Treatment of portal hypertension complicated by variceal bleeding

Abstract

Background. Mortality in variceal bleeding (VB) on the background of portal hypertension (PH) is highest among patients with gastrointestinal bleeding. The treatment of PH complicated by VB is a complex problem that is far from being solved, especially in case of Child-Pugh class B and C decompensation. The aim of the study was to determine the causes of PH complicated by VB, features of conservative and interventional therapy, indications and nature of surgical procedures, treatment efficacy, as well as causes of complications and mortality. Materials and methods. We analyzed treatment outcomes of 923 inpatients with PH complicated by VB who were treated in the clinic of the Department of Surgery of the Faculty of Dentistry of Bogomolets National Medical University on the basis of the Kyiv City Clinical Emergency Hospital from 2012 to 2023. It was possible to talk about the cause of PH based on anamnestic data in 61 % of cases. In 711 (77 %) patients, the source of bleeding was detected endoscopically within 30–60 minutes from the moment of admission to the clinic. Conservative therapy included the administration of hemostatic and agents lowering pressure in the portal system, as well as vasoconstrictors that reduce portal blood flow. For the failure of conservative therapy, unstable hemostasis, and repeated previous bleedings, 59 (6.4 %) patients were operated. The methodology of the research analysis consisted in the fact that the arithmetic mean and standard error (M ± m) were determined as the characteristics of the groups for features with a distribution corresponding to the Gaussian law. This reference method of descriptive statistics was applied to evaluate surgical treatment in comparison with conservative therapy and interventional measures. Results. Endoscopic hemostasis by the ligature method was achieved in 97 (10.5 %) patients. Repeated endoscopy due to VB recurrence was done in 276 (29.9 %) participants. In cases of unsatisfactory endoscopic hemostasis, as well as recurrent VB, a Sengstaken-Blakemore probe was installed. In case of right-sided PH, the formation of varices in the esophagus is caused by the discharge of blood mainly through the coronary vein, which required its transection during еsophagogastric devascularization. In compliance with this rule, the patients underwent esophagogastric devascularization, circular transection of the esophagus, which provided portoazygous disconnection. The total mortality rate was 43.1 %, among operated people — 8.5 %, and among non-operated ones — 42.1 %. Conclusions. PH complicated by VB is evidence of decompensated processes in the liver parenchyma or obstruction in the portal system. Conservative therapy and interventional measures make it possible to stop bleeding and prepare the patient for elective surgery, if necessary. An operation that stops blood flow through dilated veins of the esophagus or stomach is an effective method of treating bleeding in portal hypertension.

Keywords

• portal hypertension
• varicose bleeding
• interventional treatment
• surgical procedure