Esophageal Varices


Article Author:
Marcelle Meseeha


Article Editor:
Maximos Attia


Editors In Chief:
Susan Johnson
Alexandra Caley


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
2/1/2019 10:35:30 PM

Introduction

Esophageal varices are dilated submucosal distal esophageal veins connecting the portal and systemic circulations. This happens due to portal hypertension (most commonly a result of cirrhosis), resistance to portal blood flow, and increased portal venous blood inflow. The most common fatal complication of cirrhosis is variceal rupture; the severity of liver disease correlates with the presence of varices and risk of bleeding.[1][2][3][4]

Etiology

Causes of portal hypertension:

  • Prehepatic: Portal vein obstruction (EHPVO) or massive splenomegaly with increased splenic vein blood flow
  • Posthepatic: Severe right-sided heart failure, constrictive pericarditis, and hepatic vein obstruction (Budd-Chiari syndrome)
  • Intrahepatic: Cirrhosis accounts for most cases of portal hypertension.

Less frequent causes are schistosomiasis, massive fatty change, diseases affecting portal microcirculation as nodular regenerative hyperplasia and diffuse fibrosing granulomatous disease as sarcoidosis.[5]

Epidemiology

Incidence

  • At diagnosis, 30% of cirrhotic patients have varices which increase to 90% in 10 years.
  • The 1-year rate of first variceal bleeding is 5% for small varices, 15% for large varices.

Portal hypertension is common in chronic liver disease (CLD) in children.

Prevalence

  • It is more common in males than females. Fifty percent of patients with esophageal varices will experience bleeding at some point.
  • Variceal bleeding has 10% to 20% mortality rate in the 6 weeks following the episode.

Pathophysiology

Portal hypertension causes portocaval anastomosis to develop to decompress portal circulation. This leads to a congested submucosal venous plexus with tortuous dilated veins in the distal esophagus. Variceal rupture results in hemorrhage.

Pathophysiology of portal hypertension:

  • Increased resistance to portal flow at the level of hepatic sinusoids is caused by:
  1. Intrahepatic vasoconstriction due to decreased nitric oxide production, and increased release of endothelin-1 (ET-1), angiotensinogen, and eicosanoids
  2. Sinusoidal remodeling disrupting blood flow.
  • Increased portal flow is caused by hyperdynamic circulation due to splanchnic arterial vasodilation through mediators such as nitric oxide, prostacyclin, and TNF.

History and Physical

The first indication of varices is often the presence of a gastrointestinal (GI) bleeding episode: hematemesis, hematochezia, and/or melena. Occult bleeding (anemia) is uncommon.

History

  • Variceal bleed can be the initial presentation of previously undiagnosed cirrhosis
  • Alcoholism, exposure to blood-borne viruses
  • Hematemesis, melena, or hematochezia
  • Rapid upper GI bleed can present as rectal bleeding.

Physical Exam

  • Assess hemodynamic stability: hypotension, tachycardia (active bleeding)
  • Abdominal exam: liver palpation/percussion (often small and firm with cirrhosis)
  • Splenomegaly, ascites (shifting dullness; puddle splash)
  • Visible abdominal periumbilical collateral circulation (caput medusae)
  • Peripheral stigmata of alcohol abuse: spider angiomata on chest/back, palmar erythema, testicular atrophy, gynecomastia
  • Anal varices or blood on rectal exam
  • Hepatic encephalopathy; asterixis.

Evaluation

Initial Tests (lab, imaging)

  • Anemia: Hemoglobin may be normal in active bleeding and may take six to 24 hours to equilibrate. Other causes of anemia are common in cirrhotics
  • Thrombocytopenia is the most sensitive and specific lab parameter that correlates with portal hypertension and large esophageal varices
  • Elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, bilirubin; prolonged PT, low albumin suggest cirrhosis
  • BUN is often elevated in GI bleed
  • Sodium level may drop in patients treated with terlipressin

Esophagogastroduodenoscopy

  • Can identify actively bleeding varices as well as large varices and stigmata of recent bleeding
  • Can be used to treat bleeding with esophageal band ligation (preferred to sclerotherapy); prevent rebleeding; detect gastric varices, portal hypertensive gastropathy; diagnose alternative bleeding sites
  • Can identify and treat nonbleeding varices (protruding submucosal veins in the distal third of the esophagus) 

Diagnostic Procedures/Other

  • Transient elastography (TE) for identifying CLD patients at risk of developing clinically significant portal hypertension (CSPH) 
  • Hepatic vein pressure gradient (HVPG)  greater than 10 mmHg is the gold standard to diagnose CSPH (normal: 1 mmHg to 5 mmHg)
  • HVPG response of equal or greater than 10% or to less than or equal to 12 mmHg to intravenous propranolol may identify responders to nonselective beta-blocker (NSBB) and is linked to a significant decrease in risk of variceal bleeding
  • Video capsule endoscopy screening may be an alternative to traditional endoscopy
  • Doppler sonography (second line): demonstrates patency, diameter, and flow in portal and splenic veins, and collaterals; sensitive for gastric varices; documents patency after ligation or transjugular intrahepatic portosystemic shunt (TIPS)
  • CT or MRI-angiography (second-line, not routine): demonstrates large vascular channels in abdomen, mediastinum; demonstrates patency of intrahepatic portal and splenic vein
  • Venous-phase celiac arteriography: demonstrates portal vein and collaterals; diagnosed hepatic vein occlusion 
  • Portal pressure measurement using a retrograde catheter in the hepatic vein.

Treatment / Management

Treat underlying cirrhotic comorbidities.[6][7][8][9]

Hepatic encephalopathy and infection often complicate variceal bleeding.

Active bleeding:

  • Intravenous (IV) access, hemodynamic resuscitation
  • Overtransfusion increases portal pressure and increases rebleeding risk
  • Treat coagulopathy as necessary. Fresh frozen plasma may increase blood volume and increase rebleeding risk
  • Monitor mental status. Avoid sedation, nephrotoxic drugs, and beta-blockers acutely.
  • IV octreotide to lower portal venous pressure as adjuvant to endoscopic management. IV bolus of 50 micrograms followed by a drip of 50 micrograms/hr.
  • Terlipressin (alternative): 2 mg q4h IV for 24 to 48 hours, then 1 mg q4h
  • Erythromycin 250 mg IV 30 to 120 minutes before endoscopy
  • Urgent upper GI endoscopy for diagnosis and treatment

Variceal band ligation is preferred to sclerotherapy for bleeding varices and for nonbleeding medium-to-large varices to decrease bleeding risk. Ligation has lower rates of rebleeding, fewer complications, more rapid cessation of bleeding and a higher rate of variceal eradication.

Repeat ligation/sclerosant for rebleeding.

If endoscopic treatment fails, consider self-expanding esophageal metal stents or peroral placement of Sengstaken-Blakemore-type tube up to 24 hours to stabilize the patient for TIPS.

As many as two-thirds of patients with variceal bleeding develop an infection, most commonly spontaneous bacterial peritonitis, UTI, or pneumonia. Antibiotic prophylaxis with oral norfloxacin 400 mg or IV ceftriaxone, 1 g q24h for up to a week, is indicated.

With active bleeding, avoid beta-blockers, which decrease blood pressure and blunt the physiologic increase in heart rate during acute hemorrhage.[10][11][12]

Prevent recurrence of acute bleeding:

  • Vasoconstrictors: terlipressin, octreotide (reduce portal pressure)
  • Endoscopic band ligation (EBL): if bleeding recurs/portal pressure measurement shows portal pressure remains greater than 12 mmHg
  • TIPS: Second-line therapy if above methods fail; TIPS decreases portal pressure by creating communication between hepatic vein and an intrahepatic portal vein branch.

Medications

First-Line

  • NSBB reduce portal pressure and decrease the risk of the first bleed from 25% to 15% in primary prophylaxis
  • Carvedilol: 6.25 mg daily is more effective than NSBB (Propranolol and Nadolol) in dropping HVPG
  • Chronic prevention of rebleeding (secondary prevention): NSBBs and EBL reduce the rate of rebleeding to a similar extent, but beta-blockers reduce mortality, whereas ligation does not.

Second-Line

  • Obliterate varices with esophageal banding for patients not tolerant of medication prophylaxis.
  • During ligation, proton pump inhibitors are used, such as lansoprazole 30 mg/day, until varices are obliterated.
  • Management of Budd-Chiari syndrome: anticoagulation, angioplasty/thrombolysis, TIPS, and orthotopic liver transplantation
  • Management of extrahepatic portal vein obstruction: anticoagulation; mesenteric-left portal vein bypass (Meso-Rex procedure).

Refer for endoscopy, liver transplant, and interventional radiology for TIPS.

Pneumococcal and hepatitis A/B (HAV/HBV) vaccine need to be considered.

Surgery/Other Procedure

  • Esophageal transection: in rare cases of uncontrollable, exsanguinating bleeding
  • Liver transplantation
  • Inpatient admission to intensive care unit to stabilize acute bleeding and hemodynamic status, therapeutic endoscopy. 
  • Discharge criteria: bleeding cessation; hemodynamic stability and appropriate plan for treating comorbidities.

Pearls and Other Issues

Endoscopic variceal ligation should be repeated every 1 to 4 weeks until varices are eradicated. If TIPS is done, repeat endoscopy to assess rebleeding. Endoscopic screening should be done in patients with known cirrhosis every two to three years and yearly in patients with decompensated cirrhosis. Patients with liver stiffness less than 20 kPa and with platelets greater than 150,000 can avoid endoscopic screening and may follow up by annual TE and platelet count.

Prognosis

  • In cirrhosis, one-year survival is 50% for those surviving two weeks following a variceal bleed.
  • In-hospital mortality remains high related to the severity of underlying cirrhosis, ranging from 0% in Child A to 32% in Child C disease.
  • Prognosis in noncirrhotic portal fibrosis is better than for cirrhotics.

Complications

  • Formation of gastric varices after eradication of esophageal varices
  • Esophageal varices can recur.
  • Hepatic encephalopathy, renal dysfunction, hepatorenal syndrome
  • Infections after banding/ligation of varices

Enhancing Healthcare Team Outcomes

The management of esophageal varices is with a multidisciplinary team that consists of a gastroenterologist, internist, surgeon, invasive radiologist, and an intensivist. The treatment selected depends on the severity of the disease and patient status. Unless the primary cause of portal hypertension is controlled, recurrence is common with all treatments. The prognosis for patients with esophageal varices is guarded. Multiorgan failure, complications from procedures and infections often lead to premature death.[13][14]


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Esophageal Varices - Questions

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Which is false about bleeding esophageal varices?



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During an upper endoscopy, the physician recognizes large bluish varicose veins. This indicates that the patient may have which condition?



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Which of the following causes esophageal varices in patients with cirrhosis?



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Which of the following is not a treatment for esophageal varices?



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What is the most important factor that determines prognosis in patients with esophageal varices?



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The Sengstaken Blakemore tube was used to treat esophageal varices. The tube works by which of the following mechanisms of action?



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Which of the following is the most important factor that determines prognosis in patients with esophageal varices?



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Which statement is FALSE regarding esophageal disease?



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The presence of esophageal varices in a patient who consumes alcohol is an indication of which of the following disorders?



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Which of the following is indicative of esophageal varices in a patient with liver cirrhosis?



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After hemodynamic stabilization, what is the emergency treatment of variceal bleeding?



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Which of the following is true about esophageal varices?



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Which of the following is the most suitable long-term solution for recurrent variceal bleeding?



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Patients who are having acute variceal bleeding will benefit from which of the following treatments?



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Which of the following medications can be used to reduce variceal bleeding?



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A patient presents with painless hematemesis. What is the most likely diagnosis?



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What is the treatment of choice for esophageal varices with no history of bleeding?



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What is the risk of bleeding from esophageal varices in the first year after diagnosis?



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What is the most common cause of esophageal varices?



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Which of the following statements about the portal venous system is incorrect?



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A middle-aged alcoholic presents for follow up of his liver disease. He claims that for the past few days he has been vomiting bright red blood and also noticed blood in his stools. His vital signs are blood pressure 130/90 mmHg, respiratory rate 22/minute, temperature 98.5 F, and pulse of 110 bpm. The complete blood count shows white blood cells 11.0, hemoglobin 11.0 g/dL, hematocrit 33%, platelets 222, blood urea nitrogen 22 mg/dL, creatinine 1.5 mg/dL, and blood glucose 111 mg/dl. The abdominal exam reveals splenomegaly with numerous spider angiomas on the trunk. The rectal exam is guaiac negative. He undergoes an upper endoscopy. The image is shown below. His hepatic vein pressure gradient is 12 mmHg. Which of the following is the first line management of his condition and prevent further bleeding complications?



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A 61-year-man presents to the emergency for hematemesis that started 90 mins earlier. He consumes large volumes of alcohol for the past 20 years and has been admitted many times due to intoxication. Clinical findings are suggestive of jaundice and scleral icterus. Examination of his abdomen reveals a palpable spleen and ascites. Upper gastro-esophagoscopy shows bleeding esophageal varices. This patient's bleeding most likely resulted from chronic shunting of portal blood to the systemic circulation through which of the following veins?



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Esophageal Varices - References

References

Shaheen AA,Nguyen HH,Congly SE,Kaplan GG,Swain MG, Nationwide Estimates and Risk Factors of Hospital Readmission in Patients with Cirrhosis in the United States. Liver international : official journal of the International Association for the Study of the Liver. 2019 Jan 28;     [PubMed]
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Laine L, Interventions for primary prevention of esophageal variceal bleeding. Hepatology (Baltimore, Md.). 2018 Dec 18;     [PubMed]
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Aggeletopoulou I,Konstantakis C,Manolakopoulos S,Triantos C, Role of band ligation for secondary prophylaxis of variceal bleeding. World journal of gastroenterology. 2018 Jul 14;     [PubMed]
Zampino R,Lebano R,Coppola N,Macera M,Grandone A,Rinaldi L,De Sio I,Tufano A,Stornaiuolo G,Adinolfi LE,Durante-Mangoni E,Battista GG,Niglio A, The use of nonselective beta blockers is a risk factor for portal vein thrombosis in cirrhotic patients. Saudi journal of gastroenterology : official journal of the Saudi Gastroenterology Association. 2018 Jan-Feb;     [PubMed]
Wu X,Xuan W,Song L, Transjugular intrahepatic portosystemic stent shunt placement and embolization for hemorrhage associated with rupture of anorectal varices. The Journal of international medical research. 2018 Apr;     [PubMed]
Monreal-Robles R,Cortez-Hernández CA,González-González JA,Abraldes JG,Bosques-Padilla FJ,Silva-Ramos HN,García-Flores JA,Maldonado-Garza HJ, Acute Variceal Bleeding: Does Octreotide Improve Outcomes in Patients with Different Functional Hepatic Reserve? Annals of hepatology. 2018 January-February;     [PubMed]
Kuo SZ,Lizaola B,Hayssen H,Lai JC, Beta-blockers and physical frailty in patients with end-stage liver disease. World journal of gastroenterology. 2018 Sep 7;     [PubMed]
Tandon P,Bishay K,Fisher S,Yelle D,Carrigan I,Wooller K,Kelly E, Comparison of clinical outcomes between variceal and non-variceal gastrointestinal bleeding in patients with cirrhosis. Journal of gastroenterology and hepatology. 2018 Oct;     [PubMed]

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