Liver: Esophageal Varices

Esophageal Varices

Basics

  • Dilation of Esophageal Veins from Portal Hypertension
    • Blood Shunted Through Coronary Veins to Lower Esophagus & Azygous System
  • Bleeding Risk: 5-15% Yearly

Diagnosis

  • Dx: Endoscopy
  • Best Non-Invasive Test: Spleno-Portal Index
    • Calculated Using Doppler US
    • Splenic Index (Based on Spleen Diameter)/Portal Vein Velocity

Treatment of Acute Bleeding

  • Initial Tx:
    • Endoscopy – Band Ligation Preferred Over Sclerotherapy (Fewer Side Effects)
    • Vasoactive Medication – Telipressin (Preferred), Somatostatin or Octreotide
    • Prophylactic ABX
  • Rebleeds:
    • First Rebleed: Second Endoscopy
    • Second Rebleed: TIPS
  • Temporary Stabilization: Balloon Tamponade (Minnesota Tube or Sengstaken-Blakemore Tube)
    • Variable Success (30-90%) but High Rebleed Risk (50%)
    • Placement:
      • Long Esophageal & Large Round Gastric Balloons are Inflated & Placed to Traction to Compress the GE Junction
      • Distal Port Placed to Suction to Empty Luminal Contents
      • Minnesota Tubes Also Have a Proximal Port to Drain Salivary Secretions – Aspiration is Most Common Complication

Cirrhosis Prophylaxis

  • No Varices: Repeat Endoscopy Every 3 Years
  • Small Varices: β-Blockers (Nadolol or Propranolol)
    • Repeat Endoscopy Every 1-2 Years
  • Medium/Large Varices: Endoscopic Ligation
    • Repeat Endoscopy Every 1-2 Weeks Until Obliterated
    • Then at 1-3 Months & Every 6-12 Months

Esophageal Varices on EGD 1

Sengstaken-Blakemore Tube 2

Sengstaken-Blakemore Tube 3

Minnesota Tube 3

References

  1. Akiyama T, Abe Y, Iida H, Endo H, Hosono K, Yoneda K, Takahashi H, Inamori M, Ryo A, Yamanaka S, Inayama Y, Nakajima A. Endoscopic therapy using an endoscopic variceal ligation for minute cancer of the esophagogastric junction complicated with esophageal varices: a case report. J Med Case Rep. 2010 May 23;4:149. (License: CC BY-2.0)
  2. Escorsell A, Bosch J. Self-expandable metal stents in the treatment of acute esophageal variceal bleeding. Gastroenterol Res Pract. 2011;2011:910986. (License: CC BY-3.0)
  3. Wikimedia Commons. (License: CC BY-SA-3.0)