Esophageal varices develop as portosystemic collaterals when portal pressure exceeds 12 mmHg, usually due to cirrhosis or other causes of portal hypertension. Clinical features include upper gastrointestinal bleeding. Management involves prevention of initial bleeding and rebleeding through drug treatment (octreotide, vasopressin), endoscopic therapy (band ligation, sclerotherapy), TIPSS procedures, or surgery (shunts, splenectomy, transplantation). The goal is to reduce portal pressure and control acute bleeding episodes.

1. OESOPHAGEAL VARICES
Sunil Kumar Daha

2. 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. Causes
Site Causes
Pre-hepatic Obstructive thrombosis
Narrowing of portal vein
Massive splenomegaly with increased blood flow
Hepatic Cirrhosis
Fatty liver disease
Schistosomiasis
Diffuse fibrosing granulomatous
disease(sarcoidosis)
Nodular regenerative hyperplasia
Post-hepatic Right sided heart failure
Constricted pericarditis
Hepatic vein outflow obstruction

5. Pathophysiology
• Increased resistance to portal flow:
At the level of sinusoids
• Increase in portal venous blood flow:
Resulting from hyper-dynamic circulation

6. Clinical features

7. Esophageal varices
• Esophageal varices are portosystemic
collaterals that dilate when portal pressure
exceeds 12mm Hg.
• It is the 2nd most commom cause of upper
GI bleeding.

8. Management of Esophageal varices

9. Management
1. Primary
 Prevention of variceal bleeding in patient
who have never bleed and control of acute
variceal bleeding
 For all patients with larger varices
(diameter greater than 5mm)
2. Secondary
 Prevention of rebleeding in patients who
have survived in initial bleeding episodes

10. Algorithm for primary prophylaxis of esophageal variceal hemorrhage

12. Algorithm for secondary prophylaxis

14. General Resuscitation
• Varices generally present with acute onset
of large volume hematemesis
• Diagnosis may be suspected if patient is
known to have chronic liver diseases
• Liver function test and coagulation profile
• Vitamin K (10 mg IV), Correction Of
coagulopathy

15. Drug Treatment
 Octreotide
• Long acting somatostatin analogue
• Reduces hepatic blood flow
• 50- μg bolus and 50- μg/h IV infusion for 2–5 days
Vasopressin
• Potent vasoconstrictor
• For the initial control of variceal haemorrhage
• S/E- Myocardial ischemia, arythmia, mesenteric
and limb ischemia

16. Endoscopic Treatment
Use of vasoconstrictor + endoscopic therapy
Standard medical treatment for acute
variceal bleed
• Endoscopic Band ligation
–By placing constricting rubber bands at
the base of Varix.
–Better in preventing rebleeding
• Endoscopic Scleropathy: by injecting
sclerosant (Such as Polidocanol 1-3% or
Ethanolamine 5%) into or around the varix.

18. Transjugular intrahepatic porto-
systemic stent shunts(TIPSS)
• Variceal hemorrhage not responded to
drug treatment and endoscopic
therapy
• Using fluoroscopic guidance and USG
• Internal jugular vein to SVC to hepatic
vein to hepatic parenchyma to branch
of the portal vein

19. TIPSS

20. Surgical shunt for variceal
hemorrhages
• Reduces pressure in portal circulation
• Indication:
–Patients with child’s grade A cirrhosis in
whom initial bleed has been controlled by
sclerotherapy
• Commonly used shunts are:
–Selective( eg. Splenorenal)
–Non-selective(eg. Portocaval)
• Alternatives - long term β- blockers
(Propanolol, Nadolol), chronic sclerotherapy or
banding

21. side-to-side portocaval end-to-side portocaval
mesocaval splenorenal

22. Oesophageal stapled transection
• Uses the circular stapling device for stapling
and resection of doughnut ring of the lower
oesophagus
• High perioperative mortality

23. Recurrent variceal bleeds secondary to
splenic or portal vein thrombosis
• Splenectomy
• Gastro esophageal devascularisation
Orthotopic liver transplantation
• Only therapy which will treat portal hypertension
and and liver disease.
The end

24. References
• Bailey and Love’s Short Practice of Surgery;
26th Edition
• SRB’s manual of surgery; 5th edition