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Background
The portal vein carries approximately
1500 mL /min of blood from the:
small and large bowel
the spleen and
the stomach to the
liver
Esophageal Varices
Background
Background
These portosystemic collaterals form by the opening and
dilatation of preexisting vascular channels connecting :
1) the portal venous system and
2) the superior and inferior vena cava
Esophageal Varices
Background
High portal pressure is the main cause of
the development of portosystemic
collaterals
Background
The most common causes of upper GI
bleeding are:
duodenal and
gastric ulcers
responsible for 35% and 20% of cases,
respectively
Background
Other causes for upper GI bleeding are:
1) acute gastric erosions/hemorrhagic
gastritis (18%)
2) Mallory-Weiss tears (10%)
3) gastric carcinoma (6%) and
4) other causes (6%)
Pathophysiology
Obstruction of the portal venous system at any level leads
to increased portal pressure
Pathophysiology
Because the portal venous system lacks
valves, resistance at any level between the
right side of the heart and the splanchnic
vessels results in:
* retrograde flow of blood and
* transmission of elevated
pressure
Esophageal Varices
Pathophysiology
The anastomoses connecting the:
* portal and
* systemic circulation
may enlarge to allow blood to:
* bypass the obstruction and
* pass directly into the
systemic circulation
Esophageal Varices
Pathophysiology
Obstruction and increased resistance can occur
at 3 levels in relation to hepatic sinusoids, as
follows:
1) Presinusoidal venous block:
e.g.: portal vein thrombosis
schistosomiasis
primary biliary cirrhosis
These lesions are characterized by:
* elevated portal venous pressure
Pathophysiology
2) Postsinusoidal obstruction
e.g.: Budd-Chiari syndrome
venoocclusive disease
Pathophysiology
3) Sinusoidal obstruction
e.g.: cirrhosis
Pathophysiology
The following are risk factors for variceal
hemorrhage:
► Variceal size:
The larger the varix, the higher the risk of:
rupture and
bleeding
Remember:
However, patients may bleed from small varices
too
Esophageal Varices
Pathophysiology
The following are risk factors for variceal
hemorrhage:
► The presence of endoscopic red color signs
e.g.: (A) red whale markings; (B) cherry red spots
Pathophysiology
The following are risk factors for variceal
hemorrhage:
Pathophysiology
The release of endotoxin into the systemic circulation
►
► Worsening of hemostasis
Frequency
In Western countries
alcoholic and
viral cirrhosis
are the leading causes of:
portal hypertension and
esophageal varices
Frequency
Schistosomiasis
is an important cause of portal hypertension
* African and
* Asian countries
Hepatitis C
is becoming a major cause of liver cirrhosis worldwide
Esophageal Varices
Frequency
30% of patients with compensated cirrhosis and
60-70% of patients with decompensated cirrhosis
have gastroesophageal varices at presentation
Remember
The risk of bleeding from esophageal varices is 30% in the
first year after identification
Esophageal Varices
Mortality/Morbidity
Patients who have bled once from
esophageal varices have a 70% chance of
rebleeding
Age
Portal vein thrombosis and
Secondary biliary cirrhosis
are the most common causes of varices in
children
Clinical Presentation
History
1) Symptoms of liver disease
Weakness
Tiredness
Malaise
Anorexia
Esophageal Varices
Clinical Presentation
History
2) Symptoms of liver disease
Clinical Presentation
History
3) Symptoms of liver disease
Weight loss
Abdominal discomfort and
Pain - Usually felt in the right
hypochondrium
Esophageal Varices
Clinical Presentation
History
4) Symptoms of liver disease
* Jaundice or dark urine
* Edema and abdominal swelling
* Pruritus
* Spontaneous bleeding
Esophageal Varices
Clinical Presentation
History
Encephalopathy symptoms:
* Disturbance of the sleep-wake cycle
* Deterioration in intellectual function
* Memory loss
* Impotence and sexual dysfunction
* Muscle cramps - Common in patients with
cirrhosis
Esophageal Varices
Past medical history
►Previous jaundice suggests the possibility of:
a previous acute hepatitis
hepatobiliary disorder or
drug-induced liver disease