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Repeated bleeding in cirrhosis. Prognosis and treatment of bleeding in liver cirrhosis

One of the dangerous complications of cirrhosis of liver tissue is hidden or obvious blood loss. In 40% of patients, bleeding with cirrhosis is fatal. The main cause is portal hypertension. With a simultaneous increase in the volume of plasma circulating through the vessels and limitation of its flow into the liver, most of the tissues of which are replaced by fibrin, the vascular walls expand. They cannot withstand due to their fragility, which developed against the background of a deficiency of nutrients. The combination of these factors develops internal and/or subcutaneous bleeding.

Inflammation of the liver is accompanied by bleeding.

Hemorrhagic syndrome

The condition is characterized by numerous small hemorrhages under the skin, in tissues and mucous organs. The reason lies in a decrease in blood clotting and active fibrinolysis with progressive liver cirrhosis. Not only microbleedings that occur asymptomatically can develop, but also extensive blood loss that threatens the patient’s life. The syndrome is often accompanied by intense nosebleeds.

Manifestations

Clinic hemorrhagic syndrome- diverse. The most common symptoms are:

Skin rashes. The nature of the rash varies, but most often in the form of:

small petechiae up to 3 mm in size;
large ecchymoses in the form of hemorrhages, hematomas, bruises.

Usually the rash does not exceed 10 mm and appears in the form of petechiae or ecchymoses from a purple to purple hue, which do not disappear when squeezed.

Painful sensations in the joints, muscles, and abdomen of varying intensity and character - from constant aching to shooting, stabbing.
Fever, fever, chills.
Visible nasal, gum, uterine, rectal bleeding from varicose vessels.

Types and types

There are 5 main types of hemorrhagic syndrome, such as:

Bleeding due to liver inflammation can be external and internal with varying intensity.

Petechial-spotted, when bruises of different diameters appear on the body. The root cause is a decrease in coagulability due to thrombocytopenia and lack of fibrinogen.
Hematoma, in cases where cirrhosis is accompanied by hemophilia, genetic diseases blood. Hematomas often form due to minor injuries directly on the soft tissues with extensive painful swelling.
Microcirculatory, when large hematomas are formed in the retroperitoneal sheets and characteristic rash on the skin. It is observed with the development of DIC syndrome, von Willebrand pathology against the background of cirrhosis or aggravation of the condition by thrombolytics, anticoagulants.
Purple when cirrhosis is accompanied by a secondary infection in the form of vasculitis. Manifested by skin erythema, intestinal bleeding, jades.
Angiomatous, when persistent blood loss of permanent localization develops. Manifests itself against the background of general vascular disorders caused by cirrhosis.

Hemorrhages through the nose and other organs with cirrhosis may differ in intensity depending on the severity of liver atrophy, therefore they are distinguished the following types:

Nosebleeds due to liver inflammation can be mistakenly confused with problems blood pressure.

Gum bleeding of varying severity. It can appear at any stage of cirrhosis.
Nasal hemorrhages. The main reason is increased blood pressure and fragility of nasal vessels.
Uterine bleeding. Always abundant, therefore dangerous. For the most part, without taking appropriate measures, it leads to death.
Hemorrhoidal blood loss. Causes: varicose veins of the rectum and increased blood pressure vascular walls. They differ in abundance.
Internal bleeding is the most dangerous, as it occurs covertly, with vague symptoms. The category with an unfavorable prognosis includes blood loss from the upper parts of the stomach and esophagus into the esophagus.

Bleeding of varying severity can develop at any stage of cirrhosis, but more often pathology signals the onset of the last, terminal stage of liver tissue damage.

Diagnostics

To make a diagnosis you need:

collecting anamnesis, clarifying the time of onset of cirrhosis, identifying possible causative factors;
examination of the patient, who often has an emaciated appearance, pale skin, feels chronic fatigue and weakness, when the skin is compressed, specific pinpoint rashes(hemorrhages);
blood serum test: general analysis, counting the number of platelets, prothrombin and fibrinogen, determining coagulation, hematopoiesis time, clotting rate and heparin tolerance;
taking urine tests;
cerebrospinal fluid puncture;
bone marrow biopsy.

Internal bleeding in liver cirrhosis

The root cause of the development of blood loss from organs is portal hypertension. The pathology is characterized by:

disruption of blood flow from the liver;
its abundant influx to the affected organ;
the formation of a large number of collaterals - new vessels to bypass blood outside the liver.

Additional vessels can form:

in the tissues of the stomach or esophagus;
at the anus;
at the umbilical vein;
in peritoneal sheets, ligaments, folds;
in scar tissue formed after operations;
in the area of blockage of extrahepatic vessels.

These processes provoke varicose veins in the blood vessels of the organs. The esophagus and upper stomach are most often affected.

There are 3 theories of bleeding in liver cirrhosis:

Damage to the dilated vein, which occurs:

Bleeding in cirrhosis can occur against the background of vascular injury or the development of other pathologies.

spontaneous;
provoked mechanically (cough, vomiting, lifting).

Injury to a vein due to gastroesophageal reflux, when under certain conditions acidic gastric contents are refluxed into the esophagus.
The presence of extensive varicose veins.

Main symptoms:

bloody vomiting in dark masses;
discharge of mushy, semi-liquid stool with blood - melena;
chest pain and feeling of pressure;
severe weakness;
nausea;
pale skin;
nose bleed;
increased heart rate and heart rate;
drop in blood pressure.

Clinical symptoms:

blood tests reveal anemic signs;
FGDS reveals the site of bleeding.

If blood loss begins in the stomach or esophagus, symptoms include:

scarlet or coffee vomit;
melena;
disturbance of general well-being.

When intestinal or hemorrhoidal bleeding appears:

scarlet stools or blood clots after bowel movements;
frequent nosebleeds;
pain and burning with a sensation of a foreign particle in the rectum;
constipation

The diagnosis can be confirmed using colonoscopy.

From the esophagus

In 40% of cases, this type of blood loss ends in death. The root cause is a rupture of the dilated vein of the esophagus. Consequences pathological condition- ulceration of the surface of the organ mucosa and tissue atrophy.

Provoking factors for the development of bleeding:

liver cancer;
violation of diet, alcohol consumption;
terminal stage;
portal vein thrombosis;
formation of large varicose nodes.

Symptoms:

chest pain, pressure and burning;
blood in stool;
nosebleeds;
vomiting dark blood;
nausea, weakness.

From the gastrointestinal tract

Bleeding from the stomach with inflammation of the liver provokes fainting, fever, and weakness.

It appears suddenly without the first symptoms. The main consequence is ascites. Signs:

severe weakness;
fainting;
nose and eye bleeding;
vomiting blood without nausea.

Liver cirrhosis is characterized by the degeneration of the parenchyma of this organ into connective fibrous tissue, which affects its functioning. The liver gradually ceases to perform its main job - cleaning the blood from toxins and breakdown products, and other substances harmful to the body. In addition, the formation of constrictions from connective tissue impairs blood circulation in this organ, leading to portal hypertension. It represents an increase in blood pressure in the portal vein. Bleeding in liver cirrhosis poses a serious threat to the health and life of the patient.

Types of bleeding in liver cirrhosis

Depending on the degree of damage, bleeding in the body can occur in different places. With liver cirrhosis, the following pathologies most often occur:

Increased bleeding of gums. Accompanies various types and stages of cirrhosis, maybe varying degrees intensity.
Nosebleeds. They are associated with high blood pressure and high vascular fragility.
Uterine bleeding. Due to the abundance of fairly large vessels, they can be very dangerous. If appropriate measures are not taken in time, such bleeding can quickly lead to death.
Hemorrhoidal bleeding. Associated with dilation of the rectal veins caused by high pressure. Like uterine bleeding, hemorrhoidal bleeding can be exceptionally profuse, which threatens the patient’s life.
Internal bleeding. They are the most dangerous, as they can begin covertly and have blurred manifestations. This type of bleeding in cirrhosis is one of the causes of death in patients with late stages development of the disease. Particularly dangerous are bleeding associated with varicose veins of the stomach and esophagus.

Bleeding in liver cirrhosis may have different intensities, but the appearance of this problem means an advanced disease and the onset of its terminal stage.

The role of bleeding in the development of the disease

Gastrointestinal bleeding plays a major role in the death of patients with liver cirrhosis. This is very
a common complication that occurs in the later stages of cirrhosis. A huge number of internal varicose veins leads to the threat of their rupture, which can occur either from the slightest physical effort or spontaneously, under the influence internal factors. Extensive bleeding may be accompanied by fainting of the patient, severe pallor of the skin, and bloody vomiting. If small veins are opened, bleeding may be gradual. In this case, vomiting may also appear, which in its color and consistency resembles coffee grounds. This is explained by the fact that the blood has time to clot in the stomach and begins to be partially digested. In the future, unformed black stool may be detected, which is a clear sign the presence of bleeding in the esophagus or stomach. It may be accompanied by the appearance of scarlet blood at the end of a bowel movement if hemorrhoidal bleeding occurs.

Bleeding in liver cirrhosis is extremely dangerous and requires prompt hospitalization of the patient. Produced surgery However, in a third of all cases, the bleeding itself or its consequences lead to death. Only timely diagnosis of liver cirrhosis and the beginning of its treatment can prevent the occurrence of such ominous symptoms, such as portal hypertension and the development of bleeding from the internal veins.

From 50 to 70% of patients with cirrhosis of the liver have varicose veins of the esophagus and stomach, which develops in 90% of them within 10-12 years. One-third of patients experience one or more episodes of bleeding due to rupture of varicose veins, which is a serious complication of portal hypertension and one of the causes of death in patients with cirrhosis. In industrialized countries, about half of all deaths from gastrointestinal bleeding are caused by variceal bleeding.

BLEEDING FROM ESOPHAGUS VARICOSE VEINS

Among the portosystemic collaterals, the esophageal ones have the greatest clinical significance due to their tendency to bleeding (in approximately 1/3 of cases). Bleeding causes high mortality - about 30-50% of patients during the first episode die within 6 weeks. The likelihood of relapses worsens the prognosis—recurrent bleeding within a year is avoided in only 2/3 of patients. Variceal bleeding is the cause of 10-15% of deaths in patients with cirrhosis, and early relapses of bleeding are the most dangerous prognostic sign.

The risk of developing varicose veins appears when the porto-caval gradient exceeds 12 mm Hg. It is unclear to what extent the cause of cirrhosis is associated with the risk of developing varicose veins.

Diagnostics. Patients with cirrhosis should undergo endoscopic examination to determine the presence of varicose veins. If the patient does not have varicose veins, the frequency of endoscopic examinations is 1 time every two years, if present - 1 or 2 times a year. This is due to certain dynamics of the development of varicose veins: it has been established that in half of patients without varicose veins they develop after 2 years, and in 1/3 of patients with small veins they reach an average size after a year. The frequency and severity of varicose veins are proportional to the severity of cirrhosis. If varicose veins detected, the degree of risk of bleeding is assessed and the need for its primary prevention is considered.

Esophagogastroduodenofibroscopy is considered the standard for diagnosing varicose veins of the esophagus and predicting the risk of bleeding. During endoscopy, the size and condition of the veins are assessed.

To indicate a row endoscopic signs To characterize the condition of varicose veins of the esophagus with portal hypertension, the term “red color signs” is used. Red whale marking (RWM) - red stripes on varicose veins, which look like thin, short, tortuous vessels in the mucous membrane above the trunks of the varicose veins. RWM reflects the presence of intraepithelial channels and correlates with the size of varicose veins. Cherry red spots and haemocystic spots are changes in the mucosa that are similar in appearance to hemorrhagic vesicles. Histologically, these changes correspond to blood-filled cavities in the epithelium of the esophagus, communicating with sub-epithelial capillaries. Red color signs mean a 2-3 times increased risk of bleeding for the patient.

Endoluminal sonography - exact method determining the presence of varicose veins and the thickness of their walls. In addition, endosonography is used to determine the presence (absence) and size of paraesophageal veins.

In patients with varicose veins of the esophagus and stomach, three fundamental tasks are solved:

1. Prevention of the first bleeding from varicose veins of the esophagus.

2. Treatment of an acute bleeding episode.

3. Prevention of recurrent bleeding.

Risk factors for bleeding. The development of bleeding depends on the presence of risk factors. A number of signs are taken into account: the condition of the veins and mucous membrane of the esophagus (size, color and localization of varicose veins, the presence of red color signs, esophagitis), severity class, severity of individual manifestations and complications of cirrhosis. Controlled studies have allowed us to establish three risk factors for the first variceal bleeding:

Large varicose veins;

Availability of red color signs;

Severity of liver disease.

The severity of liver disease (Child-Pugh grade) is closely correlated with the size of the varices and the presence of red color signs, as well as response to treatment (including survival after bleeding, the likelihood of its recurrence, the effectiveness of certain pharmacological drugs in controlling bleeding) and results surgical treatment.

The risk of bleeding exists in 1/3 of patients with varicose veins - this applies to patients with a combination of risk factors. However, a significant number of patients with variceal bleeding do not have risk factors. Along with those mentioned, other factors are also taken into account. Thus, importance is attached to local changes - esophagitis with erosions due to acid reflux, although the effectiveness of H2-histamine receptor blockers in the prevention of bleeding has not been proven. Portal pressure also plays a role in the development of bleeding, but does not correlate with the risk of bleeding, and many patients with high blood pressure do not develop bleeding. However, early measurement of the portocaval pressure gradient in patients with cirrhosis provides prognostic information regarding the risk of bleeding. Most often, veins that bleed are located along the distal 5 cm of the esophagus or in the area of the gastroesophageal junction.

Prognosis for bleeding. The prognosis for the outcome of the first episode of bleeding depends on the severity of cirrhosis (according to Child-Pugh). Unfavorable factors are severe bleeding, ascites, azotemia, serum bilirubin level above 65 µmol/l. 33% of patients die during the first episode of bleeding, and 33% of them die within the first week. 70% of bleeding episodes stop spontaneously.

The risk of rebleeding in survivors of the first episode is very high and depends on the severity of cirrhosis: in the first year, relapse is observed in 28% of patients with Child-Pugh grade A, 48% with B, 68% with WITH . The peak frequency of relapses occurs in the first week, and the high danger persists until the second or third month. The severity of liver disease is the only risk factor for early (within 6 weeks) and late recurrent bleeding.

Clinical manifestations of bleeding and control. Clinically significant bleeding is characterized by the following signs (Portal Hypertension. II. Proceedings of the Second Baveno International Consensus Workshop on Definitions, Methodology and Therapeutic Strategies, Italy, 1990):

· the need for transfusion of two or more units of blood within 24 hours from time zero (time of admission to the hospital or time of manifestation of bleeding in the hospital);

· continuous decrease in systolic pressure from time zero (< 100 мм рт. ст.), или колебания давления >20 mm Hg, and/or pulse rate > 100/min.

According to the Baveno II consensus, the definition of failure to control acute bleeding within 6 hours is based on the following:

- transfusion of four or more units of blood;

- failure to increase systolic pressure by 20 mm Hg. from initial or up to 70 mm Hg. and more;

- inability to restore heart rate to< 100/мин или уменьшения на 20/мин от исходного.

Signs of failure to control acute bleeding after 6 hours (Baveno II):

· hematemesis;

· decrease systolic pressure more than 20 mmHg;

· increase in heart rate by more than 20 beats/min;

· transfusion of two or more units of blood to increase hematocrit > 27% or hemoglobin > 90 g/l.

Bleeding from varicose veins adversely affects the condition of the liver parenchyma - hypovolemia and anemia lead to a decrease in oxygen delivery to hepatocytes. This can provoke the development of jaundice, ascites, hepatic encephalopathy. Increased formation of ammonia from blood spilled into the intestines can cause portosystemic encephalopathy.

IN last years a number of treatment methods have been proposed variceal bleeding:

- Drug therapy.

- Balloon tamponade: Sengstaken-Blakemore probe, Linton-Nachlas probe.

- Endoscopic methods: sclerotherapy, obliteration, ligation.

- Surgical methods: suturing of varicose veins; porto-systemic shunting (decompression porto-caval anastomoses - non-selective, selective) transsection of the esophagus; liver transplantation.

- Transjugular intrahepatic portosystemic shunt stent (TIPSS).

Drug therapy. According to the Baveno II consensus, drug therapy gives good results for portal hypertension and is used in three cases: prevention of first bleeding from varicose veins of the esophagus; treatment of an acute bleeding episode; prevention of recurrent bleeding.

Vasoconstrictors and vasodilators are used, the number of which exceeds 50. In practice, drugs with proven effects are used (table, see the paper version of the journal).

Mechanism of action pharmacological agents. Vasoconstrictors - vasopressin, terlipressin, non-selective beta blockers (propranolol, nadolol) - induce vasoconstriction internal organs with a decrease in portal pressure and collateral blood flow. The drugs modify visceral blood flow in patients with liver cirrhosis, while collateral circulation and blood flow along the vv. decrease. azygos, including varicose veins of the esophagus. Selective beta blockers are less effective. Vasodilators (nitroglycerin) and long-acting nitrates (isosorbide mononitrate and dinitrate) reduce portal blood flow and pressure through peripheral vasodilation. Somatostatin (and its synthetic analogue octreotide) is a natural polypeptide that has a number of inhibitory effects on the gastrointestinal tract. Reduces portal blood flow both through a direct selective effect on the smooth muscle of the mesenteric vessels, and indirectly through suppression of the release of vasodilating peptides.

Prevention of first bleeding. If there is a risk of variceal bleeding, the issue of prevention, which is based on drug therapy, is considered. Non-selective beta-blockers have been used for this purpose since 1981, their effectiveness has been established in 9 controlled studies and assessed by three meta-analyses. Propranolol is highly effective and is used in maximum tolerated doses. It has not been established how much portal pressure should be reduced to prevent bleeding, but it is known that bleeding does not occur when the porto-caval pressure gradient decreases to less than 12 mm Hg. Art. A dose of propranolol that reduces heart rate by 25% after 12 hours reduces portal pressure by 30%, although this ratio is not constant. Beta blockers reduce the risk of bleeding by 45%. Propranolol is a safe drug - there are no fatal complications with its use, and those that arise are reversible. For preventive purposes, beta blockers are taken for life.

Contraindications for the use of beta blockers: severe deficiency blood circulation, atrioventricular block, rhythm disturbances, severe obstructive pulmonary diseases, psychosis, insulin-dependent diabetes mellitus.

An alternative means is long-acting nitrates, especially if beta blockers are poorly tolerated. Used and combination treatment: beta blockers (for example, nadolol 40-60 mg/day) + nitrates (isosorbide mononitrate 10-20 mg 2 times a day).

Features of pharmacokinetics and pharmacodynamics of β-blockers in cirrhosis. There are patients who do not respond to beta blockers. One of the reasons for this phenomenon is a decrease in the density of beta receptors in patients with cirrhosis. Propranolol has a significantly pronounced “first pass” effect through the liver, so with advanced cirrhosis, unpredictable reactions are possible. Treatment acute bleeding. Treatment of patients with acute bleeding from varicose veins often requires immediate hospitalization, the joint efforts of a hepatologist, endoscopist, surgeon, intensive care physician, and is highly costly. Emergency therapy is aimed at preventing and/or correcting hemodynamic disturbances associated with hypovolemia and shock. Detection of significant symptoms of hypovolemia (systolic pressure< 90 мм рт.ст., тахикардия >120/min, signs of peripheral hypoperfusion) necessitates oxygen inhalation and rapid infusions of plasma and blood. A very important step is aspiration of blood from respiratory tract, especially in unconscious patients. After hemodynamic stabilization, emergency endoscopy is performed to clarify the situation.

In patients with gastrointestinal bleeding against the background of portal hypertension, various complications are possible. Prevention of portosystemic encephalopathy is carried out using non-absorbable disaccharides (lactulose) and antibiotics for 5 days.

Vasopressin and its analogues (terlipressin), a combination of vasopressin + nitroglycerin, somatostatin and its analogues (octreotide) are effective for the treatment of acute bleeding.

Vasopressin reduces portal pressure by 30%. It is prescribed as an intravenous infusion and stops bleeding in 60% of cases. The use of vasopressin is associated with complications due to systemic vasoconstriction and cardiotoxicity. Cardiovascular complications include coronary vasoconstriction with myocardial ischemia and possible development heart attack, decrease cardiac output, arrhythmias (especially ventricular), hypertension, bradycardia. Peripheral arterial vasoconstriction can increase mesenteric and cerebral ischemia, and limb ischemia. The effect of vasopressin on the kidneys is to weaken the excretion of water, which can cause hypervolemia, hyponatremia and increased ascites.

The combined use of vasopressin and nitroglycerin reduces portal pressure and reduces the side effects of vasopressin on the heart and systemic circulation. Nitroglycerin is used intravenously, but can be administered sublingually (0.6 mg every 30 minutes) and transdermally (50 mg). The last two methods of administration do not always effectively control the unwanted cardiovascular effects of vasopressin. Using a combination of vasopressin 4-nitroglycerin, bleeding can be controlled in 70% of cases. Terlipressin, a synthetic analogue of vasopressin with a delayed action, can also be combined with nitrates.

Somatostatin does not have negative effects on systemic hemodynamics. Octreotide has a longer period of action and can be administered subcutaneously.

Prevention of recurrent bleeding It has great importance in the treatment of patients with liver cirrhosis. It is based on the use of pharmacological agents that reduce portal pressure, endoscopic sclerotherapy and surgical methods (bypass surgery). If pharmacological therapy is chosen, then the means of choice are non-selective beta blockers - propranolol and nadolol. Used in maximum tolerated doses. The decrease in portal pressure is moderate. There are 10 controlled studies of the effectiveness of beta blockers for the prevention of recurrent bleeding (data from a meta-analysis conducted by A.K. Burroughs et al.). The results of preventing relapses are worse than preventing the first episode of bleeding. However, it is currently believed that beta blockers reduce the risk of rebleeding by 40% and mortality by 20%. In 20-30% of patients, the drugs do not reduce or unreliably reduce portal pressure. Results are better in patients with Child-Pugh class A and B cirrhosis. Long-acting nitrates are used alone or with beta blockers - this combination is more effective and allows you to increase tolerance to the latter. There is experience using a single morning dose of long-acting drugs.

With regard to the prevention of early relapses of bleeding, there are reports of successful use subcutaneous injections of octreotide - 100 mg 3 times a day for 15 days, as well as octreotide in combination with beta blockers.

In addition to the drugs mentioned, attempts are being made to use alpha-adrenergic receptor antagonists, endothelin antagonists, angiotensin II receptor antagonists, and calcium antagonists to reduce portal pressure. Thus, safety and high activity have been demonstrated oral administration drug losartan (angiotensin-II antagonist). However clinical researches regarding the treatment and prevention of variceal bleeding with angiotensin II antagonists are few. Calcium antagonists are not widespread because, along with a decrease in portal resistance, they increase portal blood flow.

BLEEDING FROM VARICOSE VEINS OF THE STOMACH

Dilation of the gastric veins is observed in 20% of patients and is the cause of 10-36% of cases of acute gastrointestinal bleeding in patients with portal hypertension.

Varicose veins of the stomach in patients with portal hypertension can be observed isolated or in combination with dilatation of the esophageal veins. Veins are usually localized in the cardia and fundus, where they may have the appearance of polyps or grape berries.

Based on location, there are three types of gastric varicose veins:

I type - veins of the cardiac part of the stomach, which are a continuation of the veins of the esophagus;

II type - veins of the fundus and cardia of the stomach in combination with veins of the esophagus:

III type - veins of the fundus and body of the stomach without varicose veins of the esophagus.

The size of the veins, red color signs and varicose veins in the stomach correlate with the pressure value in the varicose veins of the esophagus according to the results of direct measurement.

In general, gastric varicose veins, compared to esophageal varices, have a lesser tendency to bleed, which, however, more often recurs and differs in severity.

There are no clear standards for the drug treatment of gastric varicose veins and bleeding from them.

Ectopic varicose veins. The term “ectopic varicose veins” is used for pathologically dilated veins that are localized in all regions, excluding the cardioesophageal region, and are a potential cause of 1-5% of all varicose bleeding. Along with this, the term “extraesophageal varicose veins” is used for all localizations except esophageal. In a review of 169 cases of ectopic variceal bleeding, duodenal localization was noted in 17%, jejuno-ileal in 17%, colonic in 14%, rectal in 8%, peritoneal in 9% (usually in the crescent area). ligaments). In addition, cases of biliary, ovarian and vaginal bleeding have been observed. Severe colonic bleeding has been described in patients with cirrhosis after surgical treatment of esophageal varices (devascularization, transsection), as well as sclerotherapy.

The incidence of ectopic varicose veins is especially high in cases where patients are examined using angiography.

The main method of treatment (along with endoscopic and surgical) is drug therapy (octreotide, vasopressin). The prognosis for bleeding is poor - mortality in duodenal localization reaches 40%. Drug therapy is the simplest, safest and cheapest way to prevent relapses.

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Liver is vital important organ person. - a pathology that can lead to the death of the patient. Complications of liver cirrhosis pose a huge threat to the health and life of the patient. Mostly serious complications arise due to improper treatment. All possible complications are divided into several categories:

portal hypertension;
gastrointestinal bleeding;
venous hemorrhages from the digestive organs;
ascites and edema;
spontaneous peritonitis;
hepatic coma;
hepatorenal syndrome;
hepatopulmonary syndrome;
hypersplenic syndrome;
sepsis and pneumonia;
liver cancer.

Ascites caused by cirrhosis of the liver

Ascites is a complication characterized by sudden enlargement of the abdomen as a result of fluid accumulation. Appearance painful condition associated with a huge rate of lymph formation. With ascites, the patient quickly gains weight, the stomach becomes round and greatly increases in size, the skin becomes tight and very shiny.

On initial stages diseases, small accumulations of water almost do not bother the patient. And if complications develop, the fluid can reach 25 liters. Due to increasing pressure, a patient with cirrhosis may develop an umbilical or inguinal hernia. One of the symptoms is chills, fever, and abdominal pain.

Ascites can have a bad effect on everything human body. Mortality with ascites increases by 25-30%. Approximately 20% die 1 month after the onset of the disease.

Spontaneous peritonitis in liver cirrhosis

Peritonitis is the accumulation of ascitic fluid in the abdomen, in which bacteria can multiply, and the fluid in the abdomen cannot clear them. These infections (bacteria) lead to peritonitis. Some patients do not notice symptoms of peritonitis, while others may experience abdominal pain, fever, chills, and exacerbation of ascites.
If treatment is not started in time, peritonitis will lead to infection of the body and then death. Treatment can be performed surgically and by medication. A puncture is made in the abdomen and the fluid is pumped out, after which antibiotics are prescribed.

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What is your normal blood pressure?

Do you have an “acute” desire to “drink” after taking a small dose of alcohol?

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Liver cirrhosis is most often accompanied by portal hypertension, which is an increase in blood pressure. In a normal healthy person, the pressure is usually 8-10 mm Hg; with hypertension, it can reach 12 mm Hg, or even more.

The increased pressure associated with hypertension dilates the varicose veins, hemorrhoids, around the navel. Due to these enlargements, bleeding may occur, which in most cases is the cause of death.

Dilated veins are detected by x-ray of the esophagus using ultrasound examination. The most dangerous is the expansion of varicose veins, which cause complications in the form of severe bleeding.

Therapeutic therapy is to minimize the occurrence of bleeding. Surgical portosystemic shunting is possible.

Hepatic coma

Encephalopathy or hepatic coma is a combination of neuromuscular and mental disorders. If the liver refuses to function, the condition is hepatic coma. When incapacity is lost, the liver decreases in size.

There are various signs of liver coma:

With it, the patient’s condition changes, pain is not felt, the pupils react poorly to light.
Violated mental condition, apathy and insomnia appear.
Muscle disorders.
The smell from the mouth becomes unbearable with the taste of ammonia.
Mental and neurological pathologies are expressed more noticeably, problems with orientation in space appear, the patient poorly understands the definition of time.
Hallucinations.
Yellowness of the skin (hemolytic anemia may occur).

In hepatic coma, the liver cannot perform its cleansing function, so the body becomes intoxicated with decay products. Coma is usually caused by constipation, gastrointestinal hemorrhages, and certain types of medications. It is very difficult to foresee this complication, because... it has almost no first signs.

It is difficult to distinguish a liver coma from another. It is possible to identify a coma if there are acute liver pathologies in the patient's medical history. If you find any of the above symptoms, you should definitely consult a doctor.

A patient in a coma is admitted to intensive care. Using the hemodialysis procedure, the patient's blood is cleansed of toxins.
In addition to the prescribed treatment for coma, a strict diet that limits proteins is necessary. As a result of decay, toxic substances have a very bad effect on the human brain. In addition, toxins entering the brain make it susceptible to drugs. It is necessary to reduce the doses of various drugs, which affects the treatment and makes it ineffective.

Another complication of liver disease is gastrointestinal bleeding. This bleeding in liver cirrhosis is due to the fact that fibrous tissue does not want to let the normal blood flow through. Then the vessels begin to enlarge and expand, auxiliary capillaries appear and in abdominal cavity Varicose veins form. Unable to withstand the onslaught of blood, one of the vessels may rupture, which will lead to hemorrhage and anemia. Such bleeding requires urgent hospitalization.

Symptoms of the resulting complication:

Anemia is a completely unfavorable prognosis for the patient’s recovery and the further course of the disease. Stop the bleeding with a special probe or endoscopy.

Gastrointestinal hemorrhages are generally fatal. Together with coma, they are the most dangerous complications.

Venous bleeding of the esophagus

Bleeding occurs from varicose veins of the esophagus. Blood entering the heart is not able to exit through the diseased liver. She begins to look for other ways and can exit through the veins of the esophagus, intestines and hemorrhoidal passages. Bleeding from the veins of the esophagus can cause anemia.

The main signs of venous bleeding:

weakness, fatigue, dizziness;
black loose stools;
vomiting dark scarlet blood;
low blood pressure.

If any sign appears, you need to consult a doctor; you should not self-medicate. IN surgical department The patient is given a probe that clamps the bleeding veins. A blood transfusion and some medications may be required to help bring the patient out of state of shock. The main thing here is to provide medical assistance on time.

With liver disease, anemia may develop if the level of red blood cells and hemoglobin decreases. Anemia also occurs due to hypervolemia and an increase in the size of circulating plasma.

Hepatorenal syndrome

Impaired liver function may cause hepatorenal syndrome and renal failure. Positive treatment depends on the patient’s condition and the diagnosis. In people who drink alcohol, the liver may fail, the skin will begin to turn yellow, bloating, weakness, and, in some cases, fever will appear.

If these indicators occur, you should consult a doctor:

To make a diagnosis it is necessary:

do a blood and urine test to determine the amount of sodium in the body;
determine the degree of ammonia and urea in the bloodstream;
measure blood pressure.

This complication can only be identified after testing.

Hepatopulmonary syndrome

Typically, hepatopulmonary syndrome occurs rarely in severe liver cirrhosis. Patients' lungs begin to work poorly and it becomes difficult to breathe. This happens because not enough blood passes through the small blood vessels. The blood shunts around the alveoli, unable to take enough oxygen from the air. Therefore, shortness of breath appears.

Cancer with cirrhosis

Complications of liver cirrhosis can lead to cancer. Cancer develops regardless of other complications and the stage of the disease.

Symptoms of cancer in cirrhosis of the liver are:

very sharp weight loss;
changes general state the patient for the worse;
Pain appears in the upper abdomen on the right side.

Cancer can be diagnosed using a biopsy, and ultrasound is also performed. The identified complication of cirrhosis is not curable. The prognosis becomes the most unpleasant for the patient. Chemotherapy for cancer is useless radiation therapy are not performed and surgical intervention is not practiced. The liver is also very sensitive to radiation, so it is also excluded.

Complications are very difficult to deal with. Therapy is aimed at treating the main pathology, but it is not curable.

Consequences and forecasts

The consequences of liver cirrhosis consist of destruction between the tissues and blood of the liver. Liver cells that have recovered from treatment or survived can no longer remove harmful toxins from the body as before. Scarring caused by cirrhosis prevents blood from passing through the liver. Because of this, the pressure in the main vein increases and venous hypertension appears.

Inflammation of the liver is accompanied by bleeding.

Contents [Show]

Hemorrhagic syndrome

Manifestations

The clinical picture of hemorrhagic syndrome is varied. The most common symptoms are:

Skin rashes. The nature of the rash varies, but most often in the form of:

small petechiae up to 3 mm in size;
large ecchymoses in the form of hemorrhages, hematomas, bruises.

Usually the rash does not exceed 10 mm and appears in the form of petechiae or ecchymoses from a purple to purple hue, which do not disappear when squeezed.

Painful sensations in the joints, muscles, and abdomen of varying intensity and character - from constant aching to shooting, stabbing.
Fever, fever, chills.
Visible nasal, gum, uterine, rectal bleeding from varicose vessels.

Types and types

There are 5 main types of hemorrhagic syndrome, such as:

Bleeding due to liver inflammation can be external and internal with varying intensity.

Petechial-spotted, when bruises of different diameters appear on the body. The root cause is a decrease in coagulability due to thrombocytopenia and lack of fibrinogen.
Hematoma, in cases where cirrhosis is accompanied by hemophilia, genetic blood diseases. Hematomas often form from minor injuries directly on the soft tissues with extensive painful swelling.
Microcirculatory, when large hematomas are formed in the retroperitoneal sheets and a characteristic rash on the skin. It is observed with the development of DIC syndrome, von Willebrand pathology against the background of cirrhosis or aggravation of the condition by thrombolytics, anticoagulants.
Purple when cirrhosis is accompanied by a secondary infection in the form of vasculitis. Manifested by skin erythema, intestinal bleeding, nephritis.
Angiomatous, when persistent blood loss of permanent localization develops. It appears against the background of general vascular disorders caused by cirrhosis.

Hemorrhages through the nose and other organs with cirrhosis may differ in intensity depending on the severity of liver atrophy, therefore the following types are distinguished:

Nosebleeds due to liver inflammation can be mistakenly confused with blood pressure problems.

Gum bleeding of varying severity. It can appear at any stage of cirrhosis.
Nasal hemorrhages. The main reason is increased blood pressure and fragility of nasal vessels.
Uterine bleeding. Always abundant, therefore dangerous. For the most part, without taking appropriate measures, it leads to death.
Hemorrhoidal blood loss. The reasons are varicose veins of the rectal section and increased pressure on the vascular walls. They differ in abundance.
Internal bleeding is the most dangerous, as it occurs covertly, with vague symptoms. The category with an unfavorable prognosis includes blood loss from the upper parts of the stomach and esophagus into the esophagus.

Bleeding of varying severity can develop at any stage of cirrhosis, but more often pathology signals the onset of the last, terminal stage of liver tissue damage.

Diagnostics

To make a diagnosis you need:

collecting anamnesis, clarifying the time of onset of cirrhosis, identifying possible causative factors;
examination of a patient who often has a haggard appearance, pale skin, feels chronic fatigue and weakness, and when the skin is compressed, specific pinpoint rashes (hemorrhages) appear;
blood serum examination: general analysis, counting the number of platelets, prothrombin and fibrinogen, determination of coagulation, hematopoiesis time, clotting rate and heparin tolerance;
taking urine tests;
cerebrospinal fluid puncture;
bone marrow biopsy.

Internal bleeding in liver cirrhosis

The root cause of the development of blood loss from organs is portal hypertension. The pathology is characterized by:

disruption of blood flow from the liver;
its abundant influx to the affected organ;
the formation of a large number of collaterals - new vessels to bypass blood outside the liver.

Additional vessels can form:

in the tissues of the stomach or esophagus;
at the anus;
at the umbilical vein;
in peritoneal sheets, ligaments, folds;
in scar tissue formed after operations;
in the area of blockage of extrahepatic vessels.

These processes provoke varicose veins in the blood vessels of the organs. The esophagus and upper stomach are most often affected.

There are 3 theories of bleeding in liver cirrhosis:

Damage to the dilated vein, which occurs:

Bleeding in cirrhosis can occur against the background of vascular injury or the development of other pathologies.

spontaneous;
provoked mechanically (cough, vomiting, lifting).

Injury to a vein due to gastroesophageal reflux, when under certain conditions acidic gastric contents are refluxed into the esophagus.
The presence of extensive varicose veins.

Main symptoms:

bloody vomiting in dark masses;
discharge of mushy, semi-liquid stool with blood - melena;
chest pain and feeling of pressure;
severe weakness;
nausea;
pale skin;
nose bleed;
increased heart rate and heart rate;
drop in blood pressure.

Clinical symptoms:

blood tests reveal anemic signs;
FGDS reveals the site of bleeding.

If blood loss begins in the stomach or esophagus, symptoms include:

scarlet or coffee vomit;
melena;
disturbance of general well-being.

When intestinal or hemorrhoidal bleeding appears:

scarlet stools or blood clots after bowel movements;
frequent nosebleeds;
pain and burning with a sensation of a foreign particle in the rectum;
constipation

The diagnosis can be confirmed using colonoscopy.

From the esophagus

In 40% of cases, this type of blood loss ends in death. The root cause is a rupture of the dilated vein of the esophagus. The consequences of the pathological condition are ulceration of the surface of the organ mucosa and tissue atrophy.

Provoking factors for the development of bleeding:

liver cancer;
violation of diet, alcohol consumption;
terminal stage;
portal vein thrombosis;
formation of large varicose nodes.

Symptoms:

chest pain, pressure and burning;
blood in stool;
nosebleeds;
vomiting dark blood;
nausea, weakness.

From the gastrointestinal tract

Bleeding from the stomach with inflammation of the liver provokes fainting, fever, and weakness.

It appears suddenly without the first symptoms. The main consequence is ascites. Signs:

severe weakness;
fainting;
nose and eye bleeding;
vomiting blood without nausea.

From other organs

Hemorrhages often occur from dilated veins of the uterus, hemorrhoids, and kidneys. Gum and nose bleeding are also common. The reason is a drop in platelet concentration less than 30-109/l. They are asymptomatic and sudden. With heavy blood loss, they develop general symptoms pathology.

Danger and role

The main risks of development, including posterior nasal hemorrhage, are associated with high mortality and the possibility of frequent relapses, which also threatens the life of a patient with cirrhosis of the liver. The most dangerous hemorrhages are from the gastrointestinal tract at the terminal stage of cirrhotic liver damage, when a large number of dilated veins and varicose veins of different sizes, which leads to maximizing the risk of vascular rupture and bleeding.

Blood loss through the nose or other organ can begin with the slightest effort or under the influence of special endogenous factors. Bleeding of any intensity, including nasal bleeding, with cirrhosis of the liver is dangerous due to sudden death, complications in the form of failure of some organs and irreparable changes in tissues.

Treatment

Bleeding caused by portal hypertension is treated in several stages:

Reimbursement for blood loss:

a catheter is installed in the central/peripheral vein to infuse fresh plasma;
Octreopid and Vikasol are prescribed intramuscularly.

Carrying out endoscopy to identify the source of blood loss. Gastric lavage is performed first.
Stopping bleeding. The technique is selected depending on the location and severity of blood loss:

the esophageal is blocked by sclerotherapy or endoscopic vein ligation followed by the administration of Octreopid;
gastric and intestinal problems can only be relieved with a drug to reduce pressure in the portal vein, such as Octreopid, otherwise an endoscopic procedure or liver transplant is prescribed;
massive bleeding from the esophagus is stopped with balloon tamponade.

Additional measures:

taking antibiotics to prevent secondary infection;
a strict diet with the exception of fried, fatty and other foods harmful products and liquids;
ensuring regular bowel movements (1-2 times a day), otherwise ascites may develop.

Timely stopping of blood loss allows you to avoid serious complications, and correctly applied tactics and correctly carried out prevention can reduce the risk of relapse. But in 70% of cases, bleeding resumes due to the irreversibility of the processes that occur at the terminal stage of cirrhosis throughout the body.

Forecast

The outcome of bleeding depends on the location, strength, and stage of liver cirrhosis. The risks are increased by the presence of ascites, sudden jump bilirubin in the blood. In this situation, 1/3 of patients die with the first bleeding of any location. There is always the possibility of spontaneous cessation of hemorrhage. But relapse of blood loss develops in 30% of cases after 7-10 days. In the future, this threatens brain dysfunction and the formation of cancer cells.

Prevention

In order to prevent the development of bleeding in patients with cirrhosis of the liver:

a certain rhythm and way of life is ensured;
special vasoactive medications and diet therapy are prescribed;
endoligation of varicose veins and nodes is carried out;
Liver bypass surgery is performed in particularly severe cases.

A serious complication is internal bleeding in cirrhosis of the liver from dilated portal veins or vessels of the esophagus. Often bleeding in cirrhosis of the liver ends in hepatic coma. Constant monitoring of a person’s condition, correct treatment will ensure the survival of the patient.

Causes and mechanisms of internal blood loss

Common causes of internal blood loss in the presence of liver cirrhosis are as follows:

Portal form of hypertension. Consists of a persistent increase in pressure in hepatic vein. It develops due to an increase in the volume of blood that circulates in the vessels against the background of obstruction of blood flow by overgrown liver tissue.
Dilatation of blood vessels in the liver and esophagus. As a result, the blood stagnates and the vessels become overfilled. This can lead to their rupture and the formation of a serious complication.
The formation of varicose nodes, which aggravate the course of the pathological process.

Due to disturbances in the outflow of blood from the affected liver, the active formation of so-called collaterals begins - additional small vessels allowing normalization of blood flow.

The main places of localization of collaterals:

esophagus;
stomach;
umbilical veins;
abdominal cavity, uterus;
rectum;
places of scar formation after surgical operations.

The blood flow in the stomach and esophagus is most affected, resulting in bleeding.

Factors that provoke hepatic or esophageal bleeding are the following:

spontaneous damage to the hepatic vein;
vomiting reflex;
cough, especially severe and prolonged;
damage to the esophageal and gastric veins associated with the throwing of an acidic food bolus from the stomach back into the esophagus;
rupture of varicose nodes that form when severe forms lesions;
elderly age. In such patients, the walls of blood vessels are significantly weakened.

Important! Bleeding from other affected vessels is almost always spontaneous; its cause is difficult to determine.

Characteristic symptoms of blood loss

Persons diagnosed with liver cirrhosis should remember that they have greatest danger development of bleeding from the vessels of the esophagus.

General signs of internal blood loss:

Specific symptoms of esophageal bleeding are as follows:

bloody vomiting;
the color of the vomit is dark cherry;
blood in feces, coloring them black. This symptom is medically called “melena”. Indicates the protracted nature of the pathology;
pain localized behind the sternum.

Characteristic signs of gastric blood loss:

vomiting blood;
the color of the vomit is brown, reminiscent of “coffee grounds”;
black feces - melena;
diarrhea.

Intestinal blood loss occurs less frequently and is characterized by the following symptoms:

Discharge of blood during defecation.
The color of the blood released is bright red.
Stool disorders.

More rare, but extremely dangerous, are heavy uterine discharges of blood in women. This condition requires emergency assistance, as it often ends in death.

Laboratory signs of abnormalities are as follows:

decreased hemoglobin levels;
decrease in the number of red blood cells.

Blood test data can easily establish anemia due to blood loss of varying intensity depending on the extent of the lesion. In most cases Iron-deficiency anemia is developing rapidly.

Methods of diagnosis and assistance to the victim

Different forms of blood loss can be identified using the following methods:

colonoscopy (for intestinal forms);
fibrogastroduodenoscopy, which allows you to diagnose disorders in the stomach and esophagus;
blood analysis;
hysteroscopy, endoscopy;
analysis of stool.

Important! Persons with various forms of internal blood loss accompanying cirrhosis of the liver require emergency medical care.

The main directions of treatment for victims are as follows:

intravenous administration of plasma substitutes and saline solutions to restore the volume of lost blood;
lavage of the gastric cavity until clean rinsing water is obtained;
conducting fibrogastroduodenoscopy in order to identify the site of bleeding, as well as carry out therapeutic manipulations in the affected area;
stopping blood loss using a suitable method;
introduction of hemostatic and blood clotting agents - Aminocaproic acid, Dicinone, Vikasol, etc.;
preventive measures aimed at preventing bleeding from affected vessels.

Methods to stop bleeding are selected by the doctor after a complete analysis of the patient’s condition.

The main methods are as follows:

sclerotherapy;
ligation of affected veins;
balloon tamponade of blood vessels;
vascular shunting. It is the method of choice only if the above measures and drug therapy are ineffective.

If blood loss has become frequent and it is extremely difficult to stop it, then the doctor raises the question of performing a liver transplant. It is important to understand that with repeated cases of bleeding due to liver disease, the prognosis for life rapidly worsens.

Preventive measures include the following:

exclusion of physical activity;
timely treatment of colds that are accompanied by cough. This reflex helps to increase intra-abdominal pressure and provokes bleeding;
preventing excessive and frequent vomiting;
timely diagnosis and treatment of liver pathology;
constant use of drugs to lower blood pressure - adrenoblockers of the Propranolol group;
knowledge of the main signs of liver cirrhosis and internal blood loss.

Only if you apply for it in a timely manner medical care manages to preserve the health and life of the victim. Emergency care in the department plays a decisive role in the treatment of complications of liver cirrhosis.

Bleeding in liver cirrhosis is the most common complication of this disease. Since throughout the illness the liver becomes swollen connective tissue, which cannot but affect her work. The organ gradually ceases to perform its functions, the main of which is cleaning circulatory system from harmful wastes and toxins that pollute the entire body and do not allow it to function fully and correctly. Therefore, with this disease, it is important to constantly be registered with a doctor and follow all prescribed recommendations.

Types of bleeding

Exacerbation of liver cirrhosis is always acute. First, the temperature rises, strong and frequent pain in a diseased organ, the skin acquires yellow, itchy skin, liver odor from the mouth appears. All these symptoms together should force the patient to urgently consult a doctor to prevent complications.

Depending on the degree of liver damage, bleeding may occur in different places. All of them pose a serious threat to the health and life of the patient.

This disease is characterized by the following types of bleeding:

Frequent and persistent gum problems. Bleeding begins from the slightest pressure on them. Oral hygiene becomes torture;
From the nose. This problem is quite common in cirrhosis due to the fact that the vessels are fragile and the slightest change in pressure leads to their rupture;
Uterine. This is due to the large number blood vessels, and these bleedings are quite dangerous, which can lead to the death of the patient;
Copious from the rectum. Due to dilated veins in this area, it is possible heavy bleeding which can lead to death;
The most dangerous is internal bleeding from the veins. It can begin unnoticed by the patient himself. Also serious are bleeding caused by dilation of the veins of the esophagus and stomach.

All of the above types are complications of liver cirrhosis and they can appear at any time. Therefore, if such a situation arises, you should immediately go to an ambulance for hospitalization.

Most people diagnosed with cirrhosis guessed about this disease by the following symptoms:

Pain after eating in the right hypochondrium;
Frequent nausea after eating and between meals;
Sudden weight loss may also indicate inflammatory process in the human body;
Weakness throughout the body, rapid fatigue from light work;
Fever;
Vomiting, diarrhea, and a bitter taste in the mouth also indicate the presence of this disease;
Swelling without visible reasons They also talk about disruption in the body and the development of the disease.

If one or more symptoms appear and they do not go away for several days, then an examination is necessary to identify the causes of poor health.

Since internal bleeding from the veins of the esophagus is a complication of cirrhosis, this suggests that it develops from increased pressure in the portal vein. The outflow of blood through this vein is disrupted, the blood must go somewhere, so small veins are formed through which the outflow occurs. The vessels expand, and due to the fact that they are thinned, they rupture. Most often these vessels form in the area of the stomach and esophagus.

The most common type of cirrhosis is bleeding from the esophagus. In this case, vomiting appears from the mouth with dark-colored blood, and blood is also found in the stool. Its color becomes black and mushy. Before the above symptoms appear, the patient may feel weakness, dizziness, pale face, and decreased blood pressure. All this is complemented by anemia, which can be detected by a blood test.

To establish the exact localization of bleeding, the FGDS procedure is used.

Bleeding from the stomach and intestines has similar symptoms. Vomiting in this case has Brown color, the chair is painted black. A characteristic liver odor appears from the mouth.

When bleeding from hemorrhoidal veins, fresh blood appears after visiting the toilet.

There are also other symptoms that indicate the presence of this problem:

Pain in this area.
Feeling of “unfinished stool” after going to the toilet.
Difficulty with defecation itself.

It has been proven that in almost eighty percent of cases, cirrhosis and the complications that arise with it are associated with alcohol abuse. Damage to the body begins from the oral cavity; the teeth of alcoholics are destroyed. This is due to a violation of the immune system, a violation of the correct diet and diet, as well as non-compliance with oral hygiene. Protective functions the body weakens, hence inflammation of the esophagus. The veins of the esophagus dilate and with systematic drinking of alcoholic beverages, they become thin and burst, leading to internal bleeding. Both the veins of the esophagus and the veins of the stomach can bleed. Only urgent surgery can save the patient in this case.

The second most common bleeding in cirrhosis is gastric. Alcoholism affects the functioning of the stomach. This is due to the constant flow of alcohol poisons into the organ. Gastritis develops, and against this background, stomach cancer. Pain in the stomach is constant, weakness, lack of appetite, and bad breath appear.

Constant drinking leads to inflammation of the esophagus. Alcohol, being a poison for the body, destroys everything useful material on its way, starting from the oral cavity and ending nervous system. The whole body suffers from alcohol.

If bleeding from the esophagus continues intensively, it can only be stopped by surgical intervention. A probe is urgently inserted into the patient and the bleeding is stopped. The complexity of the operation lies in the fact that patients with liver cirrhosis develop liver failure quite quickly. In this regard, doctors use a blood clotting system (hemostasis), which helps prevent further blood loss. The second most common method is called ligation. This is a rubber ring that is placed over a varicose vein to prevent bleeding.

If the crisis has been passed, then the patient must be observed by a gastroenterologist, and in no case should he self-medicate.