OESOPHAGEAL VARICES

Sunil Kumar Daha

Portal Hypertension• Normal pressure of portal vein is 5-8 mmHg

• When it is >7-8mmHg, then called as portal hypertension

• Symptoms and complications occur when the portal pressure is more than 12 mmHg.

Causes

Site CausesPre-hepatic Obstructive thrombosis

Narrowing of portal veinMassive splenomegaly with increased blood flow

Hepatic CirrhosisFatty liver diseaseSchistosomiasisDiffuse fibrosing granulomatous disease(sarcoidosis)Nodular regenerative hyperplasia

Post-hepatic Right sided heart failureConstricted pericarditisHepatic vein outflow obstruction

Pathophysiology

• Increased resistance to portal flow:

At the level of sinusoids

• Increase in portal venous blood flow:

Resulting from hyper-dynamic circulation

Clinical features

Esophageal varices

• Esophageal varices are portosystemic collaterals that dilate when portal pressure exceeds 12mm Hg.

• It is the 2nd most commom cause of upper GI bleeding.

Management of Esophageal varices

Management

1. Primary Prevention of variceal bleeding in patient who

have never bleed and control of acute variceal bleeding

For all patients with larger varices (diameter greater than 5mm)

2. Secondary Prevention of rebleeding in patients who have

survived in initial bleeding episodes

Algorithm for primary prophylaxis of esophageal variceal hemorrhage

Algorithm for secondary prophylaxis

General Resuscitation• Varices generally present with acute onset

of large volume hematemesis• Diagnosis may be suspected if patient is

known to have chronic liver diseases• Liver function test and coagulation profile • Vitamin K (10 mg IV), Correction Of

coagulopathy

Drug Treatment Octreotide• Long acting somatostatin analogue• Reduces hepatic blood flow• 50- μg bolus and 50- μg/h IV infusion for 2–5 days

Vasopressin• Potent vasoconstrictor• For the initial control of variceal haemorrhage• S/E- Myocardial ischemia, arythmia, mesenteric and limb

ischemia

Endoscopic TreatmentUse of vasoconstrictor + endoscopic therapy

Standard medical treatment for acute variceal bleed

• Endoscopic Band ligation– By placing constricting rubber bands at

the base of Varix.– Better in preventing rebleeding

• Endoscopic Scleropathy: by injecting sclerosant (Such as Polidocanol 1-3% or Ethanolamine 5%) into or around the varix.

Transjugular intrahepatic porto-systemic stent shunts(TIPSS)

• Variceal hemorrhage not responded to drug treatment and endoscopic therapy

• Using fluoroscopic guidance and USG

• Internal jugular vein to SVC to hepatic vein to hepatic parenchyma to branch of the portal vein

TIPSS

Surgical shunt for variceal hemorrhages

• Reduces pressure in portal circulation• Indication:

– Patients with child’s grade A cirrhosis in whom initial bleed has been controlled by sclerotherapy

• Commonly used shunts are:– Selective( eg. Splenorenal)– Non-selective(eg. Portocaval)

• Alternatives - long term β- blockers (Propanolol, Nadolol), chronic sclerotherapy or banding

side-to-side portocaval end-to-side portocaval

mesocaval splenorenal

Oesophageal stapled transection• Uses the circular stapling device for stapling

and resection of doughnut ring of the lower oesophagus

• High perioperative mortality

Recurrent variceal bleeds secondary to splenic or portal vein thrombosis• Splenectomy • Gastro esophageal devascularisation

Orthotopic liver transplantation• Only therapy which will treat portal hypertension

and and liver disease.

The end

References

• Bailey and Love’s Short Practice of Surgery; 26th Edition

• SRB’s manual of surgery; 5th edition