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Oesophageal varices (Pathophysiology (Usually due to liver fibrosis and…
Oesophageal
varices
Definition
Dilated sub-mucosal veins in the
lower oesophagus due to portal HTN
Pathophysiology
Usually due to liver fibrosis and nodule formation
Disrupted hepatic vascular supply and portal HTN
Splanchnic vasodilatation and increased CO
Na and water retention, hyperdynamic circulation
Collaterals between portal and systemic systems
Increased bleeding risk at collaterals e.g. lower oesophagus,
stomoch, umbilicus (caput medusae), rectum
Any cause of increased portal HTN
Aetiology
Post-hepatic
Vascular - Budd-Chiari syndrome, RHF, pericarditis,
veno-occlusive disease
Hepatic
Infection - schistosomiasis
Autoimmune - sarcoidosis
Neoplastic - MDS
Degnerative - cirrhosis (commonest)
Congenital - congenital hepatic fibrosis
Pre-hepatic
Vascular - portal/splenic vein thrombosis
Clinical
presentation
Haematemesis
Malaena
Collapse/LOC
Diagnosis
Examination
Abdo - encephalopathy, ascites, spider naevi,
gynaecomastia, caput medusae, etc.
Investigations
Bedside - obs, ECG, BM
Bloods - FBC (low Plts, anaemia), CRP, U+Es, LFTs (deranged), clotting (deranged),
Group+Save
Imaging - endoscopy (visible/bleeding veins)
History
PC/HPC: haematemesis, malaena
PMH: liver disease/cirrhosis, CV disease
SH: alcohol excess, smoking
Risk scoring
Rockall
Pre-endoscopy
Use: Indication for surgery or not
Components: age, shock (SBP, HR), comorbidity)
Interpretation: score 0-3 for each; >6 for surgery
Post-endoscopy
Use: rebleeding and mortality prediction
Components: age, shock, comorbidity,
diagnosis, signs of haemorrhage)
Interpretation: Higher mortality with higher score (>40% if 8+)
Glasgow/Blatchford
Use: admission or not
Components: Hb, SBP, HR, urea,
symptoms (malaena, syncope),
PMH (liver/heart disease)
Interpretation: admit if score 1+
Management
Initial ABCDE
Fluid resus, blood transfusions,
major haemorrhage protocol
Definitive
Conservative
Risk scoring (Rockall, Glasgow-Blatchford)
Major haemorrhage protocol if needed
Referral - liver surgeons ASAP
Medical
Proton-pump inhibitor (PPI)
Indication: ASAP bleeding varices
E.g. IV omeprazole
MOA: bolus then continue 3d
Sort clotting
Indication: clotting derangement
MOA: vitamin K, FFP, Plts
ADH analogue
Indication: ASAP bleeding varices
E.g. terlipressin
MOA: ADH analogue, promotes Na and
water loss to reduce BP and reduce bleed
B-blocker
Indication: primary prophylaxis
E.g. propanolol
MOA: reduces portal HTN
Surgical
Banding/sclerotherapy
Indication: 1L for bleeding varices, prophylaxis
MOA: banding or heat treatment
of veins to stop bleeding
Angiography/ligation
Indication: banding/sclerotherapy fails
MOA: ligation of veins
Balloon tamponade
Indication: uncontrolled bleeding
MOA: Minessota or Sengstaken-Blakemore tube compresses
varices, gives time for transfer to surgical decompression
Transjugular intrahepatic
port-systemic shunt (TIPSS)
Indication: secondary prophylaxis for rebleeding
Method: shunt to divert past the disrupted
vasculature of the liver (portal to hepatic vein)
Complications
Rebleeding
B-blocker, banding, TIPSS
Death
Acute blood loss,
shock and MOF
