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Esophageal Varices

Esophageal Varix

Esophageal varices are dilated submucosal veins in the lower third of the esophagus, usually as a result of portal hypertension.


Presentation

The most common presentation is hematemesis and there could also be melena. Other symptoms are abdominal pain, dysphagia, odynophagia, and other features of liver disease or underlying medical condition. They could also present in confusion secondary to hepatic encephalopathy. On physical examination, patient will be pale, hypotensive and could be in shock, with reduced urine output, and could be unconscious/subconscious. There would also be signs of liver disease and signs of overwhelming infection might also be seen.

Hemophilia A
  • Bleeding from esophageal varices is a serious clinical condition in hemophilia patients due to congenital deficiency or lack of clotting factors VIII (in hemophilia A) and IX (in hemophilia B), decreased clotting factor II, VII, IX, X synthesis in the[ncbi.nlm.nih.gov]
  • Authors report the first case of a severe hemophilia A patient with high titer inhibitor (40 BU) treated with repeated injection sclerotherapy.[ncbi.nlm.nih.gov]
Stridor
  • Three days later, the patient developed sudden dyspnea with stridor during inspiration under sedation with an intravenous injection of low-dose flunitrazepam prior to receiving additional treatment and was aroused with intravenous flumazenil, after which[ncbi.nlm.nih.gov]
Hematemesis
  • We herein report a case of a 50-year-old male with hematemesis due to the rupture from esophageal varices coexisting with multiple liver tumors metastasizing from sigmoid colon cancer.[ncbi.nlm.nih.gov]
  • A 46-year-old woman presented with massive hematemesis, caused by the rupture of esophageal varices. The laboratory investigations showed pancytopenia, and imaging tests revealed hepatosplenomegaly and ascites.[ncbi.nlm.nih.gov]
  • We present a 62-year-old woman who was diagnosed with both achalasia and esophageal varices in December 2014 and had a past history of hematemesis.[ncbi.nlm.nih.gov]
  • The clinical course of the patient was complicated by one episode of hematemesis without abdominal pain when the patient's PT was in therapeutic range.[ncbi.nlm.nih.gov]
  • Esophageal varices is one of the most important comorbidity related liver cirrhosis, patients usually presented with hematemesis, melena, or both, ultimately 20% is the mortality during the first attack, hence we aimed to investigate the incidence of[ncbi.nlm.nih.gov]
Melena
  • Esophageal varices is one of the most important comorbidity related liver cirrhosis, patients usually presented with hematemesis, melena, or both, ultimately 20% is the mortality during the first attack, hence we aimed to investigate the incidence of[ncbi.nlm.nih.gov]
  • A young woman with a benign superior vena cava stenosis due to a tunneled internal jugular vein dialysis catheter presented with hematemesis and melena.[ncbi.nlm.nih.gov]
  • Objective: hematemsis-bloody vomitus, either bright red (indicate fresh blood) or "coffee ground" (indicate older blood that has been in the stomach long enough for gastric juices to act on it) melena (occult blood in stool) peripheral edema Idicators[quizlet.com]
  • The most common presentation is hematemesis and there could also be melena. Other symptoms are abdominal pain, dysphagia, odynophagia, and other features of liver disease or underlying medical condition.[symptoma.com]
Black Stools
  • A 58-year-old man with hepatitis B cirrhosis noticed black stools and underwent an endoscopy at a community hospital. The presence of esophageal varices (EVs) was confirmed, but the bleeding point was not found.[ncbi.nlm.nih.gov]
  • Signs and Symptoms of Esophageal Varices Signs and Symptoms of Esophageal Varices may include the following: Lightheadedness Bloody stools Abdominal pain Hematemesis (blood in vomit) Shock or faintness due to blood loss Black stools If you or someone[eatingdisorderhope.com]
  • Ballooning of blood vessels (veins) may cause vessels to rupture causing: vomiting of blood, tarry black stools. If large volume of blood is lost sign of shock will develop.[quizlet.com]
  • If larger amounts of bleeding occur, symptoms may include: Black, tarry stools Bloody stools Lightheadedness Paleness Symptoms of chronic liver disease Vomiting blood Your health care provider will do a physical exam which may show: Bloody or black stool[medlineplus.gov]
Blood in Stool
  • Objective: hematemsis-bloody vomitus, either bright red (indicate fresh blood) or "coffee ground" (indicate older blood that has been in the stomach long enough for gastric juices to act on it) melena (occult blood in stool) peripheral edema Idicators[quizlet.com]
  • The most feared situation is a rupture of the varices that causes massive hemorrhage with blood vomiting and presence of black tarry blood in stool ( melena ). Without urgent medical assistance, the patient bleeds relatively quickly to death.[health-tutor.com]
Muscle Twitch
  • Endoscopists should be cautious of the use of sedatives in patients with diseases associated with muscle twitching or stiffness, as in the current case.[ncbi.nlm.nih.gov]
Tremulousness
  • A 57-year-old man came to our hospital in a confused, apathetic and tremulous state. The grade of encephalopathy was II. The plasma ammonia level was abnormally elevated to 119 microg/dL, and the ICGR15 was 59%.[ncbi.nlm.nih.gov]
Impulsivity
  • To evaluate liver and spleen stiffness measurements using acoustic radiation force impulse (ARFI) imaging for diagnosing grade of liver fibrosis and predicting the presence of esophageal varices in patients treated for biliary atresia.[ncbi.nlm.nih.gov]
  • This study's aimwas to determine the accuracy of the spleen stiffness value acquired using acoustic radiation force impulse (ARFI) technology, to predict the presence of esophageal varices (EVs) in patients with liver cirrhosis of various etiologies.[ncbi.nlm.nih.gov]
  • We attempted to evaluate the association of liver and spleen stiffness (LS and SS) as measured by acoustic radiation force impulse imaging, with the presence and severity of esophageal varices and variceal hemorrhage in cirrhotic patients.[ncbi.nlm.nih.gov]
  • We developed and validated a novel, acoustic radiation force impulse (ARFI) elastography-based prediction model for high-risk EVs (HEVs) in patients with compensated cirrhosis.[ncbi.nlm.nih.gov]
  • Evaluation of portal hypertension and varices by acoustic radiation force impulse imaging of the liver compared to transient elastography and AST to platelet ratio index. Ultraschall Med . 2014 Dec. 35(6):528-33. [Medline] .[emedicine.medscape.com]

Workup

  • Laboratory investigations should include complete blood count which may show low hemoglobin level and platelet count. Blood should also be taken for clotting profile including INR. Renal and liver function tests should also be done and blood should be taken for grouping and cross-matching as patient may require transfusion. 
  • Esophagogastroduodenoscopy is the main investigation for diagnosis of this condition. It will show the location and size of the varices. If it is unavailable, a Doppler ultrasound can be done. Although it is a poor second choice, it can demonstrate varices when done by a skilled handler [7]. 
  • Barium swallow and portal vein angiography and manometry should also be conducted. A chest X-ray should be done to exclude the possibility of aspiration and look for underlying chest infections. Ascitic tap for microscopy and culture is necessary if there are suspicions of bacterial peritonitis.
Gastric Varices
  • varices in the autoimmune hepatitis patients and nonbiliary atresia patients and presence of red spots on esophageal varices, presence of gastric varices, and Child-Pugh classification B or C in biliary atresia group (P   0.05).[ncbi.nlm.nih.gov]
  • The gastric varices disappeared after obliterating both the feeding and drainage vessels by means of intervention radiology. We thus, consider the occlusion of both the afferent and efferent vessels to be an effective treatment for gastric varices.[ncbi.nlm.nih.gov]
  • This 46-year-old man was diagnosed with severe gastric varices and gastrorenal shunting with only mild esophageal varices.[ncbi.nlm.nih.gov]
  • Gastric varices Gastric varices are supplied by the short gastric veins, draining into the deep intrinsic veins of the lower oesophagus, and can be classified according to site by the Sarin classification of gastric varices [ 37 ] ( Figure 6 / Table 3[intechopen.com]
  • Gastric varices and portal hypertensive gastropathy developed in 38.7% and 57.9% of patients, respectively.[ncbi.nlm.nih.gov]

Treatment

  • Treatment can be medical and surgical. Medical management involves the use of splanchnic vasoconstrictors (like vasopressin, somatostatin and non-cardioselective beta blockers), venodilators (like nitrates) or a combination of both.
  • Surgical management include endoscopic sclerotherapy and variceal band ligation. Ligation provides better control of hemorrhage and better outcomes but may be difficult to perform in a patient with active hemorrhage [8]. 
  • If the above steps fail, a transjugular intrahepatic portosystemic shunt (TIPS) is used [9]. 
  • A balloon tamponade could be used where TIPS is unavailable. It is very effective in stopping hemorrhage but carries a high risk of rebleeding and major complications when the balloon is removed.
  • Patient may present needing emergency attention and emergency management to secure airway, breathing and proper circulation should be instituted immediately.

Prognosis

There is a recurrence rate of about 70% and up to 33% of a recurring hemorrhage will result in death. The highest risk of fatality is during the first few days after the bleeding episode and the risk begins to decline progressively after 6 weeks. There is about 65% mortality in patients with esophageal varices that could be attributed to associated disorders of the renal, cardiovascular and immune system [6].

Etiology

Esophageal varices are caused by anything that can cause portal hypertension. Such cause could be prehepatic like portal vein thrombosis, portal vein obstruction and increased splenic flow. It could also be intrahepatic like liver cirrhosis, hepatitis, idiopathic portal hypertension and congenital hepatic fibrosis and posthepatic like Budd-Chiari syndrome, compression from a tumor and constrictive pericarditis.

Factors are also present which increase the risk for variceal bleeding and they include malnutrition, alcohol intake, decompensation of liver disease, increased intraabdominal pressure, non-steroidal anti-inflammatory drugs (NSAIDs), bacterial infection and circadian rhythms [2].

Epidemiology

Esophageal varices account for up to 30% of all cases of upper gastrointestinal hemorrhage and they are seen in over 50% of patients with liver cirrhosis. Annually, up to 8% of patient with liver cirrhosis develop esophageal varices and the varices are large enough to have a risk of bleeding in about 3% of those that develop it. Up to 30% of patients with small varices will progressively develop large varices and are also therefore at a risk of bleeding. The mortality rate from esophageal variceal bleed is about 20% at 6 weeks although, in up to 40% of patients, bleeding stops spontaneously [3].

Sex distribution
Age distribution

Pathophysiology

Portal hypertension develops in liver disease as a consequence of an increase in vascular resistance at either the prehepatic, intrahepatic or posthepatic levels. An increase in portal venous flow also contributes to the hypertension. Esophageal varices develop as the pressure in the portal vein continues to increase. The varices are small on the outset but as the hyperdynamic circulation increases, blood flow through the varices also increases and this raises the tension within the wall. When the expanding force exceeds the maximal wall elastic limit, there is rupture which will cause variceal hemorrhage. If the pressure in the portal vein does not reduce, then there is a risk of recurrence [4] [5].

Prevention

There is no known method to prevent the formation of esophageal varices. Newly diagnosed patients with liver cirrhosis should be screened for varices. Varices can be treated with beta blockers and esophageal band ligation to significantly reduce the risk of bleeding [10].

Summary

Esophageal varices are porto-systemic collaterals. They are vascular channels that link the portal and systemic venous system and they form as a result of portal hypertension and are mostly seen in the lower one-third of the esophagus. The rupture of esophageal varices and subsequent bleeding is a major complication of portal hypertension. It is usually associated with a high mortality rate [1].

Patient Information

  • Definition: Esophageal varices are dilated veins usually located at the lower end of the esophagus. They are usually as a result of liver disease which causes the pressure in the veins of the liver to increase. This condition could lead to death if these vessels rupture.
  • Cause: The main causes are anything that will cause a liver disease. Some risk factors for formation of varices include chronic alcoholism, anything that will cause increased intraabdominal pressure, aspirin, NSAIDs, malnutrition and bacterial infections.
  • Symptoms: The main symptoms is vomiting of pure blood and there could also be blood in the stool. Other symptoms are abdominal pain and pain on swallowing. There could also be symptoms arising due to the underlying liver disease like yellowness of the eyes and skin.
  • Diagnosis: Diagnosis is usually confirmed by an endoscopic examination. This involves looking directly into the esophagus with a small camera. Ultrasound could be done if this is not available. Special X-rays and imaging of the blood vessels can also be done. Laboratory tests are done to check the blood level and cells, to check the kidney and liver function and also to prepare for possible blood transfusion.
  • Treatment: Treatment involves the use of drugs to try and reduce the pressure in these veins. Surgery can also be done to either shrink the veins or tie them up to reduce the risk of bleeding.

References

Article

  1. Sanyal AJ, Bosch J, Blei A, Arroyo V. Portal hypertension and its complications. Gastroenterology. May 2008;134(6):1715-28
  2. Sass DA, Chopra KB. Portal hypertension and variceal hemorrhage. Med Clin North Am. Jul 2009;93(4):837-53, vii-viii.
  3. Gore RM, Livine MS, eds. Textbook of Gastrointestinal Radiology. 2nd ed. Philadelphia, Pa: WB Saunders Co; 2000:454-63, 2082
  4. Cho KC, Patel YD, Wachsberg RH, Seeff J. Varices in portal hypertension: evaluation with CT.Radiographics. May 1995;15(3):609-22.
  5. de Franchis R, Primignani M. Why do varices bleed?. Gastroenterol Clin North Am. Mar 1992;21(1):85-101.
  6. Merkel C, Zoli M, Siringo S. Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) index. Am J Gastroenterol. Oct 2000;95(10):2915-20.
  7. Liu CH, Hsu SJ, Liang CC, Tsai FC, Lin JW, Liu CJ, et al. Esophageal varices: noninvasive diagnosis with duplex Doppler US in patients with compensated cirrhosis. Radiology. Jul 2008;248(1):132-9
  8. Garcia-Pagan JC, Bosch J. Endoscopic band ligation in the treatment of portal hypertension. Nat Clin Pract Gastroenterol Hepatol. Nov 2005;2(11):526-35.
  9. Conn HO. Portal hypertension, varices, and transjugular intrahepatic portosystemic shunts. Clin Liver Dis. Feb 2000;4(1):133-50, vii.
  10. Krige JE, Shaw JM, Bornman PC. The evolving role of endoscopic treatment for bleeding esophageal varices. World J Surg. 2005;29:966-73.

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Last updated: 2018-06-22 05:38