Inoue S, Mitsuhata H, Abe M, Fukuda H, Shimizu R
Department of Anesthesiology, Jichi Medical School, Tochigi.
Masui. 1997 Jul;46(7):983-6.
Gastroesophageal variceal hemorrhage is a rare complication during an operation. We present a case of gastric variceal re-rupture during an emergent operation for devascularization of the gastric veins. The patient was a 72-year old man with liver cirrhosis, who developed gastric variceal hemorrhage on the day of surgery. Sclerotherapy with an endoscope was performed, and the hemorrhage was controlled four hours before entering the operating theater. The induction of anesthesia and tracheal intubation were done with rapid sequence because the patient was regarded as full stomach. Induction was completed successfully. However, gastric varix ruptured immediately after the beginning of the surgery. The hemorrhage into the stomach amounted to 2,165 ml. The patient developed hypotension of 40 mmHg of systolic pressure for 15 minutes. With fluid resuscitation, continuous infusion of dopamine and ligation of varix, the patient recovered from this hypotensive event. No neurological deficit developed postoperatively. Portal hypertension results from increased resistance to portal venous blood flow or increased portal venous blood flow. Therefore, increased intravascular volume may play a significant role in precipitating variceal hemorrhage. In this case, abrupt circulatory change due to inadequate depth of anesthesia may partly cause massive hemorrhage. In conclusion, since potential adverse effects of increased blood volume and hepatic resistance on variceal hemorrhage must be considered during anesthesia, patients with episode of variceal hemorrhage should be treated as full stomach although endoscopic findings before the surgery indicate controlled hemorrhage from varix.
胃食管静脉曲张出血是手术期间一种罕见的并发症。我们报告一例在急诊行胃静脉去血管化手术过程中胃静脉曲张再次破裂的病例。患者为一名72岁的肝硬化男性，在手术当天发生胃静脉曲张出血。在内镜下进行了硬化治疗，在进入手术室前4小时出血得到控制。由于患者被视为饱胃，采用快速诱导麻醉和气管插管。诱导成功完成。然而，手术开始后胃静脉曲张立即破裂。胃内出血达2165毫升。患者出现收缩压40mmHg的低血压达15分钟。通过液体复苏、持续输注多巴胺和结扎静脉曲张，患者从此次低血压事件中恢复。术后未出现神经功能缺损。门静脉高压是由于门静脉血流阻力增加或门静脉血流量增加所致。因此，血管内容量增加可能在引发静脉曲张出血中起重要作用。在本病例中，麻醉深度不足导致的突然循环变化可能部分导致了大量出血。总之，由于在麻醉期间必须考虑血容量增加和肝阻力增加对静脉曲张出血的潜在不良影响，尽管术前内镜检查结果显示静脉曲张出血已得到控制，但有静脉曲张出血发作的患者仍应视为饱胃。
