A patient who is bleeding from the rupture of his oesophageal varices will be such a formidable challenge to you, that stopping it may be impossible. You will not be able to do a portacaval shunt, or to suture them with an automatic stapling instrument, so you will have to rely on plenty of blood and a Sengstaken tube to compress them. If he has cirrhosis, his prognosis outside a major centre will be so bad, and he will need so much blood, that you may not feel justified in treating him.
Dilated varices are the result of a high pressure in his portal venous system[md]more than 18 cm of saline. The common causes are: (1) cirrhosis of his liver, (2) periportal fibrosis due to S. mansoni infection, (3) noncirrhotic portal fibrosis, and (4) thrombosis of his portal vein. He dies from loss of blood and loss of liver function. The final cause of his death may be hepatic encephalopathy, due to the failure of his liver to detoxify the breakdown products from the blood in his gut, either because its cells have failed, or because blood has been shunted from his liver. Liver failure commonly complicates cirrhosis, but not the other causes.
Aim to: (1) stop him bleeding, (2) restore his blood volume, and (3) prevent encephalopathy.
TUBE Sengstaken, 18 and 21 Ch, two only of each size. This has 3 channels and two balloons. You will need this tube if bleeding oesophageal varices are common in your area. It will usually control bleeding while the tube is in place, and bleeding may stop after it is removed. One danger is that a balloon may displace into the patient's glottis and obstruct his respiration. If you don't have a Sengstaken tube, you may be able to use a Foley catheter with a 30 ml balloon.
Fig. 11-5 A SENGSTAKEN TUBE. A, this has three channels: 1, to aspirate blood from the patient's stomach. 2, to inflate a balloon in his stomach to anchor the tube. 3, to inflate another balloon in his oesophagus to compress his varices. B, the varices that the balloon tries to compress.
BLEEDING VARICES WHEN THE PATIENT IS NOT BLEEDING If you see him between bleeds, do his liver function tests. Do a barium swallow with a thick suspension of barium to demonstrate the varices. If necessary, examine a rectal snip. Give him 3 injections of vitamin K[,1] 10 mg daily for 5 days.
WHEN HE IS BLEEDING PREVENT ENCEPHALOPATHY. Give him a saline purge through the Sengstaken tube. Empty his large gut with an enema, and give him oral neomycin 1 g 4 to 6-hourly to reduce the bacterial activity in his gut. Don't give him any protein by mouth.
DRUG CONTROL OF BLEEDING. Vasopressin (''Pitressin') will reduce his portal venous pressure by constricting his sphlanchnic arterioles. See Section 11.3.
SENGSTAKEN TUBE. Measure the capacity of the two balloons, and check that neither of them leak. The distal gastric balloon of a large tube holds about 120 ml. Inflate the oesophageal one to 30 mm Hg, checked against an ordinary sphygmomanometer. Add the contents of 2 ampoules of 45% ''Hypaque' (or a similar contrast medium) to 250 ml of saline.
Have a sucker available. Local anaesthesia of his mouth and pharynx may be helpful. Lay him on his side, and pass the tube quickly through his mouth into his stomach. Inflate the gastric balloon with the saline/hypaque mixture. Withdraw it until it impacts against his cardia, and take an X-ray film to check its position. Inflate the oesophageal balloon to 30 mm Hg. Tie a thread round the tube opposite his lips to mark the correct position of the balloons.
Aspirating the tube will show you if he has stopped bleeding. Use it to give him a mixture of magnesium hydroxide, neomycin, and glucose. He will be unable to swallow his saliva, so lay him on his side to let it dribble frm his lips, and have a nurse always available to suck out his mouth, if necessary.
After 24 hours deflate the oesophageal balloon, then the gastric one, and continue to aspirate his stomach. If he starts bleeding again, you can apply the tube for a further 12 hours, but this is a sign that he should have surgery[md]if this is possible.
CAUTION ! (1) If the tube displaces upwards, it may obstruct his glottis. Warn the nurses about this, and tell them to remove it quickly if it does so. (2) Deflate the tube after 48 hours. Don't leave it in any longer, because his mucosa will necrose. (3) If you continue to aspirate fresh blood, reconsider your diagnosis. (4) Don't take a needle biopsy of his liver while he is in the acute bleeding stage.
A FOLEY CATHETER is less satisfactory. Pass this through his mouth, inflate the balloon, and draw it upwards so that it presses against the varices at his gastro-oesophageal junction. Either tape the catheter to his cheek, or, better, tie it to a weight suspended from a pulley.
DIFFICULTIES [s7]WITH BLEEDING VARICES If he BLEEDS AGAIN after you have removed the tube, his prognosis is not good, but varies with the cause of his varices. If he is cirrhotic, his prognosis is bad.
If his RECTAL SNIP IS POSITIVE for Schistosoma mansoni, or he is excreting ova in his stools, this may be the cause of his symptoms. Unfortunately, in an endemic area most of the population will have ova in their stools. Live ova, detected by a concentration test if necessary, are more significant than dead ones. If however he does have periportal cirrhosis due to this worm, his liver function is likely to be good, and his prognosis will not be so bad[md]if you can refer him to a centre where he can have a portosystemic shunt, or a course of sclerotherapy. This is probably only justified if he is under 50, has no jaundice or ascites, and his serum albumen is above 3 g/dl.
If his PORTAL VEIN HAS THROMBOSED, or he has NON- CIRRHOTIC PORTAL FIBROSIS, he will probably have a normal liver, and his bleeding will eventually stop. Refer him if you can.