Oesophageal varices

From Ganfyd

• Dilated veins acting as collaterals when flow through the portal system is blocked or limited.

• Other sites for varices
  • rectal
  • retroperitoneal
  • umbilical

• A cause of upper GI haemorrhage, causing massive blood loss. Presents as haematemesis and/or melaena. Often associated with abdominal distension.

Causes

Pre-hepatic

• • Portal vein thrombosis
  • Trauma
  • Compression e.g. HCC
  • Schistosomiasis
  • Primary biliary cirrhosis

Hepatic

• • Chronic hepatitis leading to cirrhosis and associated portal hypertension
  • Wilson's disease
  • Haemochromatosis
  • Biliary atresia

Post-hepatic

• • Budd-Chiari
  • Thromboembolic disease

Also to look out for

• Rectal bleeding
• Caput medusae
• Stigmata of liver disease
• Splenomegaly
• RUQ laparotomy incisions
• Encephalopathy

Treatment

Acute bleeding

Sengstaken Tube insertion Call anaesthetists - patient needs to be intubated first Prepare your equipment first Tube - they come in paediatric and adult sizes - beware Contrast medium - to check for tube placement on AXR Several bladder syringes and lots of saline for gastric washout Heavy clamp Check the volume of saline/contrast needed to fill the balloons by filling them up until taut Call the radiographer - you have to hang on to the tube to exert pressure until the position is verified When you are sure balloon is wedged into GOJ, tape tube to patient's cheek - protect skin with Lyofoam Washout stomach, leave on free drainage Release tape every six hours to relieve pressure on cheek - necrosis at corner of mouth does happen! Leave in for 24 hours. See also eMedicine article and [1].

• ABC
• Resuscitation (see also Upper gastrointestinal bleed and Shock)
  • The patient is losing blood - replace with blood!
  • Remember clotting properties of packed cells - give cryoprecipitate + platelets
• O₂
• BP, HR, O2sats, Rhythm monitor
• Sengstaken-Blakemore tube - see key points - they are easy to insert ONCE YOU KNOW HOW
• Octreotide - reduce splanchnic supply

Chronic

Find and treat the cause

• • Biochemistry, haematology, blood film
  • USS, CT, MRI

Endoscopy

• • Gold standard for staging
    • Stage 1 - Visbly dilated, straight veins
    • Stage 2 - Tortuous dilated veins, filling less than 1/3 of lumen of oesophagus
    • Stage 3 - Tortuous dilated veins, filling more than 1/3 of lumen of oesophagus
  • Sclerotherapy / embolisation
  • Banding
  • Treatment should be a course - regular monitoring to ensure progression
    • Some suggest that recurrent treatment of oesophageal varices causes retroperitoneal varices to develop and that these dont tend to bleed(!)

• Shunts
  • TIPSS
  • Surgical shunts - mesocaval / mesoportal

• Liver transplant is the ultimate therapy