THE ROLE OF EROSIVE AND ULCERATIVE GASTRIC LESIONS IN THE DEVELOPMENT OF HEMORRHAGIC COMPLICATIONS IN LIVER CIRRHOSIS

Abstract

Significant and systemic increase in portal pressure is accompanied by the development of varicose veins of the esophagus and the cardiac part of the stomach, which are often complicated by gastric bleeding (GB) due to their rupture. However, it was found that this genesis of bleeding is diagnosed in 42% of patients with portal hypertension (PH) and in 58% of patients bleeding was caused by erosive and ulcerative lesions in the stomach (erosion, ulcer, gastropathy) [1]. It is well known that primary profuse GB causes the death of every fourth patient, while after recurrence of bleeding only about 50% of patients survive. It is in PH in comparison with peptic ulcer disease GB is profuse 5 times more often. This type of bleeding leads to irreversible disorders of the coagulation system [2], which cause the death of this category of patients [3]. The aim of the study was to study the factors of development of erosive and ulcerative gastric lesions in liver cirrhosis and their role in the occurrence of hemorrhagic complications. Materials and methods. There were studied results of treatment of 135 patients with hepatic form of PH (liver cirrhosis) who were hospitalized to the clinic of the Department of Surgery №2 of the Bogomolets National Medical University in the period from 2011 to 2020. Men made up 76 (56%) people, women - 59 (44%). The age of patients ranged from 28 to 62 years, the mean age was 43.2 ± 2.3 years. The cause of liver cirrhosis in 57 (42%) patients was viral hepatitis, in 47 (34%) - alcoholism, in 31 (24%) - chemical (including drugs) factors. Patients according to the specified classification (the Child-Pugh scale [4]) were divided into three groups depending on the stage of the disease (on a scale): the stage of compensation (class A)(43 persons (31.8%), subcompensation (class B)(57 persons (42.2%) and decompensation (class C)(35 (26%). Varicose veins of the esophagus were diagnosed in 115 patients (85.2%), splenomegaly - in 59 (43.7%), ascites was detected in 43 patients (31.8%). In the vast majority of patients (23 people (53.5%) ascites was detected at a stable stage, and in 15 people (34.9%) - in progressive, only 5 people (11.6%) it was transient. Symptoms of hypersplenism occurred in 49 patients (36.3)%, jaundice - in 31 (22.9%). GL during upper endoscopy were found in 66 patients (48.9%): in 22 patients 33.4%) – PGP, in 21 patients (31.8%) - gastric erosions, in 23 (34.8%) - gastric ulcers. There were 62 (45.9%) patients with cirrhosis of the liver and GB, and according to the Child-Pugh scale, the vast majority of patients were in the stage of decompensation (55 people (88.7%). GL were the cause of GB in 28 patients (45.2%): erosive gastritis - in 11 (39.3%) patients, gastric ulcer - in 12 patients (42.8%), PGP - in 5 patients (17.9%). Mild GB (circulating blood volume deficit below 20%) was found in 7 patients (25%), moderate (circulating blood volume deficit 20-30%) - in 13 (46.4%) and severe (circulating blood volume deficit more than 30%) - in 8 patients (28.6%). Chronic gastric lesions accounted for 64.3% (18 people), acute - 35.7% (10 people). Gastric mucus was obtained during upper endoscopy, followed by its homogenization and centrifugation for 30 min at a speed of 3000 revolutions per min. At the same time, a precipitate was obtained, which was a model of a native mucous gel. The rheological properties of gastric mucus (the limit of elasticity of the mucus gel, the viscosity of the mucus) were studied using a precision rotary viscometer Rheotest-2 (Germany). Two indicators of mucus viscosity were determined: the initial viscosity of intact mucus (ƞ1) and the viscosity of mucus after destruction of its gel structure (ƞ2) [5]. In order to compare the rheological changes of gastric mucus, all studied patients with GL (66 people) were combined into the main group. The comparison group consisted of 50 healthy individuals. The choice of treatment method depended on the degree of blood loss, the patient's age, the general condition of the body. Treatment of each patient began with conservative measures, while specifying the degree of its activity according to the endoscopic classification of Forest. The main direction in the treatment of ulcerative-erosive bleeding in patients with liver cirrhosis is upper endoscopy, which has long been not only a diagnostic but also a therapeutic technique. There were operated 8 patients (28.6%) with bleeding from GL on the background of liver cirrhosis at the stage of compensation and subcompensation: urgently (according to vital signs) - 5 patients (62.5%) (emergency surgery was performed in 2 patients, urgent - 3). Early delayed surgical interventions (according to absolute indications) were performed in 3 patients (37.5%). The operation of choice for ulcerative gastric bleeding is considered economy (partial) gastric resection. In the postoperative period, patients were prescribed a course of antirelapse treatment (antisecretory drugs, prokinetics (Metoclopramide), cytoprotectors, etc.). Results of the research. Based on studies of the rheological properties of gastric mucus, it was found that one of the leading factors in the development of erosive and ulcerative lesions in the stomach in portal hypertension is increased transcapillary filtration in edematous-ascitic stage of liver cirrhosis, which due to portal stagnation and reduced colloid muco-bicarbonate barrier of the stomach and causes the development of actual gastric ulcers. Erosive and ulcerative lesions on the part of the gastric mucosa were found in 66 (48.9%) of patients with cirrhosis of the liver, and in 45.2% of cases (28 persons) they are complicated by the development of gastric bleeding. Pathogenetic treatment of gastric ulcer-erosive bleeding in portal hypertension, against the background of the use of endoscopic hemostasis, should be aimed at strengthening the protective properties of the mucous-bicarbonate barrier of the stomach. Good results of surgical treatment were achieved in 64.3% of patients. The overall mortality in liver cirrhosis complicated by gastric bleeding from ulcerative lesions of the stomach was 21.4% (6 patients died), postoperative mortality was 25% (2 patients died). Conclusions. 1. In the development of erosive and ulcerative gastric lesions in liver cirrhosis the leading factor is not the actual hypertension, but increased transcapillary filtration in the edematous-ascitic stage of liver cirrhosis which due to portal stagnation and reduced colloid-osmotic properties of blood causes a decrease in protective properties of mucosal bicarbonate barrier causes the development of destructive lesions of the actual gastric localization. 2. Erosive and ulcerative gastric lesions during upper endoscopy were found in 48.9% of patients with cirrhosis of the liver and in 45.2% of cases they are complicated by the development of gastric bleeding. 3. The use of drugs aimed at strengthening the protective properties of the mucous-bicarbonate barrier of the stomach with the basic use of endoscopic hemostasis techniques for erosive and ulcerative gastric changes in liver cirrhosis is promising, but requires a separate and more thorough study. References 1. Tandon P, Bishay K, Fisher S, Yelle D, Carrigan I, Wooller K, Kelly E. Comparison of clinical outcomes between variceal and non-variceal gastrointestinal bleeding in patients with cirrhosis. J Gastroenterol Hepatol. 2018 Oct;33(10):1773-1779. doi: 10.1111/jgh.14147. Epub 2018 May 4. PMID: 29601652. 2. Kolosovych IV, Hanol IV. Hemocoagulation factors of hemorrhagic complications in acute pancreatitis. Fiziol. Zh. 2022; 68(1): 56-61. https://doi.org/10.15407/fz68.01.056 3. Ardevol A, Ibañez-Sanz G, Profitos J, Aracil C, Castellvi JM, Alvarado E, Cachero A, Horta D, Miñana J, Gomez-Pastrana B, Pavel O, Dueñas E, Casas M, Planella M, Castellote J, Villanueva C. Survival of patients with cirrhosis and acute peptic ulcer bleeding compared with variceal bleeding using current first-line therapies. Hepatology. 2018 Apr;67(4):1458-1471. doi: 10.1002/hep.29370. Epub 2018 Feb 18. PMID: 28714072. 4. Tsoris A, Marlar CA. Use Of The Child Pugh Score In Liver Disease. [Updated 2022 Mar 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542308/ 5. Ruiz-Pulido G, Medina DI. An overview of gastrointestinal mucus rheology under different pH conditions and introduction to pH-dependent rheological interactions with PLGA and chitosan nanoparticles. Eur J Pharm Biopharm. 2021 Feb;159:123-136. doi: 10.1016/j.ejpb.2020.12.013. Epub 2020 Dec 31. PMID: 33387633.