Morning Report: Esophageal Varices

Thanks to Dr. Kincade for presenting today’s Morning Report!

Esophageal Varices

Esophageal varices are dilated veins within the wall of the esophagus, usually at the distal end

Epidemiology

-50% of patients with cirrhosis; 25% to 35% variceal rupture within 2 years of diagnosis.

-Greatest risk of rupture in first year

-80% to 90% of bleeding episodes in cirrhotic due to variceal hemorrhage and one-third of deaths in cirrhotic patients can be attributed to variceal hemorrhage

-70% of patients who survive initial bleed experience a recurrence 6 weeks after the initial bleed. Mortality rebleeding is 20% to 30%

-Alcoholic and viral cirrhosis are the predominant causes

Causes

-Portal hypertension is commonly a complication of liver cirrhosis, either alcoholic or viral in origin

-Schistosomiasis (the commonest cause of portal hypertension worldwide)

-Portal vein thrombosis

-Splenic vein thrombosis

Prevention

Primary: ß-blockers with or without isosorbide mononitrate, abstinence from alcohol and hepatotoxic drugs, Endoscopic therapies for primary prevention include endoscopic injection sclerotherapy (EIS) and EBL

Symptoms

Varices, hematemesis can be minor, or massive and life-threatening, melena, dyspnea associated with anemia and/or dizziness (especially on standing) resulting from hypotension

Signs

Alcohol on the breath, signs of chronic liver disease: jaundice; palmar erythema, clubbing, asterixis, and leukonychia; scratch marks due to pruritis, bruising, spider nevi on the torso distended abdomen due to ascites and/or hepatosplenomegaly; and gynecomastia and testicular atrophy in men, warm skin, tachycardia, hypotension, splenomegaly, and dilated veins in the abdominal wall

Work up

-Electrolytes, CBC, LFTs, Coags, Type and Cross

-Endoscopy

Diff Dx

Peptic ulcer, gastritis, gastric carcinoma, budd chiari syndrome, esophagitis, malory weiss syndrome

Tx for acute bleeds

-A,B,C, IV (2 large bore), O2, monitor

-Stat GI consult

-MICU consult

-Non selective B- blockers

-Octreotide

-Antibiotic ppx: decrease rebleeding and improve survival

-EBL

-EIS

-TIPS

References

Groszmann RJ, Garcia-Tsao G, Bosch J, et al; Portal Hypertension Collaborative Group. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med. 2005;353:2254-61

Gluud LL, Klingenberg S, Nikolova D, Gluud C. Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials. Am J Gastroenterol. 2007 Dec;102(12):2842-8; quiz 2841, 2849

Gøtzsche PC, Hróbjartsson A. Somatostatin analogues for acute bleeding oesophageal varices. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD000193

Corley DA, Cello JP, Adkisson W, Ko WF, Kerlikowske K. Octreotide for acute esophageal variceal bleeding: a meta-analysis. Gastroenterology. 2001;120:946-954

Bernard B, Grange JD, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology. 1999;29:1655-61