Oesophageal varices

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  • Dilated veins acting as collaterals when flow through the portal system is blocked or limited.
  • Other sites for varices
    • rectal
    • retroperitoneal
    • umbilical

Contents

Causes

Pre-hepatic

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

Hepatic

Post-hepatic

Also to look out for

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

Treatment

Acute bleeding

LogoKeyPointsBox.pngSengstaken 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].

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
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