Esophageal varices

From Medical-Wiki

Obstruction of the portal vein creates collateral circulation — the most important of which are esophageal varices (EV). As these dilate, they are prone to bleed. Bleeding from these esophageal varices is the most severe complication of portal hypertension. Since cirrhosis is the most common cause of portal hypertension, esophageal varices are an important sequela of cirrhosis. [1]

Screening for esophageal varices

National guidelines call for all patients with significant portal hypertension to have endoscopy to evaluate the possibility of esophageal varices. “There are no reliable methods of predicting which cirrhotic patients will have esophageal varices without endoscopy.” [2]

Preventing esophageal bleeds

Guidelines also call for prophylaxis with beta blockade. Endoscopic sclerotherapy (EST) is not indicated for prophylaxis. Endoscopic variceal ligation (EVL) is recommended — in patients who cannot tolerate or have contraindications to beta-blockade, or in those who do not show a reduction in hepatic vein pressure gradient of greater than 20%.

There are a percentage of patients who do not respond to beta blockers or do not tolerate them. These patients may benefit from long-acting nitrates. The mechanism of action is a decrease in cardiac output by decreasing venous return following systemic vasodilation. One study suggested that isosorbide mononitrate was as effective as beta blockade for a two year period. However, longer term studies associated it with an increased mortality. At present, it is considered an alternative only for the short term.

Treatment for acute variceal hemorrage

Endoscopic variceal ligation is also the treatment of choice for acute variceal hemorrhage. It appears to induce bacteremia far less than EST. (For this reason, although antibiotic prophylaxis is indicated for all patients hospitalized for variceal bleeding, the decision to use antibiotic prophylaxis in high-risk patients solely to prevent the infectious complications of EVL should be individualized.)

Endoscopic sclerotherapy is, however, successful in controlling active bleeding in over 90% of patients, and in the presence of active bleeding, it may be an easier procedure to perform.

The development of the multiple band procedure has further emphasized the advantage of EVL, and as the number of experienced operators increases, the procedure is increasingly becoming standard of care.

During an acute bleed, it is crucial that patients no be over-transfused. A rule of thumb is that a hematocrit of 30% should be the target of blood replacement. Much higher runs the risk of simply further increasing portal pressure.

It is also true that levels of consciousness must be closely followed during an acute bleed as well as renal functions. [3]

Guidelines also outline an algorithm for followup care. [4]

Keywords: ESOPHAGEAL VARICES gastroesophageal varices, cardioesophageal junction varices, esophagogastric varices, varices in the fundus and esophagus, varices at the gastroesophageal junction