Esophageal varices
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
| Esophageal varices | |
 | |
|---|---|
| Gastroscopy image of esophageal varices with prominent red wale spots | |
| ICD-10 | I85. |
| ICD-9 | 456.0-456.2 |
| DiseasesDB | 9177 |
| MedlinePlus | 000268 |
| eMedicine | med/745 radio/269 |
| MeSH | D004932 |
In medicine (gastroenterology), esophageal varices are extremely dilated sub-mucosal veins in the esophagus. They are most often a consequence of portal hypertension, such as may be seen with cirrhosis; patients with esophageal varices have a strong tendency to develop bleeding.
Esophageal varices are diagnosed with endoscopy.[1]
Pathogenesis
The majority of blood from the esophagus is drained away via the esophageal veins, which drain deoxygenated blood from the esophagus to the azygos vein which in turn, directly drains into the superior vena cava. These veins have no part in the development of esophageal varices. The remaining blood from the esophagus is drained away via the superficial veins lining the esophagus interior, which drain into the coronary vein (left gastric vein) which in turn, drains directly into the portal vein. These superficial veins lining the esophagus interior (normally only approximately 1mm in diameter) become distended up to 1-2 cm in diameter in association with portal hypertension.
Normal portal pressure is approximately 9 mmHg compared to an inferior vena cava pressure of 2-6 mmHg. This creates a normal pressure gradient of 3-7 mmHg. If the portal pressure rises above 12mmHg, this gradient rises to 7-10 mmHg.[2] A gradient greater than 10 mmHg is considered portal hypertension. At gradients greater than 10 mmHg, blood flow though the hepatic portal system is redirected from the liver into areas with lower venous pressures. This means that collateral circulation develops in the lower esophagus, abdominal wall, stomach and rectum. The small blood vessels in these areas become distended, becoming more thin-walled, and appear as varicosities. In addition, these vessels are poorly supported by other structures, as they are not designed for high pressures.
In situations where portal pressures increase, such as with cirrhosis, there is dilation of veins in the anastomosis, leading to esophageal varices.
Varices can also form in other areas of the body, including the stomach (gastric varices), duodenum (duodenal varices), and rectum (rectal varices). Treatment of these types of varices may differ.
Treatment and the role of endoscopy
In emergency situations, the care is directed at stopping blood loss, maintaining plasma volume, correcting disorders in coagulation induced by cirrhosis, and appropriate use of antibiotics (as infection is either concomitant, or a precipitant).
Therapeutic endoscopy is considered the mainstay of urgent treatment. Two main therapeutic approaches exist:
- Variceal ligation, or banding
- sclerotherapy
In cases of refractory bleeding, balloon tamponade may be necessary, usually as a bridge to further endoscopy, a transjugular intrahepatic portosystemic shunt (TIPS), or a distal splenorenal shunt procedure or a liver transplantation.
Nutritional supplementation is not necessary if the patient is not eating for four days or less.[3]
Esophageal varices seven days post banding, showing ulceration at the site of banding.
Prevention
Ideally, patients with known varices should receive treatment to reduce their risk of bleeding.[4] The non-selective β-blockers (e.g., propranolol, timolol or nadolol) and nitrates have been evaluated for secondary prophylaxis. The effectiveness of this treatment has been shown by a number of different studies.[5]
Unfortunately, non-selective β-blockers do not prevent the formation of esophageal varices.Cite error: Invalid <ref> tag;
invalid names, e.g. too many
See also
References
- ↑ Biecker E, Schepke M, Sauerbruch T (2005). "The role of endoscopy in portal hypertension". Dig Dis 23 (1): 11-7. PMID 15920321.
- ↑ Arguedas M (2003). "The critically ill liver patient: the variceal bleeder". Semin Gastrointest Dis 14 (1): 34-8. PMID 12610853.
- ↑ de Lédinghen V, Beau P, Mannant PR, et al (1997). "Early feeding or enteral nutrition in patients with cirrhosis after bleeding from esophageal varices? A randomized controlled study". Dig. Dis. Sci. 42 (3): 536-41. PMID 9073135.
- ↑ Lebrec D, Poynard T, Hillon P, Benhamou J-P (1981). "Propranolol for prevention of recurrent gastrointestinal bleeding in patients with cirrhosis: a controlled study". N Engl J Med 305: 1371–1374. PMID 7029276.
- ↑ Talwalkar JA, Kamath PS (2004). "An evidence-based medicine approach to beta-blocker therapy in patients with cirrhosis". Am J Med 116: 759–766. PMID 15144913.
See also
WikiDoc Research Resources for Esophageal varices | |
|---|---|
| Articles on Esophageal varices | Most recent articles on Esophageal varices • Most cited articles on Esophageal varices • Review articles on Esophageal varices • Articles on Esophageal varices in N Eng J Med, Lancet, BMJ |
| Media (Slides, Video, Images, MP3) on Esophageal varices | Powerpoint slides on Esophageal varices • Images of Esophageal varices • Photos of Esophageal varices • Podcasts & MP3s on Esophageal varices • Videos on Esophageal varices |
| Evidence Based Medicine Regarding Esophageal varices | AND (Cochrane Database Syst Rev[http://worldselectshop.com/?id=9361 Cochrane Collaboration on Esophageal varices • Bandolier on Esophageal varices • TRIP on Esophageal varices |
| Cost Effectiveness of Esophageal varices | AND (Cost effectiveness) |
| group5 = Clinical Trials Involving Esophageal varices | list5 = Ongoing Trials on Esophageal varices at Clinical Trials.gov • Trial results on Esophageal varices • Clinical Trials on Esophageal varices at Google
| group6 = Guidelines / Policies / Government Resources (FDA/CDC) Regarding Esophageal varices
| list6 = US National Guidelines Clearinghouse on Esophageal varices • NICE Guidance on Esophageal varices • NHS PRODIGY Guidance • FDA on Esophageal varices • CDC on Esophageal varices
| group7 = Textbook Information on Esophageal varices
| list7 = Books and Textbook Information on Esophageal varices
| group8 = Pharmacology Resources on Esophageal varices
| list8 =
AND (Dose)}} Dosing of Esophageal varices • AND (drug interactions)}} Drug interactions with Esophageal varices • AND (side effects)}} Side effects of Esophageal varices • AND (Allergy)}} Allergic reactions to Esophageal varices • AND (overdose)}} Overdose information on Esophageal varices • AND (carcinogenicity)}} Carcinogenicity information on Esophageal varices • AND (pregnancy)}} Esophageal varices in pregnancy • AND (pharmacokinetics)}} Pharmacokinetics of Esophageal varices •
| group9 = Genetics, Pharmacogenomics, and Proteinomics of Esophageal varices
| list9 =
AND (pharmacogenomics)}} Genetics of Esophageal varices • AND (pharmacogenomics)}} Pharmacogenomics of Esophageal varices • AND (proteomics)}} Proteomics of Esophageal varices
| group10 = Newstories on Esophageal varices
| list10 = Esophageal varices in the news • Be alerted to news on Esophageal varices • News trends on Esophageal varices</small>
| group11 = Commentary on Esophageal varices
| list11 =
Blogs on Esophageal varices
| group12 = Patient Resources on Esophageal varices | list12 = Patient resources on Esophageal varices • Discussion groups on Esophageal varices • Patient Handouts on Esophageal varices • Directions to Hospitals Treating Esophageal varices • Risk calculators and risk factors for Esophageal varices
| group13 = Healthcare Provider Resources on Esophageal varices
| list13 =
Symptoms of Esophageal varices • Causes & Risk Factors for Esophageal varices • Diagnostic studies for Esophageal varices • Treatment of Esophageal varices
| group14 = Continuing Medical Education (CME) Programs on Esophageal varices | list14 = CME Programs on Esophageal varices
| group15 = International Resources on Esophageal varices | list15 = Esophageal varices en Espanol • Esophageal varices en Francais
| group16 = Business Resources on Esophageal varices | list16 = Esophageal varices in the Marketplace • Patents on Esophageal varices
| group17 = Informatics Resources on Esophageal varices | list17 = List of terms related to Esophageal varices
}}
Circulatory system pathology (I, 390-459) | |
|---|---|
| Hypertension | Hypertensive heart disease - Hypertensive nephropathy - Secondary hypertension (Renovascular hypertension) |
| Ischaemic heart disease | Angina pectoris (Prinzmetal's angina) - Myocardial infarction (heart attack) - Dressler's syndrome |
| Pulmonary circulation | Pulmonary embolism - Cor pulmonale |
| Pericardium | Pericarditis - Pericardial effusion - Cardiac tamponade |
| Endocardium/heart valves | Endocarditis - mitral valve (regurgitation, prolapse, stenosis) - aortic valve (stenosis, insufficiency) - pulmonary valve (stenosis, insufficiency) - tricuspid valve (stenosis, insufficiency) |
| Myocardium | Myocarditis - Cardiomyopathy (Dilated cardiomyopathy, Hypertrophic cardiomyopathy, Loeffler endocarditis, Restrictive cardiomyopathy) - Arrhythmogenic right ventricular dysplasia |
| Electrical conduction system of the heart | Heart block: AV block (First degree, Second degree, Third degree) - Bundle branch block (Left, Right) - Bifascicular block - Trifascicular block Pre-excitation syndrome (Wolff-Parkinson-White, Lown-Ganong-Levine) - Long QT syndrome - Adams-Stokes syndrome - Cardiac arrest - Sudden cardiac death Arrhythmia: Paroxysmal tachycardia (Supraventricular, AV nodal reentrant, Ventricular) - Atrial flutter - Atrial fibrillation (Familial) - Ventricular fibrillation - Premature contraction (Atrial, Ventricular) - Ectopic pacemaker - Sick sinus syndrome |
| Other heart conditions | Heart failure - Cardiovascular disease - Cardiomegaly - Ventricular hypertrophy (Left, Right) |
| Cerebrovascular diseases | Stroke - Transient ischemic attack - Intracranial hemorrhage/cerebral hemorrhage: Extra-axial hemorrhage (Epidural hemorrhage, Subdural hemorrhage, Subarachnoid hemorrhage) Intra-axial hematoma (Intraventricular hemorrhages, Intraparenchymal hemorrhage) - Anterior spinal artery syndrome - Binswanger's disease - Moyamoya disease |
| Arteries, arterioles and capillaries | Atherosclerosis (Renal artery stenosis) - Aortic dissection/Aortic aneurysm (Abdominal aortic aneurysm) - Aneurysm - Raynaud's phenomenon/Raynaud's disease - Buerger's disease - Vasculitis/Arteritis (Aortitis) - Intermittent claudication - Arteriovenous fistula - Hereditary hemorrhagic telangiectasia - Spider angioma - Dissection (Carotid artery, Vertebral artery) |
| Veins, lymphatic vessels and lymph nodes | Thrombosis/Phlebitis/Thrombophlebitis (Deep vein thrombosis, May-Thurner syndrome, Portal vein thrombosis, Venous thrombosis, Budd-Chiari syndrome, Renal vein thrombosis, Paget-Schroetter disease) - Varicose veins / Portacaval anastomosis (Hemorrhoid, Esophageal varices, Varicocele, Gastric varices, Caput medusae) - Superior vena cava syndrome - Lymph (Lymphadenitis, Lymphedema, Lymphangitis) |
| Other | Hypotension (Orthostatic hypotension) - Rheumatic fever |
| See also congenital (Q20-Q28, 745-747) | |
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