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.
The portal vein has a circulation of over 1500 ml/min of blood and if there is an obstruction, this results in elevated portal venous pressure. The response of the body to the increased venous pressure is the development of collaterals. these portosystemic collaterals divert blood from the portal venous system to the inferior and superior vena cava. At the same time, one important system is the gastroesophageal collaterals that drain into the azygos vein and lead to the development of esophageal varices. When these varices get enlarged, they rupture producing severe hemorrhage. Bleeding from esophageal varices is the third most common cause of upper GI bleeding, after duodenal and gastric ulcers.
Causes 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.
Other rare causes of portal hypertension include:
Portal hypertension is common in chronic liver disease (CLD) in children.
In the West, the two common causes of portal hypertension are alcohol and viral hepatitis. In Asia and Africa, the most common causes of portal hypertension include schistosomiasis and hepatitis B/C.
Portal hypertension causes portocaval anastomosis to develop to decompress portal circulation. Normal portal pressure is between 5-10 mmHg but in the presence of portal obstruction, the pressure may be as high as 15-20 mmHg. Since the portal venous system has no valves, resistance at any level between the splanchnic vessels and right side of the heart results in retrograde flow and elevated pressure. The collaterals slowly enlarge and connect the systemic circulation to the portal venous system. Over time, 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:
Risk factors for variceal bleeding:
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.
Initial Tests (lab, imaging)
Hepatic encephalopathy and infection often complicate variceal bleeding.
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.
Prevent recurrence of acute bleeding:
Refer for endoscopy, liver transplant, and interventional radiology for TIPS.
Pneumococcal and hepatitis A/B (HAV/HBV) vaccine need to be considered.
Percutaneous transhepatic embolization has been used to stop variceal bleeding. However, its effectiveness remains questionable. It is generally reserved for patients who are not candidates for surgery.
TIPS is a salvage procedure to stop acute variceal bleeding. However, the procedure is also associated with serious complications including encephalopathy and occlusion of the shunt within 12 months. TIPS may be a bridge to a liver transplant.
Once a patient has a single episode of variceal bleeding, there is a 70% chance of a rebleed. At least 30% of rebleeding episodes are fatal. Most deaths occur within the first few days after the bleed. Mortality rates are highest in the presence of surgical intervention and for acute variceal bleeding.
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.
The management of esophageal varices is with an interprofessional 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.this is a serious life-threatening disorder and all patients should be in a monitored setting. The role of the nurse in monitoring is crucial. Vitals and oxygenation should be continuously monitored. Blood work should be followed to ensure that the patient is not anemic and developing renal or liver dysfunction. The pharmacist should have the key medications to stop the variceal hemorrhage. In addition, all drugs that are liver toxic should be discontinued. Because patients tend to have other comorbidities, nurses should ensure that the patient has DVT and pressure ulcer prophylaxis. Several treatments to stop variceal bleeding have the potential to cause complications including perforation of the esophagus. Thus, close monitoring of the patient is critical; nurses should regularly check for emphysema. Close communication between the team is vital if outcomes are to be improved.
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.
|||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 PMID: 30688401]|
|||Yoon H,Shin HJ,Kim MJ,Han SJ,Koh H,Kim S,Lee MJ, Predicting gastroesophageal varices through spleen magnetic resonance elastography in pediatric liver fibrosis. World journal of gastroenterology. 2019 Jan 21; [PubMed PMID: 30686904]|
|||Nery F,Correia S,Macedo C,Gandara J,Lopes V,Valadares D,Ferreira S,Oliveira J,Gomes MT,Lucas R,Rautou PE,Miranda HP,Valla D, Nonselective beta-blockers and the risk of portal vein thrombosis in patients with cirrhosis: results of a prospective longitudinal study. Alimentary pharmacology [PubMed PMID: 30671978]|
|||Nigatu A,Yap JE,Lee Chuy K,Go B,Doukky R, Bleeding Risk of Transesophageal Echocardiography in Patients With Esophageal Varices. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography. 2019 Jan 18; [PubMed PMID: 30665728]|
|||Chakinala RC,Kumar A,Barsa JE,Mehta D,Haq KF,Solanki S,Tewari V,Aronow WS, Downhill esophageal varices: a therapeutic dilemma. Annals of translational medicine. 2018 Dec; [PubMed PMID: 30603651]|
|||Laine L, Interventions for primary prevention of esophageal variceal bleeding. Hepatology (Baltimore, Md.). 2018 Dec 18; [PubMed PMID: 30561058]|
|||Reiberger T,Bucsics T,Paternostro R,Pfisterer N,Riedl F,Mandorfer M, Small Esophageal Varices in Patients with Cirrhosis-Should We Treat Them? Current hepatology reports. 2018; [PubMed PMID: 30546995]|
|||Pfisterer N,Riedl F,Pachofszky T,Gschwantler M,König K,Schuster B,Mandorfer M,Gessl I,Illiasch C,Fuchs EM,Unger L,Dolak W,Maieron A,Kramer L,Madl C,Trauner M,Reiberger T, Outcomes after placement of a SX-ELLA oesophageal stent for refractory variceal bleeding-A national multicentre study. Liver international : official journal of the International Association for the Study of the Liver. 2019 Feb; [PubMed PMID: 30248224]|
|||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 PMID: 30018485]|
|||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 PMID: 29451181]|
|||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 PMID: 29338471]|
|||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 PMID: 29311398]|
|||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 PMID: 30197482]|
|||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 PMID: 29601652]|