SURGICAL TACTICS FOR PATIENTS WITH BLEEDING FROM GASTROESOPHAGEAL VAR-ICOSE VEINS

Rationale. Gastroesophageal varicose veins (GVV) bleeding is one of the most dangerous complications of portal hypertension (PG) of different genesis. The presence of clinically significant PG is a main factor that significantly impairs bleeding prognosis. We decided to evaluate the efficacy of treating of patients with bleeding caused by GVV. Materials. 168 patients with PG who were com-plicated by bleeding from the esophagus and stomach were analyzed. Results. All patients were admitted urgently, with a history of PG between one and five years. In 21 patients (12.5 %) with cirrhosis (hepatic PG), the gas-troesophageal veins spread from the esophagus to the stomach over a small curvature and had a trunk structure. In the formation of this type of GVV, the left gastric vein was essential. 85 patients (50.6 %) were diagnosed with large GVV conglomerates extending from the esophagus into the stomach over a large curvature. In 23 patients (13.7 %), bleeding was performed for the large curvature, the antral, or the duodenum. Their cause was usually vascular thrombosis of the portal system. In some patients, they spread to the esophagus, grasping the cardiac and subcardial sections of the stomach. At the time of admission to the hospital, active bleeding from the GVV was diagnosed in 109 patients (58.6 %). Hemostasis with endoscopic ligation of varices at bleeding height was only achieved in 6 (28,6 %) of 21 patients in whose the gastroesophageal veins spread from the esophagus to the stomach by a small curvature and had a trunk structure. Among 57 patients with bleeding isolated veins of the stomach, hemostasis was in 25 (43,9 %) and among 23 patients with large curvature, antral part, or duodenum bleeding achieved it was in – 9 (39,1 %). Endoscopic bleeding arrest was ineffective in patients with large GVV conglomerates extending from the esophagus in to the stomach on a large curvature due to the need for significant inversion. Systemic intravenous therapy included recovery of VCB and preservation of tissue perfusion, antifibrino-lytic therapy, oral antibiotic prevention, prevention of hepatic encephalopathy, portodecompressive therapy, intake of nonselective β-blockers. Oral antibiotic prophylaxis has been mandatory in patients with liver cirrhosis. Only 19 patients (10.2 %) with low risk of infection (Child-Pugh class A) were excluded. Acute bleeding from the esophagus of the esophagus and stomach has often been associated with bacterial infection due to the dislocation of the intestinal microflora. In order to prevent hepatic encephalopathy, complex treatment included lactulose to obtain a two-fold stool per day. Often, impaired brain activity in patients with GVV has been associated with the translocation of intestinal decay products. In addition, the presence in fecal masses increased the growth of potentially pathogenic bacteria with a decrease in the percentage of bifid and lactobacilli. The appointment of lactulose allowed restoring this balance. Conclusion. Endoscopic hemostasis is a leading measure of treatment of gastrointestinal bleeding. The choice of haemostasis method (ligation or sclerosis) should be considered individually and the possibility of recurrence of bleeding also should be anticipated. The stratified risk of prevention of recurrent bleeding from GVV with consideration of Child-Pugh liver function, hemodynamic responses to nonselective β-blockers, and NIEC index improves survival of patients.