esophageal varices

Epidemiology

• 50% of patients with cirrhosis have esophageal &/or gastric varices at diagnosis

Laboratory

• complete blood count

Diagnostic procedures

• endoscopy
  • as soon as possible after stabilization,
  • every 1-3 weeks until varices are obliterated
  • every 6 months thereafter; every 2 years if small varices (< 5 mm); every 3 years if no varices seen
  • prophylactic endoscopy is NOT effective in preventing 1st variceal hemorrhage & results in excessive mortality

Radiology

• ultrasound to evaluate spleen size.
• ratio of: platelet count in mm-3/bipolar spleen diameter mm > 909 mm-4 with 100% negative predictive value for esophageal varices

Complications

variceal hemorrhage

• predictors of variceal hemorrhage
  • variceal size
  • presence of red spots or marks on the variceal channels
  • severity of liver disease (worsening Child's score)
• mortality is 35% with 1st hemorrhage
• 70% rebleed within 2 years without effective therapy

Management

acute esophageal varices hemorrhage

• placement of 2 large bore intravenous lines
• fluid resuscitation
• RBC transfusion for goal of blood hemoglobin 7 g/dL
  • more liberal tranfusion goals increase portal pressure & bleeding
• vasoconstrictor therapy preferably prior to endoscopy
  • octreotide (Sandostatin) 1st line
    • 50 ug bolus, followed by infusion of 50 ug/hr for 2-5 days
    • bolus can be repeated in 1st hour if hemorrhage is not controlled
    • of no benefit in reducing mortality or preventing need for blood transfusion
  • terlipressin
    • 2 mg IV every 4 hours for 1st 48 hours, followed by 1 mg every 4 hours for 2-5 days
  • equal to sclerotherapy in effectiveness
  • if bleeding recurs during therapy, consider TIPS
• empiric prophylactic therapy with broad-spectrum antibiotics is indicated in hemorrhaging patients with cirrhosis regardless of presence of ascites
  • reduces sepsis, pneumonia, urinary tract infection, mortality
  • ceftriaxone 1 g IV QD
  • fluoroquinolone (ciprofloxacin 400 mg IV/PO q12h, norfloxacin 400 mg PO BID)
  • duration of antibiotic therapy: 5-7 days or until discharge
• balloon tamponade for refractory hemorrhage
  • Sengstaken-Blakemore tube (gastric & esophageal balloons)
  • Minnesota tube (gastric & esophageal balloons)
  • Linton tube (gastric balloon)
• upper GI endoscopy within 12 hours when patient is stable
  • endoscopic band ligation
    • has become preferred endoscopic treatment modality for active bleeding
      • within 12 hours of presentation for active bleeding
    • may be as effective as sclerotherapy with fewer complications
    • indicated for primary pervention if propranolol is contraindicated
    • repeat endoscopic band ligation every 2-4 weeks until varices obliterated (generally 2-4 sessions)
    • surveillance endoscopy 1-3 months after obliteration of varices, then every 6-12 months indefinitely
  • esophageal sclerotherapy:
    • active bleeding
    • 1-2% sodium tetradecyl sulfate plus octreotide
• combined endoscopy with somatostatin or octreotide may give best results for control of hemorrhage
• similar outcomes with ligation & drug therapy
• surgical transection of the esophagus .

long-term management

• beta-adrenergic receptor antagonists
  • propranolol, nadolol or carvedilol
    • non-selective beta-blocker indicated
  • titrate to reduce heart rate by 25%
  • beta-blocker alone preferable to beta-blocker plus endoscopic banding for preventing 1st variceal hemorrhage in patients with cirrhosis
  • may reduce incidence of recurrent esophageal hemorrhage
  • use in combination with nitrates
  • NO benefit in overall survival
  • reduces 5-year probability of enlargement (20% vs 50%) & likelihood of regression (24% vs 11%) if started early
  • no benefit of non-selective beta-blocker
    • not so, NEJM knowledge+ contradicts assertion in
• endoscopic band ligation if beta-blocker is contraindicated (i.e. asthma, symptomatic bradycardia ...)
  • non-selective beta-blocker + repeat endoscopic band ligation every 2-4 weeks until varices obliterated (generally 2-4 sessions)
• transjugular intrahepatic portosystemic shunt (TIPS)
  • failure of sclerotherapy or band ligation
  • reduces recurrent esophageal bleeding
  • does not improve survival
  • preemptive TIPS in patients with cirrhois & acute variceal hemorrhage improves survival
  • results in higher incidence of hepatic encephalopathy
• use intravenous not oral bisphosphonate for treatment of osteoporosis

prognosis:

• 1/3 die in hospital with initial variceal bleed
• 1/3 rebleed within 6 weeks
• 1/3 survive more than 1 year

More general terms

• varicose vein (varix)
• esophageal disease
• portosystemic shunt
• chronic gastrointestinal disease

Additional terms

• esophageal sclerotherapy
• esophageal vein
• Minnesota esophagogastric tamponade tube
• prophylaxis for cirrhotics with upper GI bleed