RU2435591C1 - Method of treating varix dilatation of esophagus in case of portal hypertension - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, and is intended for treatment of varix dilatation of gullet in case of portal hypertension. Administered is detralex in dose 750-1250 mg three times per day, on the following day 750-1250 mg four times per day. Treatment course is repeated during 1-2 months.

EFFECT: method makes it possible to reduce degree of portal hypertension and edematous-ascitic syndrome.

5 tbl, 3 ex

Description

The invention relates to medicine, namely to gastroenterology, and can be used to treat varicose veins of the esophagus with portal hypertension.

A known method of influencing portal pressure using the drug condesaptan (W. Debemardi Venom et al. J Hepatol. 2007, 46: 1026-1033 [1]). This method is taken as an analog.

There is a method of surgical treatment of varicose veins of the esophagus by devascularization of the lower third of the esophagus, the cardiac section of the stomach in combination with splenectomy and transection of the esophagus at the diaphragm. In severe patients, it is carried out in two stages: from the abdominal, and then from the thoracic access. This method is adopted as a prototype (S. Murthy et al. Dig. Dis sci. 2007, 52: 1685-1690U2 [2]). However, the known method does not allow to adjust the patient's condition with portal hypertension.

The aim of the present invention is to increase the effectiveness of the treatment of varicose veins of the esophagus with portal hypertension while reducing morbidity.

The technical result is achieved by the fact that the treatment is carried out using detralex in a dose of 750-1250 mg three times a day, the next day 750-1250 mg four times a day, with a repeat of the course of treatment for 1-2 months.

The method is implemented as follows.

Upon admission, patients note weakness in the right hypochondrium, yellowness of the skin, mild itching, in some cases, an increase in the volume of the abdomen, swelling. From the anamnesis it is known that over the past months the above complaints have appeared. During the examination, liver cirrhosis of C-viral etiology was first diagnosed. With endoscopy revealed varicose veins of the esophagus (VRVP) and polyps of the stomach.

In some patients, the appearance of jaundice was noted. Examination revealed transaminase activity, increased GGTP, alkaline phosphatase, cholesterol, bilirubin. Splenomegaly with cytopenia was revealed.

Objectively: the general condition is satisfactory, normosthenic physique, moderate nutrition. The skin and sclera are of normal color or icteric. Peripheral lymph nodes are not enlarged. Edema in some patients is significant. With auscultation - vesicular breathing, is carried out in all departments, wheezing is not heard. Heart sounds are muffled, the rhythm is correct, the pulse and blood pressure are within normal limits. The oral mucosa is pink, clear, or icteric. The abdomen is increased in volume due to subcutaneous fat and / or ascites. The ascites is moderate, not tense, there are no peritoneal symptoms. In some cases, an expanded venous network on the lateral surface of the abdomen. Palpation of the liver and spleen is not available due to the severity of ascites.

Ultrasound: the liver is not enlarged, in some cases its increase is noted. The structure of the parenchyma is heterogeneous. The gallbladder is of normal size, echogenicity is increased. The pancreas is normal in size with clear, even contours with a uniform parenchyma. The spleen is normal in size or enlarged, the splenic vein is enlarged. A moderate amount of free fluid in the abdominal cavity. Conclusion: diffuse liver damage. Portal hypertension. Ascites.

Endoscopy: esophageal mucosa smooth, pink, shiny. In the distal section, convoluted veins with or without nodes are defined. The mucous membrane above them can be changed. Veins can protrude into the lumen of the esophagus. The cardia closes completely. The lumen of the stomach straightens to its normal form. Moderate amount of fluid. Folds of the gastric mucosa of normal size, longitudinal, elastic. The mucous membrane of the stomach and antrum is diffusely swollen, diffusely hyperemic, in some cases has a mottled appearance with a tendency to depletion. The gatekeeper is going through. The duodenal bulb is rounded. Mucous pink, velvety. The posterior sections without features. Conclusion: varicose veins of the esophagus. Chronic, moderate gastritis.

The final diagnosis. Cirrhosis of the liver C-viral etiology, moderate activity. Portal hypertension: VRVP of the II century, expansion of portal and splenic veins. Transient ascites. Or primary biliary cirrhosis. Portal hypertension: varicose veins of the esophagus, expansion of the portal and splenic veins. Edematous ascites syndrome. Encephalopathy II Art. Splenomegaly with cytopenia (leukopenia, thrombocytopenia, anemia).

The treatment according to the proposed method.

The treatment is carried out using detralex in a dose of 750-1250 mg three times a day, the next day 750-1250 mg four times a day, with a repeat of the course of treatment for 1-2 months.

In the control endoscopy, there is a decrease in the severity of HRVP, ascites and a decrease in the ictericity of the skin and sclera.

The method is further confirmed by specific examples of its implementation.

Example 1

Patient T., born 1941 was admitted with a diagnosis of liver cirrhosis of C-viral etiology, HCV-positive RNA, moderate activity. Portal hypertension: VRVP of the II century, expansion of portal and splenic veins. Transient ascites. ZhKB. Complaints of general weakness, heaviness in the right hypochondrium.

From the anamnesis it is known that over the past 3 months the above complaints have appeared. Examined in the cardiology department of the district hospital, where liver cirrhosis of C-viral etiology was first diagnosed, hepatotropic therapy was carried out with a positive effect. When endoscopic hypertrophy was detected, VRVP and polyps of the stomach.

Objectively: the general condition is satisfactory, normosthenic physique, moderate nutrition. The skin and sclera of normal color. Peripheral lymph nodes are not enlarged. No swelling. With auscultation, vesicular breathing is carried out in all departments, wheezing is not heard, NPV 16 per min. Heart sounds are muffled, the rhythm is correct, pulse = heart rate = 74 per minute, blood pressure 130/80 mm Hg. The oral mucosa is pink, clean. The pharynx is clean. The tongue is wet, clean. The abdomen is enlarged due to subcutaneous fat and ascites. The ascites is moderate, not tense, there are no peritoneal symptoms. It is difficult to judge the size of the liver and spleen due to ascites. Umbilical hernia without signs of infringement. Pasternatsky’s symptom is negative on both sides.

Ultrasound: the liver is not enlarged (thickness of the right lobe 12.8 cm, thickness of the left lobe 56 mm), echogenicity is increased, echo signals of moderate and high intensity. The vascular pattern is significantly depleted. The structure of the parenchyma is heterogeneous. The gallbladder is 5.4 cm × 2.2 cm in size, the walls are 5 mm in size, the echogenicity is increased, the structure is heterogeneous, the contents with inclusions (echo signal 0.1 cm without a shadow behind, echo signals 1.4-1.7 cm s shadow behind). Caliber of choledoch 3 mm. Pancreas: dimensions not increased (head 22 mm, body 11 mm, tail 18 mm). The contours are even, clear. The structure of the parenchyma is homogeneous, echogenicity is not changed. The area of the spleen is 125 cm ² . Dimensions of the splenic vein 11 mm, portal 15 mm. The kidneys are typically located, the contours are even, clear. A moderate amount of free fluid in the abdominal cavity. Conclusion: diffuse liver damage. Portal hypertension. Ascites. Chronic calculous cholecystitis.

Endoscopy. The mucous membrane of the esophagus is smooth, pink, shiny. In the distal section, convoluted veins up to 3 mm in diameter without nodes are determined. The mucous membrane above them is not changed. Veins do not protrude into the lumen of the esophagus. The cardia closes completely. The lumen of the stomach straightens to its normal form. Moderate amount of fluid. The folds of the gastric mucosa of a normal size, longitudinal, elastic, in the body on a large curvature do not completely straighten out (normal version). The mucous membrane of the stomach and antrum is diffusely edematous, moderately diffusely hyperemic. The gatekeeper is going through. In the stomach in all departments, multiple polyps are determined with sizes ranging from 0.2 cm to 1.0 cm in diameter. The mucous membrane above them is hyperemic. The duodenal bulb is rounded. Mucous pink, velvety. The posterior sections without features. Conclusion: VRVP II Art. (by Paquet). Chronic, moderate gastritis.

The patient was transferred to the department of hepatology for treatment.

The treatment is carried out using detralex in a dose of 750 mg three times a day, the next day 750 mg four times a day, with a repeat of the course of treatment for 1 month.

After treatment with a control of ultrasound, a decrease in the expansion of the veins of the esophagus is noted, free fluid in the abdominal cavity was not found.

Admission Statement Norm Component Admission Statement Norm Hemoglobin 9.3 10.1 12-16 g / l Bilirubin 24.7 16,4 3.4-21.0 μmol / L Red blood cells 4.3 4,55 3.9- straight 7.3 0-3.4 μmol / L Hematocrit 27.3 29.3 35-47% Щ.ф. 102.7 30-120 E _d / l White blood cells 5.9 4.4 4-9 × 103 / mm ³ AST 80.5 77.3 5-35 E _d / l Eosinophils 1,0 1,0 0.5-5% Alt 64.9 59.7 5-45 E _d / l PO Box 2.0 2.0 1-6% GGTP 7-42 E _d / l S / i fifty 55 47-72% Cholesterol 3.12 1.4-5.2 μmol / L Lymphocytes 40 36 19-37% Total protein 80.5 66-87 g / l Monocytes 7.0 6.0 3-11% Albumin 33.8 35-52 g / l Platelets 124 162 150- Calcium 2.2-2.7 μmol / L ESR 6.0 5,0 3-20 mm / h Urea 6.01 1.7-8.3 μmol / L Sugar 5.29 4.1-5.9 mmol / l Creatinine 70.9 58-96 microns APTTV 32,4 25-35 sec Potassium 4.57 3.5-5.1 μmol / L Prothrombin 61 80-105% Sodium 143.6 136-146 μmol / L Mho 1.29 0.9-1.2 Chlorine 4.0 10.7-32.2 mg Fibrinogen 1.23 2.0-4.0 g / l Iron 28-80 E _d / l Blood type 0 (1) Rh-posit. Kell is denied. Amylase

General urine analysis: beats. weight 1018, protein - no, sugar - no, white blood cells - 2-3 in s / sp.

HBsAg - neg, anti-HCV - positive. HCV RNA - detected, genotype 1. RMP (07/24/09), HIV (07/22/09) - not detected.

Example 2

Patient S. born in 1952 was admitted with a diagnosis of liver cirrhosis of C-viral etiology, HCV-PHK positive, genotype 1, class A (6 points) according to Child-Pugh, moderate activity. Portal hypertension: varicose veins of the esophagus of the 1st century, expansion of the portal and splenic veins. Edematous ascites syndrome. Splenomegaly with the phenomena of biliary growth hypersplenism (thrombocytopenia, leukopenia). Mild iron deficiency anemia. On admission: complaints of an increase in the volume of the abdomen.

From the anamnesis, it is known that during a routine examination in a biochemical blood test revealed an increased activity of hepatic transaminases (ALT 208, ACT 142.8), an increase in bilirubin to 32.8, in a general blood test - thrombocytopenia (67), leukopenia (2.7 ), revealed anti-HCV. Ultrasound revealed splenomegaly, with endoscopic endoscopic hypertrophy of respiratory infections did not reveal. In 2007, he was diagnosed with Cirrhosis of the liver of C-viral etiology, positive PHK-HCV, high activity. Splenomegaly with the phenomena of two-growth cytopenia (thrombocytopenia and leukopenia). Portal hypertension: expansion of the portal and splenic veins. "

Objectively: general state of moderate severity. Normostenic physique. Adequate nutrition. The skin is of normal color, the sclera is subjective. The legs are pasty. Peripheral lymph nodes are not enlarged. The bone and muscle system without features. In the lungs, hard breathing, no wheezing, NPV 16 per min. Heart sounds are muffled, no noise. The rhythm is correct, pulse = heart rate = 88 per minute, blood pressure 140/80 mm Hg Oral mucosa of a normal color. The pharynx is clean. The tongue is moist, slightly coated with a white coating. The abdomen is involved in the act of breathing, increased in volume due to ascites, with superficial palpation painless in all departments. Palpation of internal organs is difficult due to ascites. Pasternatsky’s symptom is negative on both sides.

Ultrasound Liver: dimensions increased (thickness of the right lobe 13.8 cm, left 7.9 cm). The structure of the parenchyma is heterogeneous, echogenicity is significantly increased. The vascular pattern is significantly depleted. The portal vein is expanded, diameter 15 mm. Volumetric formations are not identified. The bile ducts are not dilated, choledoch 3 mm. Gall bladder: the shape is not changed, the dimensions are not changed, the length is 5.7 cm, the diameter is 2.3 cm. The walls are thickened, 4 mm, the echogenicity is average, the structure is homogeneous, the contents are homogeneous, there are no stones. The paravesical region is not changed. Pancreas: normal location, enlarged. Head 36 mm, body 24 mm, tail 32 mm. The contours are uneven, clear. The structure of the parenchyma is heterogeneous, echogenicity is increased, the prevalence of high-intensity echo signals. Wirsung duct is not expanded, diameter 2 mm. Spleen: normal arrangement, contours smooth, clear, capsule unchanged, dimensions increased (length 184 mm, diameter 86 mm, area 132 cm ² ). Parenchyma homogeneous, increased echogenicity. The splenic vein is expanded, diameter 11 mm. The kidneys are typically located, the contours are even, clear. The right kidney is 104 × 42 mm, the left kidney is 104 × 42 mm. Corticomedular differentiation is not changed. The pyelocaliceal system is not expanded, there are no calculi. In the abdominal cavity, a moderate amount of free fluid (anechoic zone 13 × 4 cm). There is no free fluid in the abdominal cavity. Conclusion: diffuse liver damage. Portal hypertension. Ascites. Chronic pancreatitis.

U3-control ascites: a small amount of free fluid in the abdominal cavity. Echo-KG: Aorta 3.8, AK 2.2, left atrium 2.0, KSR 33, KDR 51, PV 60%, FU 30, TM 1.0, TK 1.0, PP 4.8 × 4, 2, pancreas 3.0. E = 82 cm / s, A = 83 cm / s.

LV systolic function is preserved. Mild LV diastolic dysfunction. The cavity of the right atrium is moderately dilated. The walls of the aorta and the valves are sealed. Zones of impaired LV contractility have not been identified. No fluid was detected in the pericardial cavity. No leaf vegetation. ECG: sinus rhythm, correct, heart rate 93 beats / min. The semi-vertical position of the EOS. When ultrasound scan revealed portal hypertension.

Laboratory Results

No HBs antigen detected; anti-HCV detected. RMP is negative. No HIV antibodies were detected. Blood group A (II) Rh (+) positive, Kell antigen (-) negative.

Immunogram: IgM 650 (norm 50-130 mg%), IgG 1750 (norm 750-1300 mg%), IgA 240 (norm 90-230 mg%). General analysis of urine 15/02/10: relative density 1.014, alkaline reaction, protein, glucose, white blood cells, red blood cells, ketone bodies, no nitrites; urobilinogen 70 μmol / L.

Analysis of feces for occult blood 8/02/10 - negative.

Coagulogram

3/02/10 02/15/10 Norm Fibrinogen 2.1 2-4 g / p APTTV 30.8 95-35 s Mho 1.19 1.29 09-1,2 Prothrombin 78.6 74.6 70.0-130.0%

General blood analysis

3/02/10 8/02/10 02/15/10 Norm Hemoglobin 10.7 11.6 12.6 4-16 g / dl Red blood cells 4.32 4,54 4.85 3.9-4.7 10l ⁶ / mm ³ Reticulocytes 0.7 0.2-1% Platelets 45 56 79 150-400 10A3W White blood cells 2.6 9.5 3-3 4-9 10 l ³ / mm ³ P / Nuclear 6 one 2 1-6% C / Nuclear 55 59 54 47-79% Eosinophils four 9 9 0.5-5% Lymphocytes 33 38 36 19-39% Monocytes 2 7 56 3-11% ESR 12 12 19 3-15 mm / h

Blood chemistry

3/02/10 8/02/10 02/15/10 Norm ALT 108.8 109.8 5-34 E _d / l Albumen 36.3 38.7 35.0-52.0 g / l ACT 162.2 146.3 5-31 E _d / l Protein 75.7 66-83 g / l Common bilirubin 32,2 33.1 5-21 μmol / L Direct bilirubin 9.3 9.7 0-3.4 μmol / L GGTP 20.5 24.2 7.0-42.0 U / L Glucose 5.16 4.1-5.9 mmol / L Iron 11.9 13.5 12.5-32.2 μmol / L Lhss 73.0 27.8-53.7 μmol / L OZhSS 86.6 44.8-71.6 μmol / L STFe 15.7 20-50% Potassium 4,54 5 4.86 3.5-5.1 mmol / L Creatinine 66.7 63,4 77.9 58.0-110 μmol / L Urea 4.95 4.07 5.18 2.8-7.2 mmol / L Sodium 136 140 132.2 136-146 mmol / L Cholesterol 3.76 up to 5.2 mmol / l Alkaline phosphatase 71.8 75.3 30.0-120.0 U / L

Treatment is carried out using detralex at a dose of 1000 mg three times a day, the next day 1000 mg four times a day, with a repeat of the course of treatment for 1.5 months.

As a result of treatment, edematous ascites syndrome resolved. Moderate cytolysis persists. It is discharged in satisfactory condition.

Example 3

Patient M. born in 1941 was admitted with a diagnosis of primary biliary cirrhosis of the IV century, AMA M2-positive, active. Class C (13 points) by Child-Pugh. Portal hypertension: varicose veins of the esophagus II degree, expansion of the portal and splenic veins. Edematous ascites syndrome. Encephalopathy II Art. Splenomegaly with cytopenia (leukopenia, thrombocytopenia, anemia). Chronic pancreatitis, remission.

From the anamnesis it is known that the patient complains of yellowness of the skin, skin itching, an increase in the abdomen in volume, swelling. The appearance of jaundice is associated with a 3-month intake of marinel. Examination revealed transaminase activity: ALT 87, ACT 150, GGTP 384, alkaline phosphatase 2221, cholesterol 9.87, bilirubin 114/95. Itchy skin appeared in December 2006. HBsAg, anti-HCV - not detected. Diagnosed with primary biliary cirrhosis, active, AMA M2-positive. Class B by Child Pugh. Portal hypertension: varicose veins of the esophagus II degree, expansion of the portal and splenic veins. Ascites. Splenomegaly with cytopenia (leukopenia, anemia). IgM 320 (50-130 mg%), IgG 2100 (750-1300 mg%), IgA 340 (mg%). ANA - negative, AMA M2 150 IU / ml (normal 0-10). AFP - neg.

Survey results (upon admission).

Biochemical analysis of blood: total bilirubin 155.8, alkaline phosphatase 412, ALT 56.3, AST 112.8, GGTP 78.7; cholesterol 4.25. Clinical blood test: HB 89, erythritis 2.91, lake 3.8, blood clot 135, ESR 58. Ultrasound of the abdominal organs: pronounced signs of diffuse changes in the liver. The splenic vein is dilated 11 mm. The portal vein is dilated 15 mm. Chronic pancreatitis. Ascites.

Endoscopy: varicose veins of the esophagus 1 degree. Chronic gastritis with patches of mucosal atrophy.

The treatment is carried out using detralex in a dose of 1250 mg three times a day, the next day 1250 mg four times a day, with a repeat of the course of treatment for 2 months.

The patient was discharged with clinical and laboratory improvement, however, the level of bilirubin remained within 160 μmol / L. After discharge, I felt satisfactory. The yellowness of the skin is preserved.

Laboratory data at discharge

Test component Admission Drink ska Norm Test component Admission Statement Norm Hemoglobin 7.0 9.5 12-16 g / l Bilirubin 144.5 166.6 3,4- Red blood cells 2.72 2.96 3.9-4.7 × 6 / mm ³ straight 70 84,4 0-3,4 Hematocrit 20.3 25.1 35-47% Щ.ф. 533 548.9 30-120 E _d / L White blood cells 2,8 2,3 4-9 × 103 / mm ³ AST 125.3 135.2 5-35 E _d / l Eosinophils 1,0 2.0 0.5-5% Alt 50.3 69.5 5-45 E _d / l PO Box 1,0 5,0 1-6% GGTP 98.1 124.6 7-42 E _d / l S / i 65 2.0 47-72% Cholesterol 3,51 1,4- Lymphocytes 25 5,0 19-37% Total protein 71.7 66-87 g / l Monocytes 8.0 5,0 3-11% Albumin 21,4 24.5 35-52 g / l Platelets 122 120 150-400 × 10 ³ / mm ³ Calcium 2.2- ESR 58 45 3-20 mm / h Urea 5.64 4.26 1.7-8.3 Sugar 4,58 4.1-5.9 mmol / l Creatinine 77.9 58- APTTV 25-35 sec Potassium 4.83 4,58 3.5-5.1 Prothrombin 59.7 50,2 80-105% Sodium 142.5 131.3 136- Mho 1.3 1.4 0.9-1.2 Chlorine Fibrinogen 2.0-4.0 g / l Iron 26.6 10. ⁷ Blood type 0 (1) Rh - positive. Kell is denied. Amylase 28-80 E _d / L

Immunoglobulins: M -300 (N-130); G - 2700 (N-1300); A - 300 (N-230) HBs-Ag, anti-HCV - not detected. AT HIV (03.23.09), RMP (03.19.09) - negative. Feces for occult blood - neg.

Urinalysis: relative density 1,025, reaction 5,5, protein - no, glucose - no, white blood cells - one. in the field of view, bilirubin 34 μmol / l, urobilinogen> 200.

As a result of the treatment, a decrease in ascites, edema of the lower extremities, an increase in hemoglobin level is noted.

Using the proposed method, 35 patients of the hepatological department with cirrhosis of the liver of various etiologies, primary biliary cirrhosis were treated.

In all cases, there is a positive trend: a decrease in peripheral edema and ascites, a decrease in the degree of portal hypertension, a decrease in the ictericity of the sclera and skin, and a positive trend is achieved without the use of surgical treatment methods.

Claims (1)

A method of treating varicose veins of the esophagus with portal hypertension, including a drug effect, characterized in that the treatment is carried out using detralex in a dose of 750-1250 mg three times a day, the next day 750-1250 mg four times a day, with a repeat of the course of treatment within 1-2 months.