esophageal varices and its management

1. OESOPHAGEAL VARICES AND
ITS MANAGEMENT
-BY SHWETA SHARMA
M.SC. NURSING I YEAR
AIIMS,JODHPUR

2. DEFINITION
Oesophageal varices are dilated and tortuous
veins in the oesophageal wall, secondary to
increased venous pressure in the splanchnic
venous bed or in the superior vena cava.
They are prone to rupture and often are the
sources of massive haemorrhages from the
upper gastro-intestinal tract and rectum.

3. PORTAL HYPERTENSION
 Normal pressure of portal vein is 5-8
mmHg.
 When it is >7-8mmHg, then called as
portal hypertension.
 Symptoms and complications occur
when the portal pressure is more
than 12 mmHg.

4. EPIDEMIOLOGY
•Present in 30% of patients with compensated cirrhosis
and 60% of patients with decompensated cirrhosis at
the time of diagnosis.
•The first bleeding episode has a mortality rate of 10%
to 30% depending on the severity of the liver disease
and is one of the major causes of death in patients
with cirrhosis.
•Patients surviving the first episode of variceal
bleeding are at very high risk for recurrent bleeding
(approximately 70%) and death (30% to 50%).

5. ETIOLOGY
Portal hypertension
Abnormalities of the circulation in the
splenic vein or superior vena cava
Hepatic venothrombosis
Severe liver scarring (cirrhosis)
Blood clot (thrombosis)
Parasitic infection- Schistosomiasis

7. RISK FACTORS
High portal vein pressure
Large varices
Red marks on the varices
Severe cirrhosis or liver failure
Continued alcohol use

8. PATHOPHYSIOLOGY

10. CLINICAL MANIFESTATIONS
Hematemesis
Melena
General deterioration in mental or
physical status
Splenomegaly
Ascites
Sign and symptoms of shock (cool clammy
skin, hypotension, tachycardia) may be
present

11. FACTORS THAT CONTRIBUTE TO
HEMORRHAGE
 Muscular exertion from lifting heavy objects
 Straining at stools
 Sneezing
 Coughing
 Vomiting
 Esophagitis
 Irritation of vessels by poorly chewed foods or irritating fluids
 Reflux of stomach contents (especially alcohol)
 Salicylates and any medication that erodes the oesophageal
mucosa or interferes with cell replication

12. DIAGNOSTIC EVALUATION
 Endoscopy- To identify the cause and bleeding site.

13. Portal hypertension measurements
 Indirect measurement-

14. Direct measurement-
During laparotomy, a needle may be
introduced into the spleen; a manometer
reading of more than 20 ml saline is
abnormal.
Insertion of a catheter into the portal vein or
one of its branches.
Endoscopic measurement of pressure within
varices is used only in conjunction with
endoscopic sclerotherapy.

15.  Ultrasonography
 Computed tomography

21. Liver function tests- serum
aminotransferase, bilirubin, alkaline
phosphatase, serum proteins,
etc.(increased)
Splenoportography- To detect
extensive collateral circulation in
oesophageal vessels, which would indicate
varices.
Hepatic portography- X-ray
visualization of the hepatic portal system
made radiopaque by intravenous infusion of
a suitable medium.

22. Celiac angiography

23. COMPLICATIONS
•Hypovolemic or haemorrhagic shock
•Hepatic encephalopathy- Due to
increased nitrogen load from bleeding
into the gastro-intestinal tract and an
increased serum ammonia level.
•Electrolyte imbalance
•Metabolic and respiratory alkalosis

24. Oesophageal stricture after
surgery or endoscopic therapy
Infection (pneumonia,
bloodstream infection,
peritonitis)
Rebleeding after treatment
Kidney failure

25. MEDICAL MANAGEMENT
 Evaluate the extent of bleeding, monitor vital signs
continuously if hematemesis and melena are present.
 Intravenous fluids to restore fluid volume.
 Parenteral nutrition
 Electrolytes to treat electrolyte imbalance.
 Volume expanders
 Blood transfusion
 Urinary catheterisation to monitor urine output.
 Gastric suction to keep the stomach as empty as possible
and to prevent straining and vomiting.

26. Pharmacological therapy
1.Octreotide (sandostatin) –
 Synthetic analogue of the hormone somatostatin
 Effective in decreasing bleeding from oesophageal
varices
 Lacks the vasoconstrictive effects of vasopressin
 Because of this safety and efficacy profile, it is
considered the preferred treatment regimen for
immediate control of variceal bleeding.
 Cause selective splanchnic vasoconstriction by
inhibiting glucagon release and are used mainly in the
management of active haemorrhage.

27. 2.Vasopressin (Pitressin)-
 It can be used as the initial mode of therapy in urgent
situations because it produces constriction of the
splanchnic arterial bed and decreases portal pressure.
 Contraindication – Coronary artery disease
 The combination of vasopressin with nitro-glycerine
(administered by the IV, sublingual or transdermal
route) has been effective in reducing or preventing the
side effects caused by vasopressin alone.
 Side effects of vasopressin- myocardial and extremity
ischemia as well as cardiac dysrhythmia.

28. 3.Beta-blocking agents-
 Propranolol or nadolol that decrease portal pressure.
 Used both to prevent a first bleeding episode in
patients with known varices and to prevent
rebleeding.
 They should not be used in acute variceal
haemorrhage, but they are effective prophylaxis
against such an episode.
4.Nitrates such as isosorbide (Isordil)-
•Lower portal pressure by venodilation and decreased
cardiac output and may be used in combination with
beta-blockers.

29. Balloon tamponade

32. Endoscopic variceal ligation
(oesophageal banding therapy)-

34. Trans jugular intrahepatic portosystemic
shunt (TIPS)

35. Additional therapies

36. Coated expandable stents

37. SURGICAL MANAGEMENT
 Surgical bypass procedure- Distal splenorenal shunt

39. Devascularization and transection (Sugiura
procedure)-

40. NURSING MANAGEMENT
Nursing assessment-
•Monitor the patient’s physical condition and evaluate
emotional responses and cognitive status.
•Monitor and record the vital signs.
•Assess the patient’s nutritional and neurologic status.
•Provide oral hygiene and moist sponges to lips.
•Provide a quiet environment and calm reassurance may
help to relieve the patient’s anxiety and reduce
agitation.

41. NURSING DIAGNOSIS
Fluid volume deficit related to active bleeding as
evidenced by decreased urine output (less than
30mL/hr).
Ineffective tissue perfusion related to hypovolemia
as evidenced by abnormal arterial blood gases.
Anxiety related to change in health status as
evidenced by irritability and nervousness due to
bleeding.

42. PREVENTION
Don't drink alcohol
Eat a healthy diet.
Maintain a healthy weight.
Use chemicals sparingly and
carefully.
Reduce your risk of hepatitis.

43. RESEARCH ARTICLES
1.Use of Wireless Capsule Endoscopy for the Diagnosis and Grading
of Esophageal Varices in Patients with Portal Hypertension: A
Systematic Review and Meta-analysis
A systematic review and structured meta-analysis was performed of all eligible
studies to evaluate the efficacy of wireless capsule endoscopy for screening and
diagnosis of esophageal varices among patients with portal hypertension.
Seventeen studies from 2005 to 2015 were included in this meta-analysis. The
diagnostic accuracy of wireless capsule endoscopy in the diagnosis of esophageal
varices was 90%. The diagnostic accuracy of wireless capsule endoscopy for the
grading of medium to large varices was 92%. The use of capsule demonstrated only
mild adverse events. The study concluded that wireless esophageal capsule
endoscopy is well tolerated and safe in patients with liver cirrhosis and
suspicion of portal hypertension.

44. 2.Evaluation of the blood ammonia level as a non-invasive
predictor for the presence of oesophageal varices and the risk
of bleeding.
A cross -sectional study was performed on a total of 359 patients with
cirrhosis. The aim of this study was to evaluate the blood ammonia level as a
predictor of the presence of esophageal varices and of a high risk of
bleeding. Abdominal ultrasonography, calculation of the Child-Pugh score,
and measurement of blood ammonia were performed for each patient. The
blood ammonia level was significantly higher in patients with esophageal
varices than in those without it, and in patients with a high risk of
variceal bleeding than in those with a low risk. The study concluded that
blood ammonia level may be clinically useful as it correlates with and is
an independent predictor for both the endoscopic risk signs and risk
factors of bleeding, and therefore, it could be used in patients with
cirrhosis to decrease the number of screening endoscopies they are
subjected to.

46. CONCLUSION
 As discussed throughout the presentation, learning about
oesophageal varices and its management will help nurses
to care for patients of oesophageal varices.
 Nurses can do assessment of patients with oesophageal
varices, observe the sign and symptoms, provide the
necessary nursing care, prevent complications and support
the patient psychologically.
 Nurses can also counsel the patients and their family for
various options available in treatment for oesophageal
varices.

47. REFERENCES
1.Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of Medical Surgical
Nursing. 2015. New Delhi. Wolters Kluwer.13th Edition. Volume 2. Pg. no. 1349-1354.
2.Lewis. Medical Surgical Nursing Assessment and Management of clinical problems.2015.
New Delhi. Elsevier. 2nd Edition. Volume II. Pg. no.998, 1068.
3.Mayo Clinic. Oesophageal varices. Available from https://www.mayoclinic.org/diseases-
conditions/esophageal-varices/symptoms-causes/syc-
20351538#:~:targetText=Esophageal%20varices%20are%20abnormal%2C%20enlarged,scar%2
0tissue%20in%20the%20liver. [cited 8 nov 2019]
4.PubMed. Use of Wireless Capsule Endoscopy for the Diagnosis and Grading of Esophageal
Varices in Patients With Portal Hypertension: A Systematic Review and Meta-Analysis.
Available from https://www.ncbi.nlm.nih.gov/pubmed/27548729 [cited 8 nov 2019]
5.PubMed. Evaluation of the blood ammonia level as a non-invasive predictor for the
presence of esophageal varices and the risk of bleeding. Available from
https://www.ncbi.nlm.nih.gov/pubmed/30465524 [cited 8 nov2019]