Esophageal Varices Part2

Hepatic portal vein Illustration (Anatomy recall)

Risk factors for upper GI bleeding * Bleeding diathesis * Peptic ulcer disease * Use of alcohol or (NSAIDs) * Documented cirrhosis * Documented episodes of GI tract bleeding * History of recent forceful retching or emesis

Esophageal Varices Physical ► Pallor may suggest active internal bleeding

► Low blood pressure and increased pulse rate may suggest blood loss

► Parotid enlargement may be related to: alcohol abuse and/or malnutrition

Physical ► Cyanosis of the: tongue lips and peripheries may be due to low oxygen saturation (hypoxia)

► Patients may experience: dyspnea and tachypnea

Physical ► A hyperdynamic circulation with flow murmur over the pericardium may be present

► Jaundice may be present because of impairment of liver function

Esophageal Varices Physical ► Look for telangiectasis of the: skin lips and digits ►Gynecomastia in males results from failure of the liver to metabolize estrogen, resulting in a sex hormone imbalance

Esophageal Varices Physical ► Fetor hepaticus occurs in portosystemic encephalopathy of any cause (e.g.: cirrhosis) ► Palmar erythema and Leuconychia may be present in patients with cirrhosis

Esophageal Varices Physical ►Ascites, abdominal distention due to accumulation of fluid, may be present ► Ascites may be associated with: peripheral edema and may involve the:

* abdominal wall and * genitalia

Esophageal Varices Physical ► Numerous dilated veins radiating out of the umbilicus may be observed ► The liver may be small ► Splenomegaly occurs in portal hypertension

Esophageal Varices Physical Testicular atrophy is common in males with cirrhosis

Venous hums may be present as a result of rapid turbulent flow in collateral veins

Esophageal Varices Physical During the rectal examination, obtain a stool sample for visual inspection A black, soft, tarry stool on the gloved examining finger suggests upper GI bleeding

Esophageal Varices Causes Diseases interfering with portal blood flow can result in: * portal hypertension and * the formation of esophageal varices Causes of portal hypertension usually are classified as: prehepatic intrahepatic and posthepatic

Esophageal Varices Causes Prehepatic Splenic vein thrombosis Portal vein thrombosis Extrinsic compression of the portal vein

Causes Intrahepatic Congenital hepatic fibrosis Hepatic peliosis Idiopathic portal hypertension Sclerosing cholangitis Tuberculosis Schistosomiasis Primary biliary cirrhosis Alcoholic cirrhosis Hepatitis B virus–related and hepatitis C virus–related cirrhosis

Causes Intrahepatic Hepatitis B virus–related and hepatitis C virus–related cirrhosis Wilson disease Hemachromatosis Alpha-1 antitrypsin deficiency Chronic active hepatitis Fulminant hepatitis

Esophageal Varices Causes Posthepatic Budd-Chiari syndrome Thrombosis of the inferior vena cava Constrictive pericarditis Venoocclusive disease of the liver

Esophageal Varices • Differentials Diagnosis • Budd-Chiari Syndrome

Cirrhosis

• Duodenal Ulcers

Gastric Cancer

• Gastric Ulcers

Mallory-Weiss Tear

• Portal Hypertension

Portal Vein Obstruction

• Schistosomiasis

Wilson Disease

Esophageal Varices Workup Lab Studies Complete blood count: Results may show: anemia leucopenia and thrombocytopenia in patients with cirrhosis The hematocrit value may be low in patients with upper abdominal bleeding

Esophageal Varices Type and crossmatch blood and order 6 units of packed red blood cells Prothrombin time: Because the coagulation factors involved in this test are synthesized by the liver, impairment of the liver function may result in a prolonged prothrombin time

Esophageal Varices Liver function tests: A mild elevation of the plasma activity of: aspartate aminotransferase (AST) and alanine aminotransferase (ALT) may occur in cirrhosis, although activity may be normal

Esophageal Varices blood urea and creatinine levels may be elevated in patients with esophageal bleeding

►Cirrhosis, ► ascites, ► and blood loss may contribute to changes in the serum electrolytes of these patients

Esophageal Varices ► Arterial blood gas and pH measurements ► Hepatic serology helps in the assessment of the cause of cirrhosis

Esophageal Varices Imaging Studies Ultrasound of the upper abdomen may be indicated, specially if: * biliary obstruction or * liver cancer is suspected

Esophageal Varices

Procedures Endoscopy is required at an early stage to formulate the management plan If active variceal bleeding or an adherent clot is observed ► variceal hemorrhage can be diagnosed confidently

Esophageal Varices Endoscopy The presence of variceal red color signs e.g. cherry red spots red whale markings, blue varices

►indicates an increased risk of further bleeding

Esophageal Varices 1) Medical Care A) Esophageal varices with no history of bleeding Patients with:

* esophageal varices and no * previous history of variceal hemorrhage should be treated with: nonselective beta-adrenergic blockers e.g.: propranolol nadolol timolol

Esophageal Varices 1) Medical Care provided that the use of beta-blockers is not contraindicated e.g.: * insulin-dependent diabetes mellitus * severe chronic obstructive lung disease * congestive heart failure

Esophageal Varices 1) Medical Care If contraindications to using beta-blockers exist, long-acting nitrates

e.g.: isosorbide 5-mononitrate are alternatives Remember Treatment with beta-blockers should be continued indefinitely

Esophageal Varices 1) Medical Care B) Bleeding esophageal varices Assess the: rate and volume of bleeding Check: blood pressure and pulse with the patient in the supine position and with the patient in a sitting position

1) Medical Care B) Bleeding esophageal varices Gain: venous access and obtain blood for immediate hematocrit measurement Obtain a: type and cross-match Measure the: platelet count and prothrombin time Send blood for: renal and liver function tests and measure serum electrolytes

1) Medical Care C) Emergency treatment Promptly: resuscitate and restore the circulating blood volume of patients with suspected: cirrhosis and variceal hemorrhage Establish intravenous access for blood transfusion

1) Medical Care C) Emergency treatment While the blood is being cross-matched, start:

* rapid infusion of 5% dextrose and * colloid solution until the blood pressure is restored and urine output is adequate

Establish airway protection in patients with massive upper GI tract bleeding, especially if the patient is not fully conscious

1) Medical Care C) Emergency treatment If indicated, correct clotting factor deficiencies with: fresh frozen plasma fresh blood and vitamin K-1 Insert a nasogastric tube to assess the severity of the: bleeding and to lavage gastric contents before performing endoscopy

Esophageal Varices 1) Medical Care Endoscopic therapy probably has replaced balloon tamponade as the initial therapy for variceal bleeding

Balloon tamponade is now rarely necessary

Esophageal Varices 1) Medical Care Endoscopic therapy 1) Endoscopic sclerotherapy * Is successful in controlling acute esophageal variceal bleeding in up to 90% of patients * Hemorrhagic control should be obtained with 1-2 sessions * Patients continuing to bleed after 2 sessions should be considered for alternative methods to control their bleeding

Esophageal Varices 1) Medical Care Endoscopic therapy Complications of sclerotherapy may include: mucosal ulceration bleeding esophageal perforation mediastinitis and pulmonary complications Long-term complications, such as: esophageal stricture formation may also occur

Esophageal Varices 1) Medical Care Endoscopic therapy 2) Endoscopic variceal ligation (banding) The esophageal mucosa and the submucosa containing varices are ensnared causing subsequent strangulation, sloughing, and eventual fibrosis resulting in obliteration of the varices

Esophageal Varices 2) Surgical Care Surgical care includes: (1) decompressive shunts (2) devascularization procedures and (3) liver transplantation

Complications Variceal hemorrhage is the most common complication associated with portal hypertension

Complications ► Other complications include: hepatic encephalopathy bronchial aspiration renal failure systemic infections ascites gastric varices and hepatorenal syndrome

Thanks