[Ectopic duodenal varices as a cause of difficult diagnosis of bleeding in extrahepatic portal hypertension]. / Varikoznye veny dvenadtsatiperstnoi kishki kak prichina «trudno¼ diagnostiruemogo krovotecheniya pri vnepechenochnoi portal'noi gipertenzii.

Bleeding from ectopic varicose veins is a rare life-threatening cause of upper gastrointestinal hemorrhage. Alberti first described duodenal varices in 1931. According to the literature, incidence of duodenal varicose veins in patients with portal hypertension is 1-3% of all varicose veins. Bleeding from duodenal varices makes up 17% of all bleedings from other ectopic varices. Mortality in these patients may be up to 40%. The causes are delayed diagnosis, technical difficulties in endoscopic therapeutic procedures (sclerotherapy, endoscopic ligation), as well as ineffective Blackmore tube for hemorrhage in distal stomach and bowel. We report a rare case of upper gastrointestinal bleeding from ectopic duodenal varices.

[Self-expanding nitinol stents for bleeding from esophageal varices in patients with portal hypertension]. / Lechenie krovotecheniya iz varikozno rasshirennykh ven pishchevoda nitinolovym stentom u bol'nykh portal'noi gipertenziei.

Blakemore probe-obturator was previously preferable for primary hemostasis in patients with bleeding from esophageal varices. Currently, Danis self-expanding nitinol stent became an effective alternative. According to some manufacturers, Danis stent has some advantages over balloon tamponade. We report implantation of nitinol stent for hemostasis in a patient with multiple recurrent bleeding and ineffective endoscopic manipulations. A method of stent fixation for prevention of distal migration as the most common complication is described.

[Expression of plasminogen activator system components in the gastric mucosa in portal hypertensive gastropathy].

OBJECTIVE: to study the expression of urokinase-type plasminogen activator (uPA) and plasminogen activator inhibitor-1 (PAI-1) in the gastric mucosal (GM) vascular endothelium and epithelial cells of patients with portal hypertensive gastropathy (PHG) and those with portal hypertension (PH) without signs of PHG as compared to a control group. MATERIAL AND METHODS: GM biopsy specimens from patients with PHG, those with PH without signs of PHG, and controls with the normal gastric mucosa were immunohistochemically examined. RESULTS: Comparison of the expression of uPA in the GM vascular endothelium and epithelial vessels revealed no significant differences in the patient groups. The level of PAI-1 in the GM vessels was statistically significantly higher in the control group than in the groups of patients with PHG and PH without PHG. PAI-1 expression in the GM epithelial cells was significantly more commonly absent in the PHG group than in the control group. An analysis of an uPA and PAI-1 expression ratio showed a statistically significant predominance of the expression of uPA over its inhibitor in the GM vascular endothelium of the patients with PHG and those with PH without PHG as compared to the controls. CONCLUSION: The predominance of uPA over PAI-1 in the GM vessels and epithelial cells can play a role in the development of GM bleeding.

[Portal hypertensive gastropathy].

In spite of a great number of publications, as yet there is no agreement that which of the detected morphological changes should be considered pathognomonic in portal hypertensive gastropathy (PHG). The study of the pathogenesis of PHG suggested a diversity of mechanisms involved in varying degrees in the development of this abnormality. The paper summarizes the data available in the literature on the role of endothelial dysfunction, apoptosis, damaging factors, and H. pylori infection in the development of this abnormality. A differential diagnosis was made between PHG and GAVE syndrome and histological features in both groups were revealed.

[Surgical treatment of portal hypertension: the state of art].

The article highlights modern approaches to the treatment of portal hypertension. The differential tactics is based on the type of portal hypertension, functional liver state, urgency of the situation and severity of blood loss, localization and stage of varices, concomitant diseases, etc. The role of miniinvasive methods is stressed. The reasonability of general treatment algorithm of portal hypertention in specialized centers is proved.

[The modification of the M.D. Patsiora's operation by portal hypertension].

The direct transcutaneous transhepatic portography was performed in 85 patients with hystologically confirmed liver cirrhosis, portal hypertension and varices of the esophagus and stomach. It was found out, that the left gastric vein partakes the varicous transformation in 100% of cases. The least had an isolated division in 27% of the studied patients. 68% had the significant dilatation of the posterior gastric vein, whereas 19 (22%) patients had the combined posterior, left and short gastric veins dilatation. The study allowed the modification of the M.D. Patsiora's operation (the azygo-portal disintegration), by supplementing it with the gastric devascularization. The new method increased the 2-years survival from 77 to 97%, improved the hemostatic effect from 51 to 89% and decrease the recurrences from 25 to 5%.

[Portal gastropathy: diagnosis, classification].

Portal hypertensive gastropathy (PHG) is a complex of secondary macroscopic and microscopic changes in the mucous layer of the stomach, resulting from portal hypertension of any origin. The overall prevalence of PHG ranges from 9.1 to 80%. PHG is a potential cause of an acute or chronic gastric bleeding. The presence of PHG is associated with prognosis deterioration that dictates the need for improved diagnosis and treatment strategy. The article summarizes literature on the pathological changes, diagnosis and classification of portal hypertensive gastropathy.

[Pathogenesis of esophageal and gastric varicose veins formation in patients with liver cirrhosis].

RESEARCH OBJECTIVE: studying the features of the collateral venous blood flow and the basic ways of the formation of gastroesophageal varices in patients with cirrhosis and portal hypertension. METHODS: The following analysis is based on the interpretation of results from percutaneous transhepatic splenoportography in 85 patients. It has been established that in all 85 patients the left gastric vein plays a key role in the formation of gastroesophageal varices. RESULTS: It is established that a leading collector in 100% of observations participating in formation gastroesophageal varices, is the left gastric vein. In work the attention is focused on an insufficient estimation of a role of a back gastric vein in a pathogenesis of varicose transformation. From 85 observations its presence is taped in 58 (68%) cases, and, at 19 (22%) patients its expansion isn'ted in a combination to expansion left gastric vein, and at 39 (46%) patients - in a combination with left gastric vein and short veins of a stomach. CONCLUSION: The obtained data on the formation mechanism of varicose expanded veins of an esophagus and a stomach defines necessity of changes for algorithm of inspection of patients for the purpose of diagnostics of features of a venous blood flow of a stomach and an esophagus and definition of surgical tactics concerning volume pre- or intraoperational blockade of the basic venous collectors.

[Endoscopy combined hemostasis. Pathogenetic mechanisms of therapeutic action in gastroduodenal ulcers, complicated by severe blood loss and hemorrhagic shock].

On the basis of results of research the pathomorphology severe blood loss and haemorrhagic shock at 38 patients who have died from ulcer gastroduodenal of bleedings, with the purpose of preventive maintains of relapses of bleedings am established by authors necessity of carrying out of the general, and also local metabolic rehabilitation during the endoscopic haemostasis at massive bleedings at the patients with high risk of surgical treatment.

[Conservative treatment of giant gastric ulcer].

Clinical supervision of successful conservative treatment of the patient with a huge stomach ulcer with use in the course of performance endoscopic a metabolic homeostasis of solutions of glucose and ascorbic acid of 5%, and also pH-chromoscopy and capillary gastrointestinal a tube is presented.

[Aneurysm of the thoracic aorta with esophageal perforation].

Aneurysms of a chest department of an aorta with esophageal perforation two cases are presented and a lethal outcome. Difficulties in diagnostics have been caused by rare occurrence of the given pathology, insufficient experience of clinical physicians, and also absence during supervision of characteristic attributes Aortoesophageal Fistula.

[Non-Hodgkin's lymphoma of the stomach. A case report].

Clinical supervision diffuse large B-cell lymphoma of the stomach at the patient of young age is presented. Difficulties of the differential diagnostics of lymphom have been caused by macroscopical polyphormism. With the purpose of verification of disease are used the chromoendoscopy and immunohistochemical research.

[Use of a gastrointestinal tube in the treatment of gastric and duodenal ulcer]. / Primenenie gastrointestinal'nogo zonda v lechenii iazvennoi bolezni zheludka i dvenadtsatiperstnoi kishki.

The trial of a gastrointestinal tube in gastroduodenal ulcer indicates its high efficiency for enteral tube feeding in serious ulcer cases and as a therapeutic modality in noncomplicated cases. The tube introduction in 55 patients out of 89 promoted the defect healing within 2-3 weeks, in 30 out of 36 cicatrization occurred on week 3-5. The presence of the tube produced no effect on acid production in the stomach, cicatrization of the ulcer took place without basic therapy in remaining hypo-achlorhydria and hyperchlorhydria. Clinico-endoscopic evidence and data on gastroduodenal motility and evacuation suggest the conclusion on the neuro-reflex mechanism of the tube action which eliminates painful syndrome and motor-evacuatory abnormalities which are believed essential in pathogenesis of peptic ulcer.

[Surgical treatment of segmental extrahepatic portal hypertension]. / Khirurgicheskoe lechenie segmentarnoi vnepechenochnoi porta'lnoi gipertenzii.

The authors analyse the immediate and late-term results of surgical treatment of 39 patients who underwent 50 operations for segmental extrahepatic portal hypertension (SEPH). The threat of gastric hemorrhage was the main indication for surgery. Gastrotomy with suturing of the varicose veins of the stomach is the operation of choice when gastric hemorrhage continues. This operation produces an immediate clinical effect but fails to ensure long-term prevention of bleeding. In planned treatment splenectomy is the operation of choice only in patients with signs of marked hypersplenism when there is little threat of the development of asplenic thrombocytemia in the postoperative period. Separation of the vascular gastrosplenic connections is the operation of choice in the absence of hypersplenism. Ligation of the splenic artery and transposition of the decapsulated spleen into the retroperitoneal space have no haemostatic effect and must not be conducted for the prevention of gastric hemorrhage in this pathological condition.

[Re-evaluation of the opinions regarding vascular portacaval anastomosis in the surgical treatment of portal hypertension]. / Pereotsenka vzgliadov na sosudistye portokaval'nye anastomozy v khirurgii portal'noi gipertenzii.

Experience in the establishment of vascular portocaval anastomoses in 66 patients with cirrhosis of the liver and 52 patients with extrahepatic portal hypertension was studied. Selective portocaval anastomoses produced the best immediate and late-term results in cirrhosis of the liver, side-to-side or H-type splenorenal anastomoses were found to be optimal, they were marked by minimal trauma to the pancreas and adequate decompression of the gastroesophageal channel with maximal maintenance of the portohepatic blood flow. Maximal decompression of the portal system is expedient in extrahepatic portal hypertension; this is mostly accomplished by means of H-type mesentericocaval anastomosis with an autograft formed from the internal jugular vein. Introduction of selective anastomoses into practice and the use of an autovenous graft and precision techniques considerably widened the possibilities of vascular portocaval anastomosis in the treatment of gastroesophageal hemorrhages and made it possible to improve the results of these operations.

[Contraindications to splenectomy in primary total extrahepatic portal hypertension]. / Protivopokazaniia k splenéktomii pri pervichnoi total'noi vnepechenochnoi portal'noi gipertenzii.

The authors studied changes of hepatic circulation, hepatoportal hemodynamics, and homeostasis of peripheral and portal venous blood in response to removal of the spleen in primary total extrahepatic portal hypertension. The findings of rheohepatography, isotope hepatography, and ultrasonic flow measurement provided proof that splenectomy does not lead to intensification of the flow of arterial blood to the liver. Study of the portal pressure level did not demonstrate any significant hypotensive effect of splenectomy. Considerable changes occur after removal of the spleen, which creates real preconditions for the development of portal system thrombosis. All the above-said provides the basis for reducing considerably the range of indications for splenectomy and recommending it only in cases with marked clinical manifestations of hypersplenism hemolysis and increased tendency to bleeding.

[Enteral detoxication in patients with liver cirrhosis and bleeding from the esophageal and gastric varices ]. / Enteral'naia detoksikatsiia u bol'nykh tsirrozom pecheni i krovotecheniem iz varikozno-rasshirennykh ven pishchevoda i zheludka.

A new method of enteral detoxication with the use of both well-known medicines ("Normase", "Sorbit") and new medicine-"Rafinosa" is described. Clinical effectiveness (normalization of neurological status) of these medicines correlates with normalization of blood amino acids unbalance, decrease of the catabolic processes and accumulation of toxic products of nitrogenous metabolism. All the above medicines (Italian made "Normase", "Sorbit" and Russian made "Rafinosa") are equally important for clinical practice. Enternal detoxication may be effective only in case of preventing relapsing bleeding by all possible measures from endoscopic thrombosing and endovascular embolisation of varicose veins to direct surgical operation on the esophageal and cardial veins.

[Endovascular embolization of the gastric veins in portal hypertension complicated by esophagogastric hemorrhages]. / Endovaskuliarnaia émbolizatsiia ven zheludka pri portal'noi gipertenzii, oslozhnennoi ézofagogastral'nymi krovotecheniiami.

Through a period from 1981 to 1996 127 roentgen-endovascular embolization of gastric veins were carried out in 95 patients for portal hypertension complicated by esophagogastric bleeding or in its threatening relapse. Group 1 consisted of 73 patients, to whom endovascular treatment was carried out urgently at the background of continuing hemorrhage, in 52 patients--it was delayed and in 21 patients in the nearest posthemorrhagic period. In 73 patients bleeding resulting from embolization was stopped. In the earliest postembolization period recurrence of hemorrhage developed in 6 patients, thus initial hemostatic effect of embolization made up 91.8%, and survival rate--74% (54 from 73 patients of the 1-st group were discharged from the clinic). Group 2 consisted of 22 patients to whom embolization of gastric veins was carried out as an elective procedure. There were bleedings in the anamnesis in the patients of the latter group, and varicose veins of the esophagus with trophic disturbances in esophageal mucosa manifested real treat of the hemorrhage. The survival rate in this group of patients made up 95.5%. The analysis of the results of elective endovascular embolization of gastric veins revealed more favourable results in the nearest postembolization period, than in urgent procedures. Far off results of embolization of gastric veins were followed up in 61 patients (43 patients of the 1st group and 18 patients of the 2nd group). Index of survival up to 6 months made up 87.8%, up to 12 months--80.5%, up to 3 years--57.5% and up to 6 years--19.6%. Hemostatic effect up to 6 months made up 100%, to 12 months--84.6%, to 3 years--54.9%, to 6 years--15.6%.

[Orthotopic liver transplantation (first clinical experience)]. / Ortotopicheskaia transplantatsiia pecheni (pervyi klinicheskii opyt).

The article deals with the results of work conducted according to the orthotopic liver transplantation (OLT) program from January 1990 to January 1992. To select the patients for OLT, 54 persons (24 males and 30 females aged from 12 to 55 years) with diffuse (34) and focal (20) diseases of the liver were examined. OLT was indicated for 19 patients who were registered in the waiting list. In the period of waiting for the donor organs, 5 persons died, 3 refused to undergo OLT, and 4 remain on the waiting list. Eight OLT (including one retransplantation) were conducted on 7 patients. The indications for OLT in these patients were: unresectable hepatocellular carcinoma (4), cirrhosis of the liver of viral etiology (1), fulgurant form of hepatitis B (1), transplant rejection crisis which could not be arrested (1). Immunosuppression was conducted by the two- and three-component programs with the use of corticosteroids, cyclosporine A, and azathioprine. Eight crises of transplant rejection were encountered, successful retransplantation of the liver was accomplished for one of two crises which could not be arrested. The survival of the operated on recipients ranged from 3 days to 15 months. Various complications (mainly hemorrhagic and infectious) were encountered in the posttransplantation period. At the time that the article is written, 3 patients are living for 15, 9, and 4 months (after retransplantation of the liver in the last case), their condition is satisfactory. The death of the other recipients was caused by candidosepsis (on the 40th day), polyorganic insufficiency (on the 10th and 3rd days), sepsis (on the 12th day). The results of the liver transplantation program correspond to those of transplantation centers in other countries in the period of OLT mastering.

[Role of endoscopy in diagnosing rare sources of small intestinal bleedings due to vascular disorders]. / Znachenie éndoskopii v diagnostike redkikh istochnikov tonkokishechnykh krovotechenii, obuslovlennykh sosudistymi porazheniiami.

The authors describe two cases of intraoperative endoscopic diagnosis of hemangioma and vasculitis of the small intestine. The examination was conducted during laparotomy by colonoileoscopy and enterotomy. The authors believe this method to be most effective in emergency surgery when the operation cannot be postponed because of the patient's severe condition caused by hemorrhagic shock.