Esophageal Varices Flashcards
What are esophageal varices?
- Esophageal varices are dilated collateral blood vessels that develop as a complication of portal HTN, usually in the setting of cirrhosis
- Bleeding from esophageal varices usually occurs in the distal 5 cm of the esophagus
- Esophageal varices are present in approx. 50% of patients with cirrhosis
- Their presence correlates with the severity of liver disease
What are 3 predictors of variceal hemorrhage?
- Size (diameter) of varices (MOST IMPORTANT)
- Decompensated cirrhosis (Child-Pugh class B & C)
- Endoscopic findings of red wale marks (see below picture)
Describe the pathophysiology associated with esophageal varices
- The initial factor in the pathophysiology of portal HTN is the increase in vascular resistance to portal blood flow.
- Intrahepatic vasoconstriction accounts for 20% to 30% of the resistance.
- Portal HTN leads to the development of porto-systemic collaterals, allowing for shunting of blood around the liver.
- Portal HTN persists despite the formation of collaterals because of splanchnic arteriolar vasodilation and insufficient decompression through the collaterals that have higher resistance than the liver.
- Clinically, gastroesophageal varices, together with ascites, are the most important consequence of portal HTN.
What causes portal hypertension?
- The etiology of portal hypertension is related to 2 major mechanisms:
- Increased resistance (primarily cirrhosis which we will concentrate on in this module)
- Increased flow
- Normal hepatic vein pressure gradient (HVPG) is 5 mm Hg or less
- Patients with cirrhosis and esophageal varices have an HVPG of at least 10 mm Hg or greater
What are the management goals for patients with esophageal varices?
- Reducing the HVPG to < 12 mm Hg, variceal wall tension decreases and thereby decrease the chance of rupture
- Prevent Bleeding
What are the clinical manifestations/physical exam findings found in patients with esophageal varices?
Clinical Manifestations
- Hematemesis
- Melena
- Hematochezia
- Abdominal distention/discomfort
- Signs/symptoms shock/hypovolemia
Physical Examination
- Jaundice
- Ascites (shifting dullness)
- Splenomegaly
- Visible stigmata of alcohol abuse:
- Spider angiomas:
- Palmar erythema
- Testicular atrophy
- Gynecomastia
- Bruising
- Petechiae
- Caput medusa: visible abdominal periumbilical collateral circulation
- Tremor flapping (asterixis)
- Evidence of encephalopathy
- Anal varices or blood on rectal exam
What lab/diagnostic tests are done to diagnose esophageal varices?
- Gold Standard in Diagnosis: esophagogastroduodenoscopy (EGD)
- CBC: decreased H/H, increased WBC, normally decreased platelets (thrombocytopenia) due to decreased production, splenic sequestration and increased destruction; anemia may be normal in active bleeding and may take 6-24 hours to equilibrate
- Coagulation panel: prolonged PT, PTT with increased INR due to decreased synthetic activity of liver
- Metabolic panel
- Liver Function Tests- elevated ALT, AST, Bilirubin Alk phos, Low Albumin
- HBV and HCV serology
- Arterial blood gas
- Type and Cross PRBC’s
What medications are used to prevent bleeding of esophageal varices?
- Give patients non-selective Beta-blockers because they reduce portal pressure and decrease risk of first bleed from 25% to 15% in primary prophylaxis
- Titrate them to the maximal tolerated dose
- Carvedilol 6.25mg daily - MORE EFFECTIVE than propranolol or nadolol in reducing HVPG
- Propranolol (Inderal): starting dose 20mg BID OR
- Nadolol (Corgard): starting dose 40mg once daily
- Studies have shown that the risk of bleeding recurs when treatment with B-blockers is stopped; therefore prophylactic therapy should be continued indefinitely.
- Optimal beta-blocker efficacy is indicated by a HVPG reduction to 12 mmHg or by 20% of baseline
Describe the initial management a patient acutely bleeding esophageal varices?
1. Assess Airway and apply oxygen as indicated by SpO2
- Given that aspiration of blood can occur, elective or emergent tracheal intubation may be required for airway protection prior to endoscopy, particularly in patients with concomitant hepatic encephalopathy
2. Establish CVP line access (introducer sheath)
- Maintain SBP > 110 mmHg
- Maintain CVP 10 mm Hg or less, and
- Maintain pulmonary capillary wedge pressure 8mm Hg or less
3. Insert 2 large bore IV’s
4. Obtain labs (CBC, CMP, Coagulation panel, LFTs, ABG)
5. Foley catheter placement
6. Consult surgery and gastroenterology STAT
- Emergent EGD for endoscopic band ligation (preferred) or sclerotherapy (not shown to be as effective even in combination with pharmacologic management)
- EGD should be performed within 12 hours of bleed
How do you manage a patient with hypotension from bleeding esophageal varices?
Infuse crystalloids/blood products for the treatment of hypotension
Transfuse to a target Hgb of 8 gm/dL
- Transfusion higher than a Hgb of 8 gm/dL has been shown to increase portal pressure to levels higher than baseline and lead to more re-bleeding and mortality
Avoid vigorous resuscitation with saline
- Vigorous saline resuscitation has been shown to not only precipitate recurrent variceal hemorrhage, it can also worsen or precipitate the accumulation of ascites or fluid at other extravascular sites
Transfusion of FFP and platelets may be considered
- There is no evidence that these blood products may benefit per practice guidelines
What medications are used to treat esophageal varices that are actively bleeding?
- Octreotide (Sandostatin) 50mcg IV bolus, followed by 3-5 days of continuous infusion at 50mcg/hr – even if endoscopic therapy is performed
OR
- Somatostatin: 250mcg IV bolus, followed by an infusion of 250mcg/hr for 3-5 days
- Somatostatin and analogues, such as Octreotide,* cause splanchnic vasoconstriction, leading to a decrease in portal inflow and a decrease in portal pressures
What do you do if endoscopic therapy/pharmacologic therapy fails to control variceal hemorrhage or if bleeding re-occurs?
1. Consult Interventional Radiology for Transjugular Intrahepatic Portosystemic Shunt placement (TIPS) as rescue therapy
- This procedure shunts blood away from liver; thereby reducing portal pressures
- May cause worsening encephalopathy
2. At any stage, uncontrollable bleeding should be treated by balloon tamponade (for up to 24 hours) as a bridge to more definitive treatment.
- Has been associated with potentially lethal complications such as aspiration, migration and necrosis/perforation of the esophagus with mortality rates as high as 20%
- Airway protection is STRONGLY recommended when balloon tamponade is utilized.
3. Start short-term (5-7 days) prophylactic antibiotics (Ciprofloxacin po or IV, OR Ceftriaxone 1 gm/day IV ) to cover gram negative organisms. They are recommended due to having been shown to:
- Reduce the rate of bacterial infection
- Reduce the rate of treatment failure
- Reduce the rate of re-bleeding
- Reduce mortality rate
4. Avoid Beta-blockers with active bleeding
- BB’s reduces BP and they blunt the physiologic increase in heart rate during acute hemorrhage
What can be done to prevent recurrent bleeding in esophageal varices?
- A combination of nonselective beta blockers PLUS endoscopic variceal ligation (EVL) is BEST option for secondary prophylaxis of variceal hemorrhage.
- Chronic prevention of re-bleeding (secondary prevention): Non-selective beta-blockers and endoscopic variceal ligation reduce the rate of re-bleeding, but beta blockers reduce mortality; whereas ligation does not.
How do you manage a patient with esophageal varices who re-bleeds?
- Repeat ligation for re-bleeding
- As many as 2/3 of patients with variceal bleeding develop infections, most commonly spontaneous bacterial peritonitis (SBP), UTI or pneumonia.
- Antibiotic prophylaxis with IV ceftriaxone 1 gm q 24 hours is indicated
- With active bleeding, avoid beta-blockers.
- Consider placement of balloon tamponade tube for up to 24 hours to stabilize the patient for a TIPS placement by Interventional radiology
- TIPS decreases portal pressure by creating a communication between the hepatic vein and an intrahepatic portal vein branch.
- If TIPS has been performed, no further studies are required other than periodic ultrasound to confirm TIPS patency.
How often should you monitor patients with esophageal varices?
- The follow-up recommendations on patients with esophageal varices depend on the size of varices and whether the patients have ever had esophageal variceal bleeding:
- Patients with cirrhosis and no varices should have surveillance endoscopy every 2 to 3 years, or yearly if they develop decompensated cirrhosis.
- Patients who have cirrhosis and small varices should have repeat endoscopy every 1 to 2 years.
- Patients on beta-blocker treatment for prevention of variceal bleeding do not need surveillance endoscopy.
- Endoscopic surveillance schedule after variceal eradication by banding ligation is 3 months, then after 6 months, and then yearly.
