Esophageal Varices

Snapshot

• A 60-year-old man with a history of alcoholic cirrhosis presents to the emergency room after an episode of coffee-ground emesis. He had been drinking for the past few days and reports that he had not been eating properly. He is found to be fecal occult positive. On cutaneous exam, he has palmar erythema and scattered telangiectasias.

Introduction

• Overview
  • esophageal varices result as a collateral system often secondary to portal hypertension
  • often, these varices may present as acute gastrointestinal bleeding
• Epidemiology
  • incidence
    • 50% of patients with cirrhosis
  • risk factors
    • liver disease
      • cirrhosis
      • hepatitis C
      • alcohol use
    • NSAIDs
    • coagulopathy
      • splenic venous thrombosis
• Pathogenesis
  • mechanism
    • varices often develop in patients with portal hypertension
    • varices offer a channel that diverts pressure from portal circulation to systemic circulation
      • results from increased vasodilation of gastric and esophageal vessels and vasoconstriction of intrahepatic vessels
      • often found in lower 1/3 of the esophagus and can extend into gastric veins
• Associated conditions
  • medical conditions and comorbidities
    • hepatic encephalopathy
    • ascites
    • bacterial peritonitis
    • primary biliary cirrhosis
• Budd-Chiari syndrome

Presentation

• Symptoms
  • common symptoms
    • presentation depends on rate of gastrointestinal (GI) blood loss
      • hematemesis
      • coffee-ground emesis
      • melena
      • hematochezia
• Physical exam
  • inspection
    • signs of liver disease
      • spider angiomata
      • caput medusae
      • palmar erythema
      • gynecomastia
      • hepatosplenomegaly
• telangiectasias

Studies

• Serum labs
  • hemoglobin and hematocrit
  • platelet count
• Invasive studies
  • esophagogastroduodenoscopy (EGD)
    • indications
      • all patients with GI bleed
      • diagnostic and can be therapeutic
    • findings
• abnormal venous dilation

Differential

• Peptic ulcer disease
  • key distinguishing factor     
• EGD shows ulcers rather than abnormal venous dilation

Treatment

• Medical
  • resuscitation
    • indication
      • acute variceal hemorrhage
    • modalities
      • intravenous fluids
      • blood transfusions to maintain hemoglobin > 8 g/dL
  • somatostatin analogs 
    • indication
      • acute variceal hemorrhage
    • drugs
      • octreotide
      • vapreotide
  • antibiotic prophylaxis
    • indications
      • acute variceal hemorrhage
      • cirrhosis
    • drugs
      • ciprofloxacin
      • ceftriaxone
  • beta-blockers  
    • indications
      • after acute episode of variceal hemorrhage
      • reduces rebleeding rate and mortality
      • secondary prophylaxis of bleeding
  • isosorbide mononitrate
    • indications
      • after acute episode of variceal hemorrhage
      • adjuvant with beta-blockers
      • venodilator
• Surgical
  • EGD
    • indications
      • for all patients
      • diagnostic and therapeutic
    • modalities
      • endoscopic ligation
      • sclerotherapy
  • transjugular intrahepatic porto-caval shunt (TIPS) procedure
    • indication
• refractory variceal bleeding

Complications

• Variceal bleeding
• Hepatic encephalopathy
• Hepatorenal syndrome