What is Esophageal Varices?
Esophageal varices, a condition that affects the portal vein of our cardiovascular system. Our portal vein carries a large amount of blood from the small and large intestine, the spleen and the stomach. If there is an obstruction of the blood flow in the portal vein, this can result to a rise in the portal venous pressure. The frequency of this condition varies from one place to another. It has been reported that in the Western countries of the US have prevalent rates of esophageal varices because of their underlying conditions, alcoholism and viral cirrhosis. About 30% of patients with cirrhosis have developed gastroesophageal varices. The condition is also noted to be endemic in Asia. Underlying conditions such as schistosomiasis, hepatitis and liver cirrhosis are just some of the causes of esophageal varices.
The condition is life-threatening for one is prone to develop bleeding varices when not treated accordingly. Patients who have bled before because of these varices have a 70% chance of rebleeding. The bleeding should not be taken lightly, for this bleeding episode can be fatal. The risk of death is high when one has bled because of the varices. Females are affected with esophageal varices once they have acquired a liver disease, viral hepatitis, veno-occlusive disease, and primary biliary cirrhosis. Males are prone to such condition when they suffer from alcoholic liver disease and viral hepatitis.
The condition can be diagnosed through these tests:
CBC
Complete blood count may show anemia, leucopenia and thrombocytopenia. This can be secondary to conditions such as bleeding, nutritional deficiencies, or bone marrow suppression. The hematocrit level may be low in patients with upper abdominal bleeding.
Prothrombin time
The coagulation factors can be impaired and result to prolonged prothrombin time.
Liver function tests
There is mild elevation of the plasma activity of aspartate aminotransferase and alanine aminotransferase. This is usual in patients with cirrhosis.
Blood urea, creatinine and electrolyte levels
Elevation of the blood urea and creatinine levels is associated with esophageal bleeding. Serum electrolytes may be unstable because of the drug treatment provided to patients.
Hepatic serology
This can help in the assessment of cirrhosis.
Ultrasonography
Ultrasound of the upper abdomen may help in the identification of the esophageal varices.
Endoscopy
This is required in the early stage of the condition. It is contraindicated to perform such test if the condition is at active variceal bleeding. The mere inspection of red color signs can assist in the diagnosis of the condition.
Esophageal Varices Symptoms
The physical presentation of this condition may vary from person to person and from case to case basis. Usually, the presenting symptoms of esophageal varices are the following:
Pallor
This would suggest active internal bleeding. Patient may be anemic at this time. The CBC would have a low RBC result.
Pressure changes
Low blood pressure is a common sign of esophageal varices. Postural drop of blood pressure can be noted as this may suggest blood loss.
Parotid enlargement
This can be related with alcohol abuse and malnutrition.
Cyanosis
The tongue, lips and peripheries may be cyanotic due to low oxygen saturation.
Dyspnea and tachypnea
Compensation is done by the body through increase reuptake of oxygen.
Jaundice
Impairment of the liver function is present.
Gynecomastia
This is found in males who develop enlargement of the chest area due to sex hormone imbalance.
Palmar erythema
This is associated with cirrhosis.
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Ascites
Accumulation of fluid in the abdominal area is due to the development of peripheral edema.
Distended abdominal wall
This may be present. Dilated veins radiate out of the umbilicus.
Splenomegaly
Enlargement of the spleen is due to the portal hypertension.
Testicular atrophy
This is common in males, because of the development of alcoholic liver disease or hemachromatosis.
Stools
Black tarry stools or microscopic blood in the stools. This would suggest upper GI bleeding because of the varices.
Esophageal Varices Causes
The mechanism of this condition is to interfere with the portal blood flow of the body, resulting to portal hypertension and finally the formation of esophageal varices. There are phases classifying the development of this condition:
Prehepatic
Esophageal varices are result of splenic vein thrombosis, portal vein thrombosis and extrinsic compression of the portal vein.
Intrahepatic
Because of the following, esophageal varices are possible: congenital hepatic fibrosis, hepatic peliosis, idiopathic portal hypertension, sclerosing cholangitis, tuberculosis, schistosomiasis, primary biliary cirrhosis, alcoholic cirrhosis, and Hepatitis B virus related cirrhosis, Wilson disease, hemachomatosis, and Fulminant hepatitis.
Posthepatic
These conditions cause esophageal varices: Budd-Chiari syndrome, thrombosis of the inferior vena cava, and constrictive disease of the liver.
Esophageal Varices Treatment
The treatment for esophageal varices depends on the extent of the condition. The following are the treatment required for esophageal varices:
Medications
Vasoconstrictors
This treats variceal bleeding when the state needs emergent care. This drug can reduce portal blood flow and increase resistance to variceal blood flow inside the varices. The drugs under vasoconstrictors include vasopressin and terlipressin.
Vasodilators
These can reduce the intrahepatic vascular resistance without decreasing the peripheral resistance.
Beta-adrenergic blockers
Beta-adrenergic blocker may block the effect of vasodilators, decrease platelet aggregation and increase the release of oxygen to tissues. Propranolol is the usual prescribed medication in this class.
Antisecretory agents
These agents are used as adjuncts to nonoperative management of secreting cutaneous fistulas of the digestive system. Somatostain and octreotide are the drugs available to public.
Esophageal varices with no bleeding
Treatment includes nonselective beta-adrenergic blockers such as propranolol, nadolol and timolol. This can decrease the risk of initial variceal bleeding by an approximation of 45%.
Bleeding esophageal varices
Checking the vital signs of the patient is essential in the treatment of bleeding esophageal varices. Blood pressure and heart or pulse rates should be monitored. Volume replacement is necessary as one is losing most of their fluids in the body. 5% dextrose or colloid solutions are prescribed by doctors to replace such loss.
Emergency treatment
If one has uncontrolled bleeding, he or she should be provided with correct clotting factors. Establishing airway in patients with massive bleeding is very much important. Inserting a nasograstric tube is necessary for patients with no oral access. Gastric lavage is performed do to assess the material aspirated from the stomach.
Endoscopic sclerotherapy
Sclerotherapy is aimed to control acute esophageal variceal bleeding. This provides hemorrhagic control and can be easily attained with one to two sessions of endoscopic sclerotherapy. Sclerosants such as sodium tetradecyl sulfate or sodium morrhuate are popular in the United States.
Surgical care
Variceal hemorrhage is a common side effect of any surgical intervention for the varices. In order to avoid such complication, placement of a balloon tamponade (Sengstaken-Blakemore tube) can reduce the occurrence of bleeding. The surgical interventions possible for this condition are portosystemic shunt, devascularization and orthotopic liver transplantation.
Esophageal Varices Grading
The grading of the esophageal varices is based according to their size:
- Grade 1 – small straight varices.
- Grade 2 – medium-sized or enlarged tortuous varices occupying less than one third of the lumen.
- Grade 3 – large coil-shaped varices can occupy less than 1/3 of the lumen.
Esophageal Varices Banding
Banding or endoscopic variceal ligation is a widely based used technique of ligating hemorrhoids. The esophageal mucosa that contains the varices is banded by ensnaring them, resulting to subsequent strangulation, sloughing, and eventual fibrosis – as a result, there is obliteration of the varices. The aim of this procedure is to attain hemostasis – impede bleeding. Rebleeding is still possible but can occur less frequently compared with endoscopic sclerotherapy.
