[Diagnostic and therapeutic measures in acute catastrophic bleeding esophageal varices]

Principles of management of bleeding esophageal varices are 1. fluid therapy of bleeding shock, 2. prevention of hepatic coma, 3. emergency endoscopy, 4. balloon tubes (Senkstaken-Blakemore, Linton-Nachlas), and 5. with some restriction, selective infusion of vasopressin into the a. mesenterica superior. If these procedures fail, sclerosing of esophageal varices stops bleeding in more than 90% of the cases. Bleeding from varices of the gastric fundus may be stopped by gastro-esophageal disconnection (Pettinari-Hassab). Both procedures have with 15% and 25% respectively, the lowest mortality. Patients for surgical shunt are carefully selected within the interval after bleeding. Shunts are the distal splenal-renal and the mesenteric-caval anastomosis with dacron prothesis (H-shunt). The shunt is the favorable therapy for prehepatic block in patients older than 14 to 16 years. The endoscopic sclerosing of esophageal varices and the gastro-esophageal disconnection are chosen in younger patients or when shunt procedures are not possible. The posthepatic block is treated successfully by conservative means. In most cases, surgical therapy is contraindicated because of poor prognosis. When conservative measures fail, in few cases emergency endoscopic sclerosing of esophageal varices or latero-lateral porto-caval anastomosis can be tried.