Esophageal (or Oesophageal) Varices:
Definition:
Oesophagal varices refer to dilated, tortuous mucosa or sub-mucosal esophageal veins.
Causes:
Portal hypertension is the main cause of dilatation of oesophagal veins. Portal hypertension is due to hepatic cirrhosis of any origin.
Pathogenesis:
Increased pressure in the portal vein results in the opening of collaterals veins between the portal and systemic venous system.
Clinical features and signs:
Dilated oesophagal veins may rupture and show clinical signs and symptoms. In un-ruptured condition, there will be no clinical symptoms.
when rupture the patient present with hematemesis, oesophagal laceration, peptic ulcer, 40 % of patients die during the first episode of hematemesis.
Treatment:
Treatment of Esophageal varices in patients who have no history of oesophagal bleeding.
1. Betablockers: betablockers such as propranolol, timolol and nadolol are used provided that these agents are not contra-indicated (eg, because of insulin-dependent diabetes mellitus, severe chronic obstructive lung disease, congestive heart failure) betablockers decreased the incidence of bleeding by 45%
2: Nitrates: if beta blockers are contra indicated nitrates can be used ( e.g isosorbide mononitrate.)
3. Endoscopic sclerotherapy and variceal ligation is an effective treatment to prevent bleeding.
4. Combined therapy: that is with endoscopic sclerotherapy and betablockers.
Treatment of Esophageal varices in patients who have no history of oesophagal bleeding.
1. Asses the rate and volume of bleeding, check blood pressure, pulse. take a blood sample of the patient and send it for cross match and hematocrit measurement, liver function test, platelet count, PT and APTT.
2. Start emergency treatment.
Emergency Treatment:
1. Monitor blood pressure, pulse respiration and heart rate.
2. Establish and maintain an intravenous line for blood transfusion. If blood is not available or it is being cross-matched start 5% dextrose and colloid infusion until the blood pressure and adequate urine output is restored.
3. Establish airway protection in a patient with massive upper GI bleeding, especially if the patient is unconscious.
4. If indicated, correct clotting factor deficiencies with fresh frozen plasma, fresh blood, and vitamin K-1.
5. Insert a nasogastric tube to asses the volume of bleeding and perform a gastric lavage before sending the patient for endoscopy.
6. support with pharmacological therapies.(octreotide or somatostatin, vitamin K, tranexamic acid)
7. Endoscopic therapy probably has replaced balloon tamponade as the initial therapy for variceal bleeding. Balloon tamponade is now rarely necessary, and, when it is used, it must be performed by experienced personnel because the procedure is potentially dangerous.
8. and finally endoscopic sclerotherapy and variceal ligation.