ESOPHAGEAL VARICES
GENERAL FEATURES
• Esophageal varices are defined as dilated esophageal veins.
• Varices are most often caused by portal hypertension, which is an increased pressure gradient between the wedged hepatic vein pressure and the free hepatic vein pressure.
• The most common cause of portal hypertension is liver cirrhosis. Rarer causes of portal hypertension include portal or splenic vein thrombosis, splenomegaly from lymphoma, schistosomiasis, Budd-Chiari syndrome, and cardiac diseases leading to vascular congestion.
• The most serious complication of esophageal varices is bleeding, which occurs in about 30% of patients. Each episode of bleeding carries a mortality rate of approximately 20%.
• Other potentially life-threatening complications related to variceal bleeding include aspiration pneumonia, sepsis, hepatic encephalopathy, and renal failure.
CLINICAL ASSESSMENT
• Esophageal varices should be suspected in any patient with an upper GI bleed and known liver cirrhosis or with other diseases that can cause portal hypertension.
• History should assess for risk factors that increase the likelihood of bleeding, including GI bleed, known large varices, liver failure, continued alcohol use, and presence of "red wale" signs on endoscopy.
• Physical examination findings in patients with a GI bleed secondary to esophageal varices include positive hematochezia, melena, hematemesis, hypotension, and tachycardia.
• Stigmata of liver disease such as spider nevi, palmar erythema, jaundice, and clubbing of the nails may indicate long-standing liver failure.
• Because esophageal varices do not become evident until they result in GI bleed, screening with esophagogastroduodenoscopy (EGD) in patients with portal hypertension is vital.
• Patients with cirrhosis should undergo an EGD screening when the condition is first diagnosed.
DIAGNOSIS
• Upper endoscopy utilizing EGD is the gold standard for diagnosing and treating esophageal varices.
• CT or MRI can detect varices and evaluate the portal system but are generally not used for acute diagnosis.
• Laboratory testing should include CBC, partial thromboplastin time (PTT), international normalized ratio (INR), prothrombin time (PT), electrolytes, and liver function. In patients with esophageal varices, the CBC often shows anemia and thrombocytopenia. The hematocrit level is often followed to track treatment progress. Serum electrolytes should be followed if treatment for GI bleed is instituted.
TREATMENT
• Mainstay therapy consists of band ligation and sclerotherapy.
• Patients with an upper GI bleed secondary to varices should undergo emergent EGD and be monitored closely for continued decreases in hemoglobin levels and hypotension.
• Medications used to treat an active variceal hemorrhage include
–Octreotide bolus (Sandostatin, generics) followed by drip to decrease portal pressure
–Proton pump inhibitor (PPI) bolus followed by drip to suppress acid and prevent rebleed
–Antibiotics with gram-negative coverage to reduce infectious complications
–Beta-blockers, which should be started as soon as hemodynamically feasible.
• Transfusion of packed RBCs is discouraged unless the hemoglobin level is less than 8 g/dL, as aggressive volume resuscitation can increase portal pressure and precipitate new or continued variceal bleeding.
• Band ligation is generally considered more effective than sclerotherapy at preventing rebleeding; however, banding may be difficult to visualize during an active bleed.
• After the initial treatment, patients should be retreated with EGD approximately every 2 weeks until the varices are eradicated. Three to 6 months later, EGD should be performed again to confirm eradication. If no further band ligation is required, surveillance EGD may be repeated after 6 to 12 months.
• In refractory cases, a transjugular intrahepatic portosystemic shunt (TIPS) should be considered. Because TIPS can decrease life expectancy in patients with cirrhosis, bleeding should be controlled with banding when possible; TIPS should also be avoided in patients who are not transplant candidates.
• Patients with medium to large varices should be placed on a beta-blocker with a goal resting heart rate of 50 to 60 beats per minute to reduce the risk of bleeding.
• Those who have small varices at the initial screening should have repeat EGD after 1 year to assess for growth; those who do not have varices at the initial screening should have repeat EGD in 2 to 3 years.
• Lifestyle modifications, including discontinuing alcohol use and maintaining a healthy weight, will help.
QUESTIONS & ANSWERS
1. Mr. Smith is a 60-year-old male with a history of alcohol abuse. He presents to the clinic after having an ultrasound and abdominal CT scan with findings suggestive of liver cirrhosis and splenomegaly. He asks when he should be screened for the dilated veins he read about online. The correct answer is
a. In 1 year
b. After he has symptoms of GI bleeding, including melena and hematemesis
c. As soon as possible
d. He does not require screening
Answer: c
Explanation: Mr. Smith has a new diagnosis of cirrhosis and has demonstrated portal hypertension as he has splenomegaly. He should have an EGD screening as soon as possible. If grade II or greater varices are discovered, prophylaxis with a beta-blocker will be necessary.
2. Mrs. Jones is a 48-year-old female with a history of cirrhosis secondary to hepatitis C who presents to the emergency department complaining of melena for the past 2 days. Her hemoglobin level is 8.5 g/dL, down from a baseline of 10 g/dL. She received a diagnosis of grade I varices in the past. Which of the following should her treatment include?
a. Octreotide and PPI drip with antibiotics
b. Emergent EGD for possible banding or sclerotherapy of bleeding varices
c. Aggressive resuscitation with two units of packed red blood cells (pRBCs) and IV fluids
d. A and B
e. All of the above
Answer: d
Explanation: Aggressive resuscitation
should be avoided in patients with esophageal varices, as this can lead to increased portal pressure and, therefore, continued or new GI bleeding. Patients should not be transfused with pRBCs beyond a hemoglobin level of 8 g/dL, and IV fluids should be used with caution.