Esophageal Varices

Epidemiology

  • xxx

Etiology


Physiology

  • Portal Hypertension

Clinical Manifestations

  • Upper Gastrointestinal Bleeding (UGI) Bleeding: may be precipitous and life-threatening

Treatment

Proton Pump Inhibitor (PPI) (see Proton Pump Inhibitors, [[Proton Pump Inhibitors]])

  • Indications
    • Esophageal Varices with Active Bleeding
  • Pantoprazole (Protonix) Drip (see Pantoprazole, [[Pantoprazole]])

Octreotide Drip (see Octreotide, [[Octreotide]])

  • Indications
    • Esophageal Varices with Active Bleeding
  • Contraindications
    • xxx

Correction of Coagulopathy

  • Indications
    • Esophageal Varices with Active Bleeding

Transfusion Strategy

  • Avoid over-transfusion, as this may further distend varices and increase risk of bleeding (or re-bleeding)

Esophagogastroduodenoscopy (EGD) with Banding or Sclerotherapy

Variceal Banding

  • Indications
    • Esophageal Varices with/without Active Bleeding
  • Endoscopic U/S can be used to visualize paraesophageal and gastric varices after sclerotherapy or banding ligation
  • Paraesophageal varices were more frequently noted in patients undergoing ligation
  • The presence of paraesophageal varices may predict the recurrence of esophageal varices and recurrent bleeding

Variceal Sclerotherapy

  • Technique: usually, about 1 mL of the agent is injected in and around a varix -> total of 15-20 injections during a single procedure
    • Agents
      • Sodium Morrhuate
      • Sodium Tetradecyl Sulfate
      • Ethanolamine Oleate
  • Incidence of Adverse Effects: CXR was abnormal in 85% of cases post-procedure in one series (but these were rarely clinically significant)
  • Adverse Effects
    • Pleural Effusion (see Pleural Effusion-Exudate, [[Pleural Effusion-Exudate]])
      • Epidemiology
        • Occurs in approximately 25% of cases (range reported in literature: 0-50% of cases)
        • More common with larger number of injections and larger amount per injection
      • Diagnosis
        • CXR/Chest CT: pleural effusion
      • Clinical: usually asymptomatic
      • Treatment/Prognosis: effusion usually resolves spontaenously
    • Mediastinal Widening/Mediastinitis (see Mediastinitis, [[Mediastinitis]])
      • Mediastinal widening occurs in 33% of cases
    • Atelectasis (see Atelectasis, [[Atelectasis]]): occurs in 12% of cases
    • Pulmonary Infiltrates (see Pneumonia, [[Pneumonia]]): occurs in 9% of cases
    • Fever (see Fever, [[Fever]]): rarely significant
    • Chest Pain (see Chest Pain, [[Chest Pain]]): rarely significant
    • Odynophagia (see Odynophagia, [[Odynophagia]]): rarely significant
    • Esophageal Perforation (see Esophageal Perforation, [[Esophageal Perforation]])
    • Acute Lung Injury-ARDS (see Acute Lung Injury-ARDS, [[Acute Lung Injury-ARDS]])
      • Epidemiology: occurs in <1% of patients

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

  • Indications
    • xxx
  • Successful TIPS: reduction of hepatic wedge pressure to <12 or at least 20% reduction
  • Contraindications
  • Complications

Sengstaken-Blakemore Tube

SENGSTAKEN-BLAKEMORE TUBE

  • Indications
    • Esophageal Varices with Active Bleeding: vascular supply to esophageal varices originates from stomach and traverses the gastroesophageal (GE) junction -> this allows mechanical compression of variceal blood supply
    • Mallory-Weiss Tear with Active Bleeding: use of Sengstaken-Blakemore or Minnesota tube has been reported in some cases to control active bleeding
  • Tube Structure: 3-lumen with gastric aspiration port (may require additional NG tube placement, is esophageal aspiration is required)
  • Directions for Tube Placement
    • Intubate patient for airway protection
    • Place patient supine or in left lateral decubitus position
    • Place hockey helmet
    • Remove white pegs from esophageal and gastric balloon ports -> test balloons with air
    • Deflate balloons completely, lubricate tube, and insert to at least 50 cm
    • Using 60 ml catheter-tip syringe and blue tubing clamps, inflate gastric balloon with 200 ml of air
    • Tug tube back -> should feel resistance, if gastric balloon is properly in stomach
    • Secure tube to rung of hockey helmet using chest tube white tie, keeping tension (take note of the tube marking at the rung)
    • Add additional 250 ml of air to gastric balloon -> total volume = 450 ml of air
    • Keep clamped and place white peg back into gastric balloon port
    • Optionally (though usually not necessary), inflate esophageal balloon using manometer to 25-40 mm Hg
    • Connect esophageal/gastric aspiration ports to low-intermittent suction
    • Obtain CXR and KUB to confirm placement and confirm ETT positioning
    • Deflate esophageal balloon for 10 min out of every 2 hrs -> esophageal balloon inflation should not be used for >12-24 hrs in total duration
  • Complications
    • Migration of Gastric Balloon into Esophagus: causes abrupt tracheal compression and high peak inspiratory pressure (PIP) on ventilator
    • Esophageal Necrosis: in cases where esophageal balloon is not periodically deflated

Minnesota Tube

MINNESOTA TUBE

  • Indications: same as above for Sengstaken-Blakemore tube
  • Tube Structure: 4-lumen with esophageal gastric aspiration ports (does not require additional NG tube placement)
    • Also, Minnesota tube has larger gastric balloon than Sengstaken-Blakemore tube
  • Directions for Tube Placement: same as above for Sengstaken-Blakemore tube
  • Complications: same as above for Sengstaken-Blakemore tube

References

  • Prevalence of paraesophageal varices and gastric varices in patients achieving variceal obliteration by banding ligation and by injection sclerotherapy. Gastrointest Endosc. 1999 Apr;49(4 Pt 1):428-36