Esophageal varices
Encyclopedia
In medicine
(gastroenterology
), esophageal varices (or oesophageal varices) are extremely dilated
sub-mucosal vein
s in the lower esophagus
. They are most often a consequence of portal hypertension
, commonly due to cirrhosis
; patients with esophageal varices have a strong tendency to develop bleeding
.
Esophageal varices are diagnosed with endoscopy
.
is drained via the esophageal veins
, which carry deoxygenated blood from the esophagus to the azygos vein
, which in turn drains directly into the superior vena cava
. These veins have no part in the development of esophageal varices. The remaining blood from the esophagus is drained into the superficial veins lining the esophageal mucosa, which drain into the coronary vein (left gastric vein
), which in turn drains directly into the portal vein. These superficial veins (normally only approximately 1mm in diameter) become distended up to 1–2 cm in diameter in association with portal hypertension.
Normal portal pressure is approximately 9 mmHg compared to an inferior vena cava pressure of 2-6 mmHg. This creates a normal pressure gradient of 3-7 mmHg. If the portal pressure rises above 12 mmHg, this gradient rises to 7-10 mmHg. A gradient greater than 5 mmHg is considered portal hypertension
. At gradients greater than 10 mmHg, blood flow though the hepatic portal system is redirected from the liver into areas with lower venous pressures. This means that collateral circulation
develops in the lower esophagus
, abdominal wall, stomach
, and rectum
. The small blood vessels in these areas become distended, becoming more thin-walled, and appear as varicosities
. In addition, these vessels are poorly supported by other structures, as they are not designed for high pressures.
In situations where portal pressures increase, such as with cirrhosis
, there is dilation of veins in the anastomosis
, leading to esophageal varices. Splenic vein thrombosis is a rare condition which causes esophageal varices without a raised portal pressure. Splenectomy
can cure the variceal bleeding due to splenic vein thrombosis. The most common cause of esophageal varices is from aging changes in the vessels.
Varices can also form in other areas of the body, including the stomach
(gastric varices
), duodenum
(duodenal varices
), and rectum
(rectal varices). Treatment of these types of varices may differ.
Blood volume resuscitation should be done promptly and with caution. Goal should be hemodynamic stability and hemoglobin of over 8. Resuscitation of all lost blood leads to increase in portal pressure leading to more bleeding. Volume resuscitation can also worsen ascites and increase portal pressure. (AASLD guidelines)
Therapeutic endoscopy
is considered the mainstay of urgent treatment. Two main therapeutic approaches exist:
In cases of refractory bleeding, balloon tamponade
with Sengstaken-Blakemore tube may be necessary, usually as a bridge to further endoscopy
or treatment of the underlying cause of bleeding (usually portal hypertension). Methods of treating the portal hypertension include: transjugular intrahepatic portosystemic shunt
(TIPS), or a distal splenorenal shunt procedure
or a liver transplantation
.
Nutritional supplementation is not necessary if the patient is not eating for four days or less.
Terlipressin
and octreotide
(50mcg bolus IV followed by 25-50mcg/h IVF for 1 to 5 days) have also been used.
or nadolol
20 mg PO OD) and nitrates (e.g. isosorbide mononitrate (IMN) 20 mg BD to TID) have been evaluated for secondary prophylaxis. Non-selective β-blockers (but not cardioselective β-blockers like atenolol) are preferred because they decrease both cardiac output by β1 blockade and splanchnic blood flow by blocking vasodilating β2 receptors at splanchnic vasculature. The effectiveness of this treatment has been shown by a number of different studies.
Unfortunately, non-selective β-blockers do not prevent the formation of esophageal varices.
and ulceration
of the mucosa. Evidence of past variceal hemorrhage includes inflammation and venous thrombosis
.
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
(gastroenterology
Gastroenterology
Gastroenterology is the branch of medicine whereby the digestive system and its disorders are studied. The name is a combination of three Ancient Greek words gaster , enteron , and logos...
), esophageal varices (or oesophageal varices) are extremely dilated
Vasodilation
Vasodilation refers to the widening of blood vessels resulting from relaxation of smooth muscle cells within the vessel walls, particularly in the large arteries, smaller arterioles and large veins. The process is essentially the opposite of vasoconstriction, or the narrowing of blood vessels. When...
sub-mucosal vein
Vein
In the circulatory system, veins are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood to the heart...
s in the lower esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
. They are most often a consequence of portal hypertension
Portal hypertension
In medicine, portal hypertension is hypertension in the portal vein and its tributaries.It is often defined as a portal pressure gradient of 10 mmHg or greater.-Causes:Causes can be divided into prehepatic, intrahepatic, and posthepatic...
, commonly due to cirrhosis
Cirrhosis
Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules , leading to loss of liver function...
; patients with esophageal varices have a strong tendency to develop bleeding
Bleeding
Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
.
Esophageal varices are diagnosed with endoscopy
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
.
Pathogenesis
The majority of blood from the esophagusEsophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
is drained via the esophageal veins
Esophageal veins
The esophageal veins drain blood from the esophagus to the azygos vein, in the thorax, and to the inferior thyroid vein in the neck. It also drains, although with less significance, to the hemiazygos vein, posterior intercostal vein and bronchial veins....
, which carry deoxygenated blood from the esophagus to the azygos vein
Azygos vein
The azygos vein is a vein running up the right side of the thoracic vertebral column. It can also provide an alternate path for blood to the right atrium by allowing the blood to flow between the venae cavae when one vena cava is blocked.-Structure:...
, which in turn drains directly into the superior vena cava
Superior vena cava
The superior vena cava is truly superior, a large diameter, yet short, vein that carries deoxygenated blood from the upper half of the body to the heart's right atrium...
. These veins have no part in the development of esophageal varices. The remaining blood from the esophagus is drained into the superficial veins lining the esophageal mucosa, which drain into the coronary vein (left gastric vein
Left gastric vein
The left gastric vein carries blood low in oxygen, tributaries derived from both surfaces of the stomach; it runs from right to left along the lesser curvature of the stomach, between the two layers of the lesser omentum, to the esophageal opening of the stomach, where it receives some esophageal...
), which in turn drains directly into the portal vein. These superficial veins (normally only approximately 1mm in diameter) become distended up to 1–2 cm in diameter in association with portal hypertension.
Normal portal pressure is approximately 9 mmHg compared to an inferior vena cava pressure of 2-6 mmHg. This creates a normal pressure gradient of 3-7 mmHg. If the portal pressure rises above 12 mmHg, this gradient rises to 7-10 mmHg. A gradient greater than 5 mmHg is considered portal hypertension
Portal hypertension
In medicine, portal hypertension is hypertension in the portal vein and its tributaries.It is often defined as a portal pressure gradient of 10 mmHg or greater.-Causes:Causes can be divided into prehepatic, intrahepatic, and posthepatic...
. At gradients greater than 10 mmHg, blood flow though the hepatic portal system is redirected from the liver into areas with lower venous pressures. This means that collateral circulation
Collateral circulation
Collateral circulation is when an area of tissue or an organ has a number of different pathways for blood to reach it. This is often as a result of anastamoses - branches formed between adjacent blood vessels....
develops in the lower esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
, abdominal wall, stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
, and rectum
Rectum
The rectum is the final straight portion of the large intestine in some mammals, and the gut in others, terminating in the anus. The human rectum is about 12 cm long...
. The small blood vessels in these areas become distended, becoming more thin-walled, and appear as varicosities
Varicose veins
Varicose veins are veins that have become enlarged and tortuous. The term commonly refers to the veins on the leg, although varicose veins can occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards . Leg muscles pump the veins to return blood to the heart, against the...
. In addition, these vessels are poorly supported by other structures, as they are not designed for high pressures.
In situations where portal pressures increase, such as with cirrhosis
Cirrhosis
Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules , leading to loss of liver function...
, there is dilation of veins in the anastomosis
Anastomosis
An anastomosis is the reconnection of two streams that previously branched out, such as blood vessels or leaf veins. The term is used in medicine, biology, mycology and geology....
, leading to esophageal varices. Splenic vein thrombosis is a rare condition which causes esophageal varices without a raised portal pressure. Splenectomy
Splenectomy
A splenectomy is a surgical procedure that partially or completely removes the spleen.-Indications:The spleen, similar in structure to a large lymph node, acts as a blood filter. Current knowledge of its purpose includes the removal of old red blood cells and platelets, and the detection and fight...
can cure the variceal bleeding due to splenic vein thrombosis. The most common cause of esophageal varices is from aging changes in the vessels.
Varices can also form in other areas of the body, including the stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
(gastric varices
Gastric varices
Gastric varices are dilated submucosal veins in the stomach, which can be a life-threatening cause of upper gastrointestinal hemorrhage. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis...
), duodenum
Duodenum
The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms anterior intestine or proximal intestine may be used instead of duodenum...
(duodenal varices
Intestinal varices
Intestinal varices are dilated submucosal veins in the intestine.One treatment includes a transjugular intrahepatic portosystemic shunt....
), and rectum
Rectum
The rectum is the final straight portion of the large intestine in some mammals, and the gut in others, terminating in the anus. The human rectum is about 12 cm long...
(rectal varices). Treatment of these types of varices may differ.
Treatment
In emergency situations, the care is directed at stopping blood loss, maintaining plasma volume, correcting disorders in coagulation induced by cirrhosis, and appropriate use of antibiotics (usually a quinolone or ceftriaxone, as infection by gram-negative strains is either concomitant, or a precipitant).Blood volume resuscitation should be done promptly and with caution. Goal should be hemodynamic stability and hemoglobin of over 8. Resuscitation of all lost blood leads to increase in portal pressure leading to more bleeding. Volume resuscitation can also worsen ascites and increase portal pressure. (AASLD guidelines)
Therapeutic endoscopy
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
is considered the mainstay of urgent treatment. Two main therapeutic approaches exist:
- Variceal ligation, or banding.
- SclerotherapySclerotherapySclerotherapy is a procedure used to treat blood vessels or blood vessel malformations and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations...
.
In cases of refractory bleeding, balloon tamponade
Balloon tamponade
Balloon tamponade usually refers to the use of balloons inserted into the esophagus or stomach, and inflated to stop refractory bleeding from vascular structures—including esophageal varices and gastric varices -- in the upper gastrointestinal tract....
with Sengstaken-Blakemore tube may be necessary, usually as a bridge to further endoscopy
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
or treatment of the underlying cause of bleeding (usually portal hypertension). Methods of treating the portal hypertension include: transjugular intrahepatic portosystemic shunt
Transjugular intrahepatic portosystemic shunt
A Transjugular Intrahepatic Portosystemic Shunt is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein...
(TIPS), or a distal splenorenal shunt procedure
Distal splenorenal shunt procedure
In medicine, a distal splenorenal shunt procedure , also splenorenal shunt procedure and Warren shunt, is a surgical procedure in which the distal splenic vein is attached to the left renal vein...
or a liver transplantation
Liver transplantation
Liver transplantation or hepatic transplantation is the replacement of a diseased liver with a healthy liver allograft. The most commonly used technique is orthotopic transplantation, in which the native liver is removed and replaced by the donor organ in the same anatomic location as the original...
.
Nutritional supplementation is not necessary if the patient is not eating for four days or less.
Terlipressin
Terlipressin
Terlipressin is an analogue of vasopressin used as a vasoactive drug in the management of hypotension. It has been found to be effective when norepinephrine does not help.Indications for use include norepinephrine-resistant septic shock and hepatorenal syndrome...
and octreotide
Octreotide
Octreotide is an octapeptide that mimics natural somatostatin pharmacologically, though it is a more potent inhibitor of growth hormone, glucagon, and insulin than the natural hormone...
(50mcg bolus IV followed by 25-50mcg/h IVF for 1 to 5 days) have also been used.
Prevention
Ideally, patients with known varices should receive treatment to reduce their risk of bleeding. The non-selective β-blockers (e.g., propranolol 10 mg PO TID, timololTimolol
Timolol maleate is a non-selective beta-adrenergic receptor blocker.-Uses:In its oral form , it is used:* to treat high blood pressure* to prevent heart attacks* to prevent migraine headaches...
or nadolol
Nadolol
Nadolol is a non-selective beta blocker used in the treatment of high blood pressure, migraine headaches, and chest pain.-Pharmacology:...
20 mg PO OD) and nitrates (e.g. isosorbide mononitrate (IMN) 20 mg BD to TID) have been evaluated for secondary prophylaxis. Non-selective β-blockers (but not cardioselective β-blockers like atenolol) are preferred because they decrease both cardiac output by β1 blockade and splanchnic blood flow by blocking vasodilating β2 receptors at splanchnic vasculature. The effectiveness of this treatment has been shown by a number of different studies.
Unfortunately, non-selective β-blockers do not prevent the formation of esophageal varices.
Histology
Dilated submucosal veins are the most prominent histologic feature of esophageal varices. The expansion of the submucosa leads to elevation of the mucosa above the surrounding tissue which is apparent during endoscopy and is a key diagnostic feature. Evidence of recent variceal hemorrhage includes necrosisNecrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
and ulceration
Peptic ulcer
A peptic ulcer, also known as PUD or peptic ulcer disease, is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions equal to or greater than 0.5 cm...
of the mucosa. Evidence of past variceal hemorrhage includes inflammation and venous thrombosis
Venous thrombosis
A venous thrombosis is a blood clot that forms within a vein. A venous thrombosis is a blood clot that forms within a vein. A venous thrombosis is a blood clot that forms within a vein. (Thrombosis is a medical term for blood clotting (Haemostasis) occurring in the wrong place, i.e...
.
See also
- Gastric varicesGastric varicesGastric varices are dilated submucosal veins in the stomach, which can be a life-threatening cause of upper gastrointestinal hemorrhage. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis...
- Intestinal varicesIntestinal varicesIntestinal varices are dilated submucosal veins in the intestine.One treatment includes a transjugular intrahepatic portosystemic shunt....
- EsophagitisEsophagitisEsophagitis is inflammation of the esophagus. It may be acute or chronic. The acute esophagitis can be catarrhal or phlegmonous, whereas the chronic esophagitis may be hypertrophic or atrophic.-Infectious:...
- Mallory-Weiss syndromeMallory-Weiss syndromeMallory–Weiss syndrome or gastro-esophageal laceration syndrome refers to bleeding from tears in the mucosa at the junction of the stomach and esophagus, usually caused by severe retching, coughing, or vomiting.-Causes:...
- Peptic ulcerPeptic ulcerA peptic ulcer, also known as PUD or peptic ulcer disease, is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions equal to or greater than 0.5 cm...
- Caput medusaeCaput medusaeCaput medusae is the appearance of distended and engorged paraumbilical veins, which are seen radiating from the umbilicus across the abdomen to join systemic veins...
- Portal hypertensive gastropathyPortal hypertensive gastropathyPortal hypertensive gastropathy refers to changes in the mucosa of the stomach in patients with portal hypertension; by far the most common cause of this is cirrhosis of the liver. These changes in the mucosa include friability of the mucosa and the presence of ectatic blood vessels at the surface...
External links
- Treatment of Esophageal Varices - World Gastroenterology Organisation (WGO)
- Upper Endoscopy of a Normal Esophagus Video