-ray J. J. The large-scale placebo-controlled beta-blocker studies in systolic heart failure revisited: results from CIBIS-II, COPERNICUS and SENIORS-SHF compared with stratified subsets from MERIT-HF.//J Intern Med. - 2014. - Vol. 275, № 2. - Р. 134-143.
Karimov Shavkat Ibragimovich, MD, Academician of MS, Professor of the Surgery Department
of Tashkent Medical Academy Khakimov Murod Shavkatovich, MD, Professor, Head of the Surgery Department Matkuliev Utkirbek Ismoilovich, PhD. Assistant of the Surgery Department E-mail: [email protected]
Comparative efficacy emergency endoscopic sclerotherapy in the treatment of bleeding from the varices of esophagus and stomach. The urgency of the problem
Abstract:
Purpose: Evaluating the effectiveness of endoscopic sclerotherapy of the varicose veins in patients with portal origin bleeding from esophagus and stomach in different periods.
Results of treatment: In 108 patients with complicated liver cirrhosis with portal hypertension (PH) and bleeding from varicose veins (VV) in esophagus and stomach that were hospitalized into the 2nd clinic of the Tashkent Medical Academy in 2008-2011.
For a comparative analysis all the patients were divided into 2 groups. Control group consisted of 57 (52.7 %) patients with esophageal and gastric bleeding from VV, who delayed endoscopic sclerotherapy 2-3 days after admission, controlled bleeding with Blackmore probe obturator and performed intensive conservative therapy. The study group included 51 (47.3 %) patients with esophageal and gastric bleeding from VV, who performed emergency endoscopic sclerotherapy after admission at an altitude of bleeding or even stopped the bleeding in the event of a subsequent installation of Blackmore probe.
Recurrence of bleeding contained in 8 (15.7 %) patients. It should be noted that rebleeding observed only in patients with grade III varices with the transition into the stomach, while the control group of patients with recurrent bleeding heterogeneous in degree of varicose veins.
6 patients underwent re-sclerotherapy with the installation of the probe-obturator. In 2 patients performed operation by Sugiura due to profuse bleeding.
The mortality rate was 11.8 % (6 patients). In 1 patient the cause of death was the hemorrhagic shock in 4 — progressive liver failure. After surgery, the patient 1 Sugiura died as a result of hepatorenal syndrome and multiple organ failure.
During the 1-year because of recurrent bleeding re-hospitalized patients 2, both made emergency sclerotherapy, thereby achieved hemostasis.
The effectiveness of endoscopic sclerotherapy in the main group reached 84.3 %.
Keywords: portal hypertension, varicose veins of esophagus, endoscopic sclerotherapy, liver failure.
Despite the increasing quality of life, continuous improvement of methods of diagnosis and treatment, the incidence of cirrhosis of the liver has no downward trend. Portal hypertension (PH) syndrome in cirrhosis leads to the development of serious, sometimes fatal complications, such as bleeding from varicose veins of the esophagus and stomach, liver failure (LF), ascitic syndrome and hepatic encephalopathy [1, 9]. Bleeding from varicose veins (VV) — one of the most difficult, dangerous and difficult to forecast complications, which
often leads to death. Patients die of acute and chronic posthemorrhagic anemia, progression of LF [8].
The introduction of new and improvement of existing minimally invasive endoscopic hemostasis opened a new page in dealing with esophageal-gastric bleeding portal genesis [6; 10]. According to various sources, the rate of achieving hemostasis at active bleeding greater than 90 % and the mortality rate is reduced to 15 % [7]. In addition, the proven efficacy of endoscopic methods in the prevention
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Section 8. Medical science
of recurrence of bleeding from VV of the esophagus and stomach [8].
The survival rate of patients with acute esophageal-gastric bleeding of portal origin being treated using minimally invasive endoscopic techniques are significantly higher at all stages of observation comparable to patients receiving treatment as conservative therapy in conjunction with the installation of the probe of Blackmore [4]. However, despite the large number of studies on this issue, there is no precise definition of the terms of application of endoscopic methods of hemostasis.
In this regard, we decided to determine the timing of endoscopic sclerotherapy for bleeding from VV of the esophagus and stomach.
Purpose of the research. To evaluate the effectiveness of endoscopic sclerotherapy of the VV of esophagus and stomach in patients with bleeding of portal hypertension in different periods.
Materials and methods. Results oftreatment of108 patients with liver cirrhosis complicated by PH and bleeding from VV esophagus and stomach that were hospitalized at the 2nd clinic of the Tashkent Medical Academy between 2008-2011 years. The average age was 45.7 ± 18.8 years. Among them 71 patients
The technique of sclerotherapy — the procedure was performed in the endoscopic room using a fiber-optic endoscopy, endoscopic instruments firm Olympus, endoscopic injector. Emergency endoscopic sclerotherapy was carried out after a gastric lavage, delayed — after stopping the bleeding with Blackmore probe. We used intravasal and paravasal sclerotherapy with a solution of 1 % polydacanol. During one session of endoscopic sclerotherapy administered 15-18 ml. of 1 % sclerosant into two or three varicose veins. The drug is injected below the bleeding. Reintroducing sclerosants to other varicose veins of the esophagus was performed at intervals of 3-4 days. Endoscopic treatments were carried out in parallel with intensive conservative therapy.
Results of the research
To evaluate the results of treatment, we studied the frequency of recurrent bleeding, rate of complications and mortality in the early postoperative period.
were male. We had a history of bleeding in 37 % of patients. The duration of the bleeding continued about 12.8 ± 5.2 hours. Ascites was observed in 67 % of patients, some of them had ascites of resistant character. To assess the severity of liver failure used the classification of Child-Turcotte-Pugh. Expression and dissemination of VV of esophagus and stomach was evaluated by classification of N. Soehendra, K. Binmoeller.
For a comparative analysis all the patients were divided into 2 groups. Control group consisted of57 (52.7 %) patients with bleeding from esophageal and gastric VV, who underwent delayed endoscopic sclerotherapy 2-3rd day after admission, stopped bleeding with Blackmore probe obturator and intensive conservative therapy. The study group included 51 (47.3 %) patients with bleeding from esophageal and gastric VV, who underwent emergency endoscopic sclerotherapy after admission at an altitude of bleeding or even stopped bleeding in the event of a subsequent installation of Blackmore probe.
The status of all patients was assessed as heavy, due to which they were admitted to the surgical intensive care department. In order to monitor all patients underwent a comprehensive study, including general clinical, laboratory and special instrumental methods (Table 1).
In the control group treatment policy is to temporarily stop the bleeding by placing the Blackmore probe. Intensive therapy was carried out for 24-72 hours. At 2-3 day the Black-more probe and performed endoscopic sclerotherapy.
Prolonged staying of Blackmore probe in the esophagus in patients of the control group resulted in the development of bronchopulmonary complications, inflammation of the sinuses and the oropharynx. In 10.5 % of patients had a pronounced swelling of the epiglottis, which greatly complicated the conduct of endoscopic intervention. Prolonged staying of Blackmore probe caused pressure sores and ulcers of cardioesophageal zone in 5 % of patients, marked inflammation in 27 (47.4 %), which not only complicate the conduct of sclerotherapy, but also caused a marked bleeding at the puncture site in 16 patients. This required a long pressure of the distal end of the instrument on the puncture site or re-install the Blackmore probe 8.8 % of patients, as well as
Table 1. - Clinical characteristic of the patients, n = 108
Clinical criteria Control group Main group
Number of patients 57 51
Gender (m/f) 38/20 33/17
Age 45.7 ± 18.3 40.2 ± 19.5
Laboratory analyses
Hb, g/l 61.6 ± 23.2 69.5 ± 18.5
Ht, % 16.9 ± 7.6 18.4 ± 5.8
Protrombine time, % 73.2 ± 21.9 72.9 ± 20.4
Common bilirubin, pmol/l 35.4 ± 7.4 34.9 ± 9.2
Liver failure by Child -Turcotte- Pugh (A/B/C) 6/32/19 3/27/21
Degree of VV of esophagus and stomach ( %)
II 15 (26.3) 10 (19.6)
III 23 (40.3) 24 (47.0)
III with passing to the stomach 19 (33.4) 17 (33.4)
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Comparative efficacy emergency endoscopic sclerotherapy in the treatment of bleeding from the varices of esophagus...
the introduction of additional volume of sclerosant at 7 %, which also negatively affected the results of sclerotherapy. This caused a pronounced inflammation of the entire esophageal wall and led to the development of pleurisy in 10 (17.5 %) patients. The development of bronchopulmonary complications in the long-term presence of the Blackmore probe also exacerbates the PN, which contributed to the progressive development of hepatorenal syndrome with severe encephalopathy in 0.7 % of patients.
All patients after sclerotherapy felt slight pain in the epigastric region, which was associated with the development of the inflammatory process in the entered sclerosant.
In 1 patient during sclerotherapy of esophageal perforation occurred in connection with what has been undertaken emergency surgery.
Recurrence ofbleeding in the hospital came in 13 (12.8 %) patients. 11 of them made repeated sclerotherapy with the installation of the probe Blackmore, 2 because of the inefficiency of endoscopic hemostasis and install Blackmore probe azigop-ortal separation operation is performed on the type of Sugiura.
The average number ofhospital days was equal to 10.1 ± 2,4.
The mortality rate was 19.3 % (11 patients). In one case, death occurred as a result of purulent mediastinitis developed after surgery undertaken on the perforation of the esophagus. As a result, three died of hemorrhagic shock patient. After surgery of Sugiura 1 patient developed postoperative wound eventration, suture failure. The patient is taken to a second operation, but postoperative death occurred as a result of multiple organ failure. Another patient developed postoperative Sugiura myocardial infarction complicated by cardiogenic shock. The other 5 patients died from progressive LF.
Within 1 year after discharge repeatedly for recurrent bleeding hospitalized in 9 patients. Management of patients was identical to that described. 1 patient due to the inefficiency of the operation performed endoscopic hemostasis Sugi-ura. 1 patient died due to multiple organ failure.
Thus, the effectiveness of sclerotherapy in the control group was 77.2 %.
Critical analysis of the unsatisfactory results of treatment of patients in the control group showed that, firstly, a temporary stop bleeding Blackmore probe created unfavorable conditions (mucosal edema, pressure sores, ulceration, inflammatory infiltration of the walls of the esophagus, etc.) for later execution sclerotherapy. Second, using a Blackmore probe reached a temporary stop bleeding. However, during this time there was an increase of portal pressure with an increase in esophageal varices, which also created unfavorable conditions for the technical implementation of sclerotherapy (active bleeding at the puncture site, an increase of sclerosant, etc.).
With this in mind, we decided to perform endoscopic sclerotherapy esophageal varices urgently, at the time of admission of patients to the hospital, as VV reducing during a recent or ongoing bleeding creates favorable conditions for the technical implementation of sclerotherapy. After
the installation of the Blackmore probe sclerotherapy limited time 6-12 hours obturationof the veins of esophagus and stomach, or installing a nasogastric tube to control.
Patients of the main group were in the hospital an average of 7.1 ± 2.5 bed-days.
Considering that the patient was placed Blackmore probe for a short period, complications such as inflammation of the lining of the esophagus, swelling of the epiglottis and deep ulcers and pressure ulcers of the esophagus were observed. This allowed us to successfully carry out the rest of repeated sclerotherapyof the esophageal varices, which was carried out on 3-4 th day.
During the endoscopy at 72.5 % of the patients showed an active, ongoing bleeding. This situation required the introduction of additional sclerosant around the bleeding veins. Despite this, the active bleeding from the injection point was observed only in 7.8 % of patients. Given that these patients had esophageal VV III degree with the transition into the stomach after sclerotherapyBlackmore probe was set for up to 12 hours. In 2 patients developed pleural effusion in 7.8 % observed transient dysphagia.
Recurrence of bleeding originated in 8 (15.7 %) patients. It should be noted that rebleeding observed only in patients with grade III varices with the transition into the stomach, while the control group of patients with recurrent bleeding heterogeneous in degree of varicose veins.
6 patients underwent repeat sclerotherapy with the installation of the probe-obturator. In 2 patients due to profuse bleeding operation is performed Sugiura.
The mortality rate was 11.8 % (6 patients). In 1 patient the cause of death was the hemorrhagic shock in 4 — progressive liver failure. After surgery, the patient 1 Sugiura died as a result of hepatorenal syndrome and multiple organ failure.
During the 1-year because of recurrent bleeding re-hospitalized patients 2, both made emergency sclerotherapy, thereby achieved hemostasis.
The effectiveness of endoscopic sclerotherapy in the main group reached 84.3 %.
Discussion
Bleeding from VV esophagus and stomach — life-threatening complication of portal hypertension, in which 6 weeks after admission killed more than one-third of patients [8, 10]. Active bleeding from the esophagus and stomach VV is the urgent problems of modern endoscopic surgery [2; 4].
The main issue that remains controversial is the deadline for the sclerotherapy: some authors hold emergency sclerotherapy, while others prefer to conduct sclerotherapy after installation of the Blackmore probe and stabilize the patient’s condition [1; 2; 3; 8]. According to some reports, conducting emergency sclerotherapy is difficult due to low bleeding vessel visualization during active bleeding, although the frequency of postoperative complications and recurrence of bleeding is significantly reduced, and the patient’s general condition improves. Efficacy emergency sclerotherapy varies from 75 to 90 % [1; 3].
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Our results showed that the holding emergency sclerotherapy in the treatment of patients with gastroesophageal VV complicated by bleeding, is significantly more effective than sclerotherapy Blackmore probe after installation.
One of the main problems in the treatment ofpatients with esophageal and gastric VV is the occurrence of relapses [3; 8]. According to our data, relapse after emergency sclerotherapy occurred in 15.7 % of patients, and delayed after sclerotherapy — at 22.8 %. This is due to the fact that during the delayed sclerotherapy patients underwent intensive infusion therapy, which leads to increased blood volume, resulting in portal pressure also rises, the walls of VV esophagus and stomach tighten and become thinner. This clearly complicates the sclerotherapy, especially with III degree of varicose veins. Although above the injection creates a cushion ethanol, but the high rate of
According to some authors, a clear correlation between the number of deaths and timing of sclerotherapy is not [4; 10]. When considering the structure of deaths shows that the number of deaths from progression ofMo in the two groups was the same, but deaths due to hemorrhagic shock in the study group was 1.9 % and 5.2 % in the control.
Survival analysis according to functional class showed that functional status at the start of the treatment plays an important role in the prognosis of survival and life expectancy of patients with liver cirrhosis after various interventions. Treatment of patients with bleeding portal genesis the more effective the more preserved functional capacity of the liver and the earlier it is started [12]. However, a high percentage of post-operative recurrence of bleeding in the immediate and long-term period, and the progression of edematous-ascitic syndrome forces the use of different endovascular interventions portal system in patients with portal hypertension after endoscopic.
Thus, the bleeding from the VV esophagus and stomach is one of the main problems of surgical hepatology. Although previous studies have indicated a significant difference in the
When analyzing the complications seen that the number of complications resulting from sclerotherapy higher in the group where it was held in a delayed manner. This is due to long-term presence of the probe-obturator (Table 2).
blood flow in the varicose vein does not allow the sclerosant to focus at the desired location, and part of it stems from the puncture site, and the rest of the mass leaves the bloodstream.
The amount of sclerosing agent introduced during emergency sclerotherapy was significantly less than when delayed, so that the pressure due to a decrease in portal vein system at active bleeding [9; 11].
According to international data, the use of emergency sclerotherapy reduces the duration of hospital stay doubled [7]. In our study, these data are confirmed: the number of bed-days decreased from 10.1 ± 2.2 to 7.1 ± 2.5 (Table 3).
results and delayed emergency sclerotherapy, our findings suggest the benefits of emergency intervention. Based on the available data and the results of our study emergency sclerotherapy can be recommended as the first line of action in the treatment of patients with esophageal and gastric VV
Conclusions
1. To conduct delayed sclerotherapy of VV of esophagus and stomach is difficult due to the long-term presence of the probe Blackmore, which leads to the development of inflammation of the mucous of cardioesophageal zone, pressure sores, ulcers, increased bleeding from the puncture site.
2. The urgent endoscopic sclerotherapy in patients with VV of esophagus and stomach compared with delayed sclerotherapy delayed reduced the number of relapses, from 22.8 to 15.6 % and increased the effectiveness of treatment from 77.2 to 84.3 %, and reduced duration of hospital stay from 10.1 ± 2.2 to 7.1 ± 2.5 bed-days.
3. Conduction of an emergency endoscopic sclerotherapy has reduced the mortality rate from 19.3 to 11.8 %.
4. The most important prognostic factor for survival in patients who have had bleeding of portal genesis is that they
Table 2. - Complications in the groups, %
Complication Control group, n = 57 Main group, n = 51
Edema of epiglotis 5.3 -
Deep ulcers 8.8 -
Pleuritis 12.3 3.9
Perforation of the esophagus 1.9 -
Active bleeding from the place of injections 28.1 7.8
Dysphagia (transitor) 19.3 7.8
Recurrence of bleeding 22.8 15.7
Table 3. - Results of treatment of the patients with the bleeding from the VV of esophagus and stomach
Clinical criteria Control group, n = 57 Main group, n = 51
Number of days 10.1 ± 2.2 7.1 ± 2.5
Number of sessions during the stationary treatment 2.3 ± 0.7 2.1 ± 0.4
Mortality, % 19.3 14.0
Effectiveness of the bleeding stopping, % 77.2 84.3
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Clinical and diagnostic features of the infectious lesions of the central nerve system in hiv-infected patients
belong to functional class Child-Turcotte- Pugh and the de- liver failure requires the use of decompressive endovascu-
velopment of recurrent bleeding. lar interventions in patients with bleeding of the esophagus
5. Endoscopic intervention is a treatment to stop the and stomach VV.
bleeding, but for the prevention of recurrent bleeding and
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Kuranbaeva Satima, Assistant of Tashkent Medical Academy, Republic Uzbekistan Atabekov Nurmat Satimniyazovich, Director of Republican centre struggle against AIDS Kalandarova Sevara Khujanazarovna, Doctor of of Tashkent Medical Academy, Republic Uzbekistan
E-mail:[email protected]
Clinical and diagnostic features of the infectious lesions of the central nerve system in hiv-infected patients
Abstract: Among the observed patients the dominant route of transmission of human immunodeficiency virus (HIV) infection was injecting. The most wide-spread reason of the infection central nervous system (CNS) in HIV-positive patients was Epstein-Barr virus, Toxoplasmosis and Mycobacterium tuberculosis. The disease developed mostly in young patients, regardless of gender. Infectious lesions CNS in HIV-positive patients progressed gradually as well as advanced against the background of clinically sthenic immunodeficiency.
Keywords: HIV-positive patients, immunodeficiency virus, Epstein-Barr.
HIV infection — a viral disease characterized by aggravat- and other systems of the body with the development of ac-
ing steadily, leading to destruction of the immune, nervous quired immunodeficiency syndrome (AIDS) [1; 2; 4].
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