Treatment of variceal upper gastrointestinal bleeding

Abstract

Introduction. Variceal upper gastrointestinal bleeding is a direct complication of portal hypertension and adequate management is essential in positive outcome of patients prognosis and prevention of hemorrhage relapse. Upper varices include esophageal and gastric varices, the first ones being the most frequent. Other causes of upper variceal bleeding, besides cirrhosis, can be occlusion of portal or splenic vein, schistosomiasis, non-cirrhotic fibrosis of portal vein, previous endoscopic or surgical variceal management, tumors of the hepatobiliary area. Nowadays, the endoscopic treatment is widely used in variceal management, and it includes: sclerotherapy, obturation with cyanoacrylate and lipidol, ligation with removable loops, injection of thrombin, combined therapy (loop ligation and cyanoacrylate obturation), sonographically guided endoscopic therapy, hemospray. Case statement. A 73 y.o. male was admitted urgently to the surgery department within Gheorghe Paladi Municipal Clinical Hospital on 11.10.2019, with the following symptoms: vomiting with fresh blood, hematochezia, loss of consciousness, general weakness, abdominal pain, BP 90/60 mmHg, heart rate 100 bpm, respiratory frequency 17/min. The onset occurred 12 hours prior to hospitalization with no history of previous such episodes. The clinical and paraclinical examination established jaundice, swollen abdomen with ascitis, melena, HGB 62 g/l, RBC 1.8x1012/l, HCT 0,21/l, WBC 11x109/l, ESR 20 mm/h, albumin 38 g/l, total protein 60 g/l, ALT 120 U/l, AST 150 U/l, ALP 500 U/l, urea 12 mmol/l, creatinine 156 mmol/l, glycemia 4,2 mmol/l, total bilirubin 87 mcmol/l (direct 50 mcmol/l, indirect 37 mcmol/l), PT 30%, fibrinogen 2 g/l, INR 1.8. Diagnostic endoscopy proved esophageal and gastric varices GOV 2, F2, grade 2. Endoscopy haemostasis has been made with paravariceal injection of 500 units of thrombin. The patient remained under observation for 6 days, was discharged in a satisfactory condition, with no relapse of bleeding. Discussions. Although some experts advise the use of cyanoacrylate in variceal management, paravariceal thrombin administration proves to be an effective procedure as well. However, there is yet to be established an agreed-upon primary and secondary prophylaxis of gastrointestinal variceal bleeding, as the subject is still studied, and the treatment must be customized to each individual. Conclusion. Upper gastrointestinal variceal bleeding is a medical emergency that needs endoscopic management on a first episode, and preferably surgical intervention whenever multiple episodes occur. hypertension and adequate management is essential in positi ve outcome of patients prognosis and prevention of hemorrhage relapse. Upper varices include es ophageal and gastric varices, the first ones being the most frequent. Other causes of upper varice al bleeding, besides cirrhosis, can be occlusion of portal or splenic vein, schistosomiasis, no n-cirrhotic fibrosis of portal vein, previous endoscopic or surgical variceal management, tumors of th e hepatobiliary area. Nowadays, the endoscopic treatment is widely used in variceal managemen t, and it includes: sclerotherapy, obturation with cyanoacrylate and lipidol, ligation with removable loops, injection of thrombin, combined therapy (loop ligation and cyanoacrylate obturat ion), sonographically guided endoscopic therapy, hemospray. Case statement. A 73 y.o. male was admitted urgently to the surgery departmen t within Gheorghe Paladi Municipal Clinical Hospital on 11.10.2019, with the foll owing symptoms: vomiting with fresh blood, hematochezia, loss of consciousness, general weakness, abdominal pain, BP 90/60 mmHg, heart rate 100 bpm, respiratory frequency 17/min. The o nset occurred 12 hours prior to hospitalization with no history of previous such episodes . The clinical and paraclinical examination established jaundice, swollen abdomen with asc itis, melena, HGB 62 g/l, RBC 1.8x1012/l, HCT 0,21/l, WBC 11x109/l, ESR 20 mm/h, albumin 38 g/l, total pr otein 60 g/l, ALT 120 U/l, AST 150 U/l, ALP 500 U/l, urea 12 mmol/l, creatinine 156 mmol/l, g lycemia 4,2 mmol/l, total bilirubin 87 mcmol/l (direct 50 mcmol/l, indirect 37 mcm ol/l), PT 30%, fibrinogen 2 g/l, INR 1.8. Diagnostic endoscopy proved esophageal and gastric varice s GOV 2, F2, grade 2. Endoscopy haemostasis has been made with paravariceal injection of 500 units of thrombin. The patient remained under observation for 6 days, was discharged in a satisfactory condition, with no relapse of bleeding. Discussions. Although some experts advise the use of cyanoacrylate in variceal management, paravariceal thrombin administration proves to be an effec tive procedure as well. However, there is yet to be established an agreed-upon primary and secondary prophylaxis of gastrointestinal variceal bleeding, as the subject is still studied, and the treatment must be customized to each individual. Conclusion. Upper gastrointestinal variceal bleeding is a medical emer gency that needs endoscopic management on a first episode, and preferably surgical intervention whenever multiple episodes occur.