Esophageal varices

Esophageal varices is swollen veins in the lower esophagus and possibly the upper part of the stomach; can cause vomiting of blood and passing of black stool.Varices can also form in other areas of the body, including the stomach (gastric varices), duodenum (duodenal varices), and rectum (rectal varices). Treatment of these types of varices may differ. In some cases, schistosomiasis also leads to esophageal varices.

Esophageal varices seven days after banding, showing ulceration at the site of banding

Risk factors

They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis. Gastric varices may also be found in patients with thrombosis of the splenic vein, into which the short gastric veins which drain the fundus of the stomach flow. The latter may be a complication of acute pancreatitis, pancreatic cancer, or other abdominal tumours, as well as hepatitis C. Gastric varices and associated bleeding are a potential complication of schistosomiasis resulting from portal hypertension.

Axial CT showing varices of the fundus in liver cirrhosis with portal hypertension

Axial CT showing esophageal varices in liver cirrhosis with portal hypertension

Signs and symptoms

Patients with bleeding gastric varices can present with bloody vomiting (hematemesis), dark, tarry stools (melena), or rectal bleeding. The bleeding may be brisk, and patients may soon develop shock. First, patients with cirrhosis may be enrolled in screening gastroscopy programs to detect esophageal varices. These evaluations may detect gastric varices that are asymptomatic. When gastric varices are symptomatic, however, they usually present acutely and dramatically with upper gastrointestinal bleeding. The symptoms can include vomiting blood, melena (passing black, tarry stools); or passing maroon stools or frank blood in the stools. Many people with bleeding gastric varices present in shock due to the profound loss of blood. Secondly, patients with acute pancreatitis may present with gastric varices as a complication of a blood clot in the splenic vein. The splenic vein sits over the pancreas anatomically and inflammation or cancers of the pancreas may result in a blot clot forming in the splenic vein. As the short gastric veins of the fundus of the stomach drain into the splenic vein, thrombosis of the splenic vein will result in increased pressure and engorgement of the short veins, leading to varices in the fundus of the stomach. In very rare cases, gastric varices are caused by splenic vein occlusion as a result of the mass effect of slow-growing pancreatic neuroendocrine tumors.

Diagnosis

Diagnosis of gastric varices is often made at the time of upper endoscopy.

Classification

The Sarin classification of gastric varices identifies four different anatomical types of gastric varices, which differ in terms of treatment modalities.

Treatment

Initial treatment of bleeding from gastric varices focuses on resuscitation, much as with esophageal varices. This includes administration of fluids, blood products, and antibiotics. Other techniques for refractory bleeding include:

• Transjugular intrahepatic portosystemic shunts (TIPS)
• Balloon occluded retrograde transvenous obliteration techniques (BORTO)
• Coil-Assisted Retrograde Transvenous Obliteration (CARTO)
• Gastric variceal ligation, although this modality is falling out of favour
• Intra-gastric balloon tamponade as a bridge to further therapy
  • a caveat is that a larger balloon is required to occupy the fundus of the stomach where gastric varices commonly occur
• Liver transplantation

In emergency situations, care is directed at stopping blood loss, maintaining plasma volume, correcting disorders in coagulation induced by cirrhosis, and appropriate use of antibiotics such as quinolones or ceftriaxone. Blood volume resuscitation should be done promptly and with caution. The goal should be hemodynamic stability and hemoglobin of over 8 g/dl. Resuscitation of all lost blood leads to increase in portal pressure leading to more bleeding. Volume resuscitation can also worsen ascites and increase portal pressure. (AASLD guidelines)

Therapeutic endoscopy is considered the mainstay of urgent treatment. The two main therapeutic approaches are variceal ligation (banding) and sclerotherapy.

The medication(s) listed below have been approved by the Food and Drug Administration (FDA) as orphan products for treatment of this condition.

• Ethanolamine oleate (Brand name: Ethamolin)Treatment of patients with esophageal varices that have recently bled, to prevent rebleeding.

Esophageal varices Resources
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