TREATMENT AND DIAGNOSTIC ALGORITHM DURING BLEEDINGS FROM ESOPHAGEAL AND GASTRIC VARICES IN PATIENTS WITH LIVER CIRRHOSIS
F.G.NAZIROV, R.A.IBADOV, SH.KH.KHASHIMOV, A.V.DEVYATOV, N.R.GIZATULINA, A.H.BABAJANOV
Republican Specialized Center of Surgery named of acad. V. Vakhidov,
A significant part of patients with liver cirrhosis (LC) with esophageal and gastric varices (EGV) continue to die from esophageal-gastric bleeding. The majority of leading medical clinics achieve the reduction of mortality due to hemorrhagic syndrome just to 30%, and in the group of patients, corresponding to the functional class Child «S», mortality reaches 100%.
The aim of the study: to develop an algorithm of treatment and diagnostic tactics in bleedings of esophageal and gastric varices under the conditions of ICU.
Materials and methods. Results of treatment of 152 patients with liver cirrhosis with gastro-oesophageal bleeding, admitted to RSSC named after acad. V. Vahidov, were retrospectively analyzed and summarized.
Results: The main objectives of treatment and diagnostic tactics in case of bleeding from EGV in the intensive care unit include:
- Recognition of the source and arrest of bleeding;
- assessment of a degree of severity and adequate blood replacement;
- pathogenic influence on the disease, complicated by bleeding.
Use of a Blackmore probe within 12 hours against the background of drug therapy remains the main method of hemostasis in endoscopically visible blood leakage (Forrest Ib) from gastric veins and during active bleeding of any intensity (Forrest Ia-b) from esophageal veins.
Differentiated intensive therapy in patients with LC may be used based on the following protocol:
1. Restoration of the volume of circulating blood: blood preparations, as well as the use of synthetic colloids solutions derivatives of gelatinole and hexaethylenestarch.
2. Hemostatic therapy (PABA, tranexamic acid, sodium ethamsylate, Vikasol), two patients recombinant factor VIIa (Novoseven) was used.
3. Pharmacotherapy of portal hypertension (Vasopressin; Somatostatin in the form of a stable infusion, a) β-blockers, and d) Nitrates.
4. Gastroprotection a) Enveloping in the probe, and b) Infusion solutions of proton pump inhibitors, and c) Infusion solutions of H2-blockers.
5. Pharmacotherapy of hepatic encephalopathy) L-ornithine-L-aspartate (Hepa-Merz); Preparations based on lactulose, and c) a group of enteroseptics in the probe. c) the group of lactobacilli in the probe.
6. Replacement therapy: amino acids with the branched chain (Aminoplasmal Hepa 10%), Albumin 10/20%.
7. Antibiotic therapy subject to the sensitivity of drugs to Hp (amoxicillin, 1gr/day, metronidazole 250 mg/day)
Conclusions: The universal tactical solution for patients with profuse bleeding from the EGV is the use of Blackmore probe and complex conservative measures with traditional haemostatic therapy, the use of drugs which reduce portal pressure, prevention or treatment of already developed hepatic failure.
Date: 2014-12-28; view: 450