Tratamentul endoscopic al hemoragiei digestive superioare variceale

Abstract

Hemoragia digestiva superioara variceala este o complicatie severa in cazul pacientilor cu hipertensiune portala, avand o rata ridicata de mortalitate. De cele mai multe ori este vorba despre hemoragii de la nivelul varicelor esofagiene. In cazuri mai rare hemoragia are originea la nivelul varicelor gastrice, situatie in care mortalitatea este mult mai ridicata. Tratamentul hemoragiilor variceale prezinta un moment pre-endoscopic (reechilibrarea pacientului, administrarea de Terlipresina sau substante similare), precum si un moment endoscopic. Tratamentul endoscopic al hemoragiei variceale difera in functie de origine sangerarii. In cazul varicelor esofagiene se pot injecta substante sclerozante (glucoza hipertona, alcool, etoxisclerol) sau, de preferat, se pot monta ligaturi elastice. In cazul in care este vorba despre varice gastrice, tratamentul de electie este injectarea de cianoacrilat sau injectarea unei combinatii de coil-uri si cianoacrilat. Acestea reprezinta metode endoscopice, dar in ultima vreme se prefera efectuarea acestor manopere ecoendoscopic–ghidat, ceea ce confera o mai mare precizie gestului terapeutic, precum si reducerea ratei complicatiilor. In situatiile in care manoperele mentionate nu reusesc sa stapaneasca sangerarea, exista posibilitatea montarii fie a unei proteze speciale Danis (pentru hemoragiile de la nivelul varicelor esofagiene), fie a balonasului Blakemore (pentru hemoragii de la nivelul varicelor esofagiene sau gastrice), aceste metode reprezentand un “pod” pana la efectuarea TIPS-ului ca terapie de salvare.

Upper digestive bleeding is a severe and life-threatening complication in patients with portal hypertension, with a high mortality rate. In most of the cases its origin is at the level of the esophageal varices, but in rare cases it is about the rupture of a gastric varix, in which situation, the mortality rate is much higher. The treatment of esophageal bleeding comprises pre-endoscopic measures (restoration of fluid and electrolyte balance, administering Terlipressin or similar drugs) and endoscopic techniques. Endoscopic treatment of variceal bleeding is differs depending on the origin of bleeding. In case of esophageal varices, we can inject sclerosants (hypertonic glucose, alcohol, ethoxysclerol) or, preferably, we may band them. In case of gastric varices, the treatment of choice is cyanoacrylate injection or a combination of coils and cyanoacrylate. These are endoscopic methods but recently it is preferred to use endoscopic ultrasound-guided methods, which would result in a higher precision of the medical gesture and a lower complication rate. In situation in which the methods mentioned above do not succeed in managing the bleeding, there is the possibility of using a special Danis stent (for esophageal variceal bleeding) or a Blakemore tube (for esophageal or gastric variceal bleeding), these methods representing just a bridge to the salvage TIPS.