Portal hypertension and splenic disease
Esophageal and gastric fundic varices
【History taking】
1.Extrahepatic portal hypertension such as portal vein thrombosis, abdominal trauma, intra-abdominal tumor, pancreatitis, splenic cysts, congenital anomalies, pregnancy, oral contraceptives, etc.
2, intrahepatic portal hypertension. Including.
(1) Intrahepatic pre-sinusoidal portal hypertension, such as schistosomal liver fibrosis.
(2) intrahepatic mixed portal hypertension, mainly seen in cirrhosis.
(3) Intrahepatic post-sinusoidal portal hypertension, such as Budd-Chiari syndrome, etc.
(3) Idiopathic portal hypertension.
(4) History of upper gastrointestinal bleeding.
Physical examination]
The presence of liver palm, demented spider nevus, abdominal wall varices, jaundice, ascites, splenomegaly, hemorrhoids, etc.
Auxiliary examination
1.B-type ultrasound: it can show whether there is enlargement, obstruction and thrombosis of portal vein, splenic vein, superior mesenteric vein, etc., but it cannot directly observe whether there is varices in esophagus and fundic veins.
2.Barium meal examination of esophagus: it can be used to diagnose esophageal varices, and its degree and scope can be understood, but it is less used now. If endoscopy is not available, it is still the main examination method to diagnose this disease.
3.Endoscopy: diagnose esophageal and fundic varices with high accuracy. The scope and degree can be understood. This examination should be strived for when conditions permit in order to determine the diagnosis.
4.CT scan, portal angiography, portal manometry and other examinations are also helpful for diagnosis, but they are non-conventional examinations. These tests should be performed when necessary and when conditions permit.
Diagnosis and differential diagnosis
1.Esophageal and fundic varices themselves have no specific clinical manifestations. The possibility of esophageal and fundic varices should be considered if the patient has an etiology that can lead to portal hypertension, especially if he has a history of upper gastrointestinal bleeding.
2, Ancillary tests suggest the presence of esophageal and fundic varices.
3, endoscopy not only can confirm the diagnosis of esophageal and fundic varices, but also can understand their scope and degree.
4, not all patients who have the cause of portal hypertension or upper gastrointestinal bleeding have esophageal and fundic varices. For patients with the cause of portal hypertension, barium meal or endoscopy should be chosen according to the situation to understand the presence or absence of esophageal and fundic varices. For those who have upper gastrointestinal bleeding, emergency endoscopy should be performed as much as possible to clarify the diagnosis when conditions permit.
Treatment principles
1.Treatment of ruptured esophageal and fundic varices bleeding.
(1) First aid treatment.
(1) Keep the airway unobstructed and circulatory monitoring.
(2) restore blood volume and maintain red blood cell pressure volume above 30%.
(3) Placement of nasogastric tube and urinary catheter.
4) invasive hemodynamic monitoring methods when condition permits.
5) transfusion of fresh frozen plasma, condensed proteins, platelets and other corrective coagulation should be considered.
6) infusion of glucose, vitamins B, K, C, etc.
(7) sedation may be applied at the discretion of the agitated patient.
8) prevention and control of hepatic encephalopathy in patients with liver cirrhosis.
9) correction of electrolyte metabolism disorders.
(10) Preventive use of antibiotics as appropriate.
(2) Internal medicine treatment.
(1) gastric lavage.
(2) the use of posterior pituitary hormone, nitroglycerin can be used to counteract the side effects of posterior pituitary hormone, growth inhibition can be used when available (or Zantac).
(3) balloon compression: double-lumen single-cyst, three-lumen double-cyst and four-lumen double-cyst tubes can be used to stop bleeding. Its first hemostasis rate is about 80%, and the hemostasis rate for rebleeding is 60%; in addition, it may lead to complications such as airway tamponade, which should be given high priority.
(4) transendoscopic injection sclerotherapy: the hemostasis rate of this therapy is 80% to 90%, and it can be repeated after hemostasis.
(5) percutaneous transhepatic portal vein puncture variceal vein embolization and transfemoral artery cannulation splenic artery embolization can be considered for a few cases when conditions and certain experience are available.
(3) Emergency surgery.
It is generally believed that the mortality rate of emergency surgery for ruptured esophageal and fundic variceal bleeding is high, and we should strive to stop the bleeding and improve the general condition and liver function before elective surgery. The ruptured esophageal and fundic variceal bleeding that cannot be stopped by non-surgical treatment or has been adequately prepared for elective surgery should be stopped by surgery. There are two types of surgical methods: dissection and bypass. The choice of which type of surgery is preferable is still controversial. Most people think that it is relatively safer to choose dissection in emergency situation, and fundic cardia portal-body circulation block is the preferred procedure.
2.Preventive treatment of esophageal and fundic varices.
(1) Drug treatment: β-blockers, nitroglycerin, calcium channel blockers, H2 receptor antagonists, Chinese medicine, etc. can be chosen. However, the efficacy is not yet certain.
(2) Compared with drug therapy, the recurrent bleeding rate is reduced by about half and the survival rate is improved. However, the recurrent bleeding rate can still be about 40%. It must be repeated to achieve better results. For those who intend to do esophageal transection or bypass surgery should not be treated with this therapy before surgery.
(3) Surgical treatment.
Surgical methods to prevent ruptured esophageal and fundic varices from bleeding still include two types of dissection and bypass; for intrahepatic portal hypertension with advanced cirrhosis, liver transplantation can still be considered as an option.
The choice of dissection and bypass is still controversial in China. In recent years, there is an increase in the number of patients opting for flow dissection, and this type of procedure is especially suitable for some primary hospitals. In principle, it should be considered according to the patient’s condition, hospital conditions and operator’s experience.
Efficacy criteria
1, cure: bleeding stops, symptoms are relieved, varicose veins disappear, no complications.
2.Good: bleeding stops or there is still a small amount of black stool, symptoms are relieved, varicose veins are reduced, no treatment complications.
3.Unhealed: untreated or ineffective treatment.
Discharge criteria]
Meet the criteria of cure or improvement.
Splenomegaly, hypersplenism
History taking]
1. Pay attention to the presence of congenital hemolytic anemia and acquired autoimmune anemia in the primary disease, which can cause primary hypersplenism. The common cause of secondary hypersplenism is cirrhotic portal hypertension, and other causes include infection, amyloidosis, lymphoma, and myeloproliferative disorders.
2. The main symptoms of this disease are the corresponding symptoms due to the reduction of one, two or whole blood cells in the three blood lines of red blood cells, white blood cells and platelets, such as weakness, panic, dizziness, susceptibility to upper respiratory tract infections, bleeding from the gums and nose, and skin purpura.
Physical examination]
The clinical manifestations of splenomegaly and hypersplenism depend on the degree of splenomegaly and the reduction of hematopoietic fraction caused by hypersplenism. There may be rapid and strong pulse, increased pulse pressure, pale skin and mucous membranes, subcutaneous hemorrhagic spots, congestion in the throat, enlarged tonsils, enlarged heart borders, heart murmurs and pathological heart sounds, enlarged splenic turbinates or masses in the left upper abdomen. There may also be signs of primary disease, such as enlarged superficial lymph nodes, swelling of lower limbs, jaundice, liver palm, demented spider nevus, abdominal distention, abdominal wall varices and positive ascites sign.
Auxiliary examination】
1.B ultrasound examination helps to determine the diagnosis. CT or ECT examination can be done if conditions permit.
2.For splenomegaly whose cause is not clear, further examination can be done for its possible cause. Such as hemolysis, liver function test, barium swallow of esophagus, fiber endoscopy. If necessary, ultrasound, CT or MRI of the pancreas and splenic venography can be performed to understand the presence of splenic vein obstruction.
Bone marrow aspiration is also required for those who have decreased blood cells but splenomegaly is not obvious and the cause of splenomegaly is not clear. If necessary, other etiologic tests should be done.
Diagnosis
1. History of the primary disease causing splenomegaly and hypersplenism.
2. clinical manifestations of splenomegaly and hypersplenism.
3. Ancillary tests support splenomegaly and hypersplenism.
Differential diagnosis]
The diagnosis of splenomegaly and hypersplenism should be differentiated from the following diseases: splenic tumors, splenic cysts, certain infectious diseases, splenomegaly caused by hematologic diseases, etc.
【Treatment principles
The main treatment for splenomegaly and hypersplenism is splenectomy. However, patients under 15 years of age and those with hemolytic crisis are contraindications to surgery.
Efficacy criteria】
1.Cure: disappearance of symptoms, normalization of peripheral blood picture; splenectomy, no surgical complications.
2.Improvement: symptom reduction and peripheral blood picture rebound.
3, not cured: no treatment or no significant improvement in symptoms and peripheral blood picture after treatment.
Discharge criteria
Achieve the standard of cure or improvement.
Hematologic splenomegaly
History taking]
The presence or absence of hematologic diseases causing splenomegaly, including benign hematologic diseases and malignant hematologic diseases. The former include hereditary spherocytosis, symptomatic oval erythrocytosis, structural hemoglobinopathy, thalassemia, and acquired hemolytic anemia. The latter include leukemia, chronic myelofibrosis, etc. Presence of clinical symptoms caused by these diseases.
[Physical examination].
Clinical signs of primary blood disorders, enlarged splenic turbid zone or masses found in the left upper abdomen, etc.
Auxiliary examinations
1.Checking of primary blood diseases, such as blood routine, bone marrow aspiration examination, etc.
2. B-ultrasound examination can help to determine the diagnosis of splenomegaly. CT, ECT or MRI can be done when conditions permit and when needed.
Diagnosis and differential diagnosis]
The etiology of splenomegaly in hematologic diseases is clear, and the diagnosis is usually made clearly during the diagnosis and treatment of hematologic diseases. However, it needs to be differentiated from portal hypertension, splenic cysts and other occupational lesions of the spleen, as well as splenomegaly caused by certain infectious diseases.
Principles of treatment
There is a wide variety of hematologic diseases, and it is inconclusive whether all splenomegaly caused by different hematologic diseases are suitable for surgical treatment. The choice of splenectomy for hematologic splenomegaly has the following observations.
1. Hematologic diseases complicated by splenic abscess, splenic infarction, splenic vein thrombosis causing regional portal hypertension or the occurrence of splenic rupture are indications for splenectomy.
For certain hematologic diseases, splenectomy may have an ameliorative or “curative” effect and is considered a relative indication for splenectomy. These include: hereditary spherocytosis, Evans syndrome, thrombotic thrombocytopenic purpura, chronic idiopathic thrombocytopenic purpura, warm antibody autoimmune hemolytic anemia, and certain hereditary disorders of red blood cell metabolism such as pyruvate kinase deficiency.
3. Hematological diseases for which the efficacy of splenectomy is still unclear include: hereditary disorders of hemoglobin synthesis, such as thalassemia, Gaucher’s disease, chronic granulocytic leukemia, hairy cell leukemia, chronic aplastic anemia, and myelofibrosis without obvious extramedullary hematopoiesis. For splenomegaly caused by the above diseases, if no other complications occur, the decision to perform splenectomy should be made on the basis of the specific conditions and trade-offs.
Efficacy criteria
1.Cure: splenectomy with no surgical complications.
2, improved: spleen shrinkage and symptom reduction after treatment.
3, not cured: no treatment or no significant improvement in symptoms and signs after treatment.
【Discharge criteria 】
Achieve the standard of cure or improvement.