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Esophageal Varices

BASICS

DESCRIPTION

  • Dilated submucosal veins connecting portal and systemic circulation in distal esophagus.
  • Result from portal hypertension, usually due to cirrhosis.
  • Variceal rupture is the leading fatal complication of cirrhosis.
  • Severity of liver disease correlates with varices presence and bleeding risk.

EPIDEMIOLOGY

  • At diagnosis, 30% of cirrhotics have varices; 90% at 10 years.
  • 1-year first bleed risk: 5% (small varices), 15% (large varices).
  • 50% of variceal patients experience bleeding during their disease.
  • Bleeding mortality 10-20% within 6 weeks.
  • Male predominance.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Portal hypertension increases resistance to portal flow at hepatic sinusoids via vasoconstriction, sinusoidal remodeling.
  • Increased portal flow due to splanchnic arterial vasodilation mediated by nitric oxide, prostacyclin, TNF.
  • Causes:
  • Prehepatic: portal vein thrombosis, splenomegaly.
  • Intrahepatic: cirrhosis (most common), schistosomiasis, fatty liver, granulomatous diseases.
  • Posthepatic: Budd-Chiari syndrome, right heart failure.

RISK FACTORS

  • Cirrhosis severity, thrombocytopenia, splenomegaly.
  • Varix size, endoscopic red signs, variceal wall thickness, portal pressure changes.
  • MELD/Child-Pugh score, portal vein thrombosis, hepatic venous pressure gradient (HVPG).

DIAGNOSIS

HISTORY

  • Underlying liver disease or cirrhosis.
  • Risk factors: alcohol abuse, hepatitis B/C, IV drug use.
  • Presentation with hematemesis, melena, hematochezia.
  • Rapid bleeding may present as rectal bleeding.

PHYSICAL EXAM

  • Hemodynamic instability signs: hypotension, tachycardia.
  • Signs of chronic liver disease: small firm liver, splenomegaly, ascites.
  • Caput medusae, spider angiomas, palmar erythema.
  • Rectal varices, blood on digital rectal exam.
  • Hepatic encephalopathy signs.

DIFFERENTIAL DIAGNOSIS

  • Upper GI bleeding: peptic ulcer, gastritis, malignancy, Mallory-Weiss tear, arteriovenous malformations.
  • Lower GI bleeding: hemorrhoids, diverticulosis, malignancy.

DIAGNOSTIC TESTS

  • Labs: anemia, thrombocytopenia, liver function tests, prolonged PT, elevated BUN.
  • Endoscopy (EGD): identifies varices, bleeding, red wale marks; enables band ligation.
  • Transient elastography (Fibroscan): risk stratification for portal hypertension.
  • HVPG measurement: gold standard for portal pressure.
  • Doppler US, CT/MRI angiography (second line).

TREATMENT

GENERAL MEASURES

  • Treat underlying liver disease and complications.
  • Resuscitate with IV fluids and blood products (avoid overtransfusion).
  • Avoid sedation and nephrotoxic drugs during bleeding.
  • Use vasoactive agents (octreotide, terlipressin) to reduce portal pressure.

MEDICATION

First Line

  • Nonselective Ξ²-blockers (NSBB): propranolol, nadolol, carvedilol for primary prophylaxis to reduce first bleed risk.
  • NSBB dosing titrated to reduce heart rate by ~25%.
  • Carvedilol may be more effective in reducing portal pressure.

Secondary Prevention

  • Combination of NSBB and endoscopic variceal ligation (EVL) reduces rebleeding risk.
  • Proton pump inhibitors during EVL to reduce complications.

ENDOSCOPIC THERAPY

  • Variceal band ligation preferred over sclerotherapy.
  • Repeated ligation for eradication and rebleeding control.

OTHER PROCEDURES

  • Balloon tamponade or self-expanding metal stents for temporary bleeding control.
  • Transjugular intrahepatic portosystemic shunt (TIPS) for refractory cases.
  • Liver transplantation for definitive treatment.

ISSUES FOR REFERRAL

  • Urgent endoscopy for diagnosis and treatment.
  • Referral for TIPS or liver transplant evaluation.
  • Management of portal hypertension complications.

ONGOING CARE

FOLLOW-UP

  • Surveillance endoscopy every 1-4 weeks during variceal eradication.
  • Routine screening endoscopy every 1-3 years in compensated cirrhosis.
  • Avoid unnecessary endoscopy in low-risk patients (TE <20 kPa, platelets >150,000).

PATIENT EDUCATION

  • Lifestyle modifications to reduce liver injury.
  • Importance of adherence to medications and follow-up.

PROGNOSIS

  • 1-year survival ~50% after variceal bleeding; mortality correlates with liver disease severity.
  • Recurrence of varices and bleeding common without prophylaxis.

COMPLICATIONS

  • Rebleeding, infection, hepatic encephalopathy, renal dysfunction, hepatorenal syndrome.
  • Formation of gastric varices post-eradication.

REFERENCES

  1. Jakab SS, Garcia-Tsao G. Evaluation and management of esophageal and gastric varices in patients with cirrhosis. Clin Liver Dis. 2020;24(3):335-350.
  2. Simonetto DA, Liu M, Kamath PS. Portal hypertension and related complications: diagnosis and management. Mayo Clin Proc. 2019;94(4):714-726.

CODES

  • ICD10 I85.0 Esophageal varices
  • ICD10 I85 Esophageal varices
  • ICD10 I85.1 Secondary esophageal varices

CLINICAL PEARLS

  • Thrombocytopenia is a sensitive marker for portal hypertension and large varices.
  • Half of cirrhotics have varices; one-third will bleed.
  • Bleeding risk increases with varice size and red wale marks.
  • Avoid Ξ²-blockers during active bleeding.
  • Overtransfusion increases portal pressure and bleeding risk.