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Varices

Hepatic portal vein


Illustration (Anatomy recall)
Esophageal Varices

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

Obstruction of portal venous flow, whatever the


etiology, results in a rise in portal venous pressure

The response to increased venous pressure is the


development ► of a collateral circulation diverting
the obstructed blood flow to ► the systemic veins
Esophageal Varices

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

However, other factors such as active


angiogenesis also may be involved
Esophageal Varices
Background
The most important portosystemic anastomoses are
the gastroesophageal collaterals

Draining into the azygos vein, these collaterals include


esophageal varices

which are responsible for the main complication of portal


hypertension ► massive upper GI hemorrhage
Esophageal Varices

Background
The most common causes of upper GI
bleeding are:
duodenal and
gastric ulcers
responsible for 35% and 20% of cases,
respectively

Bleeding from esophageal varices is responsible


for only 5-11% upper GI bleeding (incidence varies
depending on geographic location)
Esophageal Varices

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

Normal pressure in the portal vein is 5-10 mm Hg

Because the vascular resistance in the hepatic sinusoids is


low
An elevated portal venous pressure (>10 mm Hg)
* distends the veins proximal to the site of the block and

* increases capillary pressure in organs drained by the


obstructed veins
Esophageal Varices

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

* but a normal wedged hepatic venous pressure


(WHVP)
Esophageal Varices

Pathophysiology
2) Postsinusoidal obstruction
e.g.: Budd-Chiari syndrome
venoocclusive disease

* in which the central hepatic venules are


the primary site of injury

* WHVP characteristically is elevated


Esophageal Varices

Pathophysiology
3) Sinusoidal obstruction
e.g.: cirrhosis

* is characterized by increased hepatic


venous pressure gradient (HVPG)

* with WHVP being equal to portal venous


pressure
Esophageal Varices
Pathophysiology
Gastroesophageal varices have 2 main inflows:
the first is the:
1) * left gastric (or coronary vein)

The other major route of inflow is the:


2) * splenic hilus, through the short
gastric veins

The gastroesophageal varices are important


because of their propensity to bleed
Esophageal Varices

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

►The presence of ascites, increases the risk of


hemorrhage
Esophageal Varices

Pathophysiology
The following are risk factors for variceal
hemorrhage:

A well-documented association exists between:


variceal hemorrhage and
bacterial infections
and this may represent a causal relationship
Esophageal Varices

Infection could trigger variceal bleeding by a


number of mechanisms, including the following:

► Active alcohol intake in patients with chronic alcohol-


related liver diseases

► Local changes in the distal esophagus


e.g.: gastroesophageal reflux
have been postulated to increase the risk of
variceal hemorrhage
Esophageal Varices

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

Hepatitis B is endemic in the


* East and Southeast Asia
* Africa and
* other countries in the Middle East
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

Approximately one third of further bleeding


episodes are fatal
Esophageal Varices
Sex
In females
alcoholic liver disease
viral hepatitis
venoocclusive disease and
primary biliary cirrhosis
usually are responsible
In males
alcoholic liver disease and
viral hepatitis usually
are responsible
Esophageal Varices

Age
Portal vein thrombosis and
Secondary biliary cirrhosis
are the most common causes of varices in
children

Cirrhosis is the most common cause of


esophageal varices in adults
Esophageal Varices

Clinical Presentation
History
1) Symptoms of liver disease
Weakness
Tiredness
Malaise
Anorexia
Esophageal Varices

Clinical Presentation
History
2) Symptoms of liver disease

Sudden and massive bleeding with ►►shock


on presentation

► Nausea and vomiting


Esophageal Varices

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

► Recurrence of jaundice suggests the possibility of:


reactivation
infection with another virus or
the onset of hepatic decompensation
Esophageal Varices

Past medical history


► blood transfusion
► schistosomiasis

Family history of hereditary liver disease


such as
► Wilson disease