LEARNING OBJECTIVES

1-Introduction

2-Definition

3-Causes of esophageal varices 

4-Pathophysiology

5- Clinical features 

6- Classification of esophageal varices 

7- Diagnosis 

8- Management of esophageal varices 

9- Complications 

10- Prognosis 

11- Conclusion 

12- Quiz

INTRODUCTION:

Esophageal varices are enlarged abnormally dilated veins which mostly occur in lower 3rd part of esophagus due to high pressure in portal vein[portal hypertension].They are dangerous because they can rupture and cause bleeding.

DEFINITION:

Dilated tortuous veins in the esophagus as a result of portal hypertension commonly due to liver cirrhosis  

 OTHER SITES: 

 Can develop in other sites  

1. Gastric varices[found in stomach]
2. Rectal varices[swollen veins in rectum mostly known as hemorrhoids]
3. Caput medusae[enlarged veins appearing on abdomen radiating from navel]
4. Duodenal varices[enlarged veins in duodenum-first part of small intestine]

*CAUSES OF ESOPHAGEAL VARICES

1-PRE-HEPATIC CAUSE

• Portal vein thrombosis[blood clot in portal vein which carries blood from digestive system to liver]
• Portal vein obstruction[it occur when blood flow to liver is blocked or slowed down]
• Splenic vein thrombosis[clot in vein draining spleen]
• Splenomegaly[enlargement of spleen]

2-HEPATIC CAUSES

• Schistosomiasis[parasitic infection caused by blood fluke -flat worms. The parasite lodge its egg in portal vein causing inflammation and fibrosis. This blocks blood flow in liver . ]
• Congenital hepatic fibrosis[rare inherited condition in which liver develops malformed bile duct and fibrous tissue] 
• Idiopathic[unknown cause]

3-POST HEPATIC CAUSES

• Budd-Chiari syndrome[hepatic vein draining blood away from liver to hear are blocked due to blood clot]
• Right sided heart failure[ right side of heart fails to pump blood to lungs and blood will backflow to systemic circulation via inferior vena cava 

CLINICAL FEATURES OF ESOPHAGEAL VARICES:

SYMPTOMS:

• Early asymptomatic
• Fatigue
• Loss of appetite
• Weight loss
• Hematemesis[blood in vomiting]
• Melena [black color stools]

SIGNS

• Hypotension[low blood pressure]
• Tachycardia[fast heart rate]
• Pale skin
• Ascites[fluid in abdomen]
• Jaundice

*DIAGNOSIS OF ESOPHAGEAL VARICES:

1-History

vomiting

black stools 

jaundice

Ascites

                                                                                                                                              2-Endoscopy[gold standard]

3-LABORATORY INVESTIGATION

• CBC=Anemia ;low platelets
• LFTs =Abnormal
• PT\INR=Prolonged

4-IMAGING STUDIES

• Ultrasound abdomen
• CT-scan\MRI

Grading of Esophageal Varices

Esophageal varices are graded endoscopically according to their size.

BAVENO GUIDELINES

Many current guidelines classify varices simply as:

• Small varices 
• Large varices >5mm

High Risk Endoscopic Signs

• Red whale marks
• Cherry red spots
• Hematocystic spots

MANAGEMENT OF ESOPHAGEAL VARICES:

• Work up and treatment of portal hypertension
• Airway stabilization
• Resuscitation fluid=maintain Hb up to 7g\dl
• Vasoactive drugs=
• Terlipressin  (first-line in many guidelines)
• Octreotide
• Somatostatin
• Endoscopic treatment=band ligation[Sclerotherapy]   
• Balloon tamponade 

Treatment of Esophageal Varices 

1. Acute bleeding
2. Primary prophylaxis 
3. Secondary prophylaxis 

 Management of Acute bleeding:

•  i- Airway breathing and circulation control
•  ii- IV fluids 
• iii- blood transfusion
•  Vasoactive  drugs {Octreotide, Terlipressin}
•  iv- Antibiotics{ Ceftriaxone} to prevent infection in cirrhosis patient
• v- Urgent endoscopy
• vi- EVBL ( in this process a rubber band is placed around the dilated when to stop bleeding)
• vii- Sclerotherapy ( in this process sclerosant injection is administered into the dilated when which stops the bleeding)
• viii- Balloon tamponade (in this process a balloon is dilated  to apply pressure on dilated when ever the pressure is applied that dilated veins compresses and it stops blood ultimately.)
• ix- TIPS (it is a radiological process in which a channel is created between portal vein and hepatic vein to reduce portal hypertension and bleeding varices. It allows blood to bypass hepatic vein and flow directly to systemic circulation.)

2- Primary prophylaxis:

It is prevention of first bleeding or prevention of bleeding in future when patient already know about varices .

i- Beta blocker PropranololCarvedilol

ii- EVBL

3- Secondary prophylaxis:

It is prevention of recurrent bleeding from varices.

i- Combination of Beta blocker 

ii- Repeat EVBL

iii- Treat the cause (hepatitis, cirrhosis)

Emergency warning🚨🚑

• Blood in vomiting 🩸
• Black color stool⚫
•  Fainting 😵‍💫
• Low blood pressure 🪫
• Confusion🫤

*COMPLICATION:

• HEMATEMESIS     
• MELENA 
• HYPOVOLEMIC SHOCK
• ANEMIA
• ASPIRATION PNEUMONIA
• HEPATIC ENCEPHALOPATHY
• INFECTION
• STRICTURE 
• ULCERATION

*PROGNOSIS:

Esophageal varices are asymptomatic early. Their  Prognosis is poor if bleeding occurs .Prognosis is better if varices are detected early and prevented from bleeding

*SUMMARY:

Esophageal varices results from portal hypertension

Screening is very important

Upper GI endoscopy is good for diagnosis

Long term prevention include betablocker and band ligation

FAQs:

1-What is most common cause of esophageal varices?
2-Name gold standard test for esophageal varices?
3-How many grades of esophageal varices are in above classification?

ANSWERS:                                                                                                          1-Portal hypertension                                                                                      2-Upper GI endoscopy                                                                                    3-there are 4 grades of esophageal varices.

References

1. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. Feldman M, Friedman LS, Brandt LJ, editors. 11th ed. Philadelphia: Elsevier; 2021.
2. Sherlock’s Diseases of the Liver and Biliary System. Dooley JS, Lok ASF, Garcia-Tsao G, Pinzani M, editors. Wiley-Blackwell; 2022.
3. American Association for the Study of Liver Diseases (AASLD). Practice guidance on portal hypertension and variceal bleeding.
4. European Association for the Study of the Liver (EASL). Clinical Practice Guidelines on the management of portal hypertension.
5. Baveno VII Consensus Workshop. Renewing consensus in portal hypertension. Journal of Hepatology. 2022.
6. American Society for Gastrointestinal Endoscopy (ASGE). Guidelines on the role of endoscopy in the management of variceal hemorrhage.
7. Robbins and Cotran Pathologic Basis of Disease. Kumar V, Abbas AK, Aster JC. Elsevier; 2020.