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.
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.
5. Pathophysiology
• Increased resistance to portal flow:
At the level of sinusoids
• Increase in portal venous blood flow:
Resulting from hyper-dynamic circulation
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.
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
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.
17.
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
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
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
Editor's Notes
Guidewire is inserted via internal jugular vein. Can cause complication like post-stent encephalopathy, recurrent varices, stenosis of shunt, perforation of liver capsule intraperitoneal haemorrhage. C/I portal vein thromobosis.