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Esophageal varices

 
Esophageal Varices

 
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Esophageal varices
 
 
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In medicine
Medicine

Medicine is the art and science of healing. It encompasses a range of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
 (gastroenterology
Gastroenterology

Gastroenterology is the branch of medicine whereby the digestive system and its disorders are studied. Etymology, the name is a combination of three Ancient Greek words gastros , enteron , and logos ....
), esophageal varices are extremely dilated
Dilation

Dilation or dilatation may refer to:In physiology:* Pupillary response, dilation of the pupil of the eye* Cervical dilation, the widening of the cervix in childbirth, miscarriage etc....
 sub-mucosal vein
Vein

In the circulatory system, veins are blood vessels that carry blood toward the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary vein and umbilical veins, both of which carry oxygenated blood....
s in the esophagus
Esophagus

The esophagus or oesophagus , sometimes known as the gullet, is an Organ in vertebrates which consists of a Muscle tube through which food passes from the pharynx to the stomach....
. They are most often a consequence of portal hypertension
Portal hypertension

In medicine, portal hypertension is hypertension in the portal vein and its tributaries.It is often defined as a portal pressure gradient of 5 mm Hg or greater....
, such as may be seen with cirrhosis
Cirrhosis

Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver Tissue by fibrous scar tissue as well as regenerative Nodule , leading to progressive loss of liver function....
; patients with esophageal varices have a strong tendency to develop bleeding
Bleeding

Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood from the circulatory system. Bleeding can occur internally, where blood leaks from blood vessels inside the body or externally, either through a natural opening such as the vagina, Mouth , nose, or anus, or through a break in the skin....
.

Esophageal varices are diagnosed with endoscopy
Endoscopy

Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an instrument called an endoscope....
.

Pathogenesis
The majority of blood from the esophagus
Esophagus

The esophagus or oesophagus , sometimes known as the gullet, is an Organ in vertebrates which consists of a Muscle tube through which food passes from the pharynx to the stomach....
 is drained away via the esophageal veins
Esophageal veins

The esophageal veins drain blood from the esophagus to the inferior thyroid vein.In the abdomen, some drain to the left gastric vein....
, which drain deoxygenated blood from the esophagus to the azygos vein
Azygos vein

The azygos vein is a vein running up the right side of the thoracic vertebral column. It can also provide an alternate path for blood to the superior vena cava....
 which in turn, directly drains into the superior vena cava
Superior vena cava

The superior vena cava is a large, yet short vein that carries deoxygenated blood from the upper half of the body to the heart's right atrium....
.






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In medicine
Medicine

Medicine is the art and science of healing. It encompasses a range of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
 (gastroenterology
Gastroenterology

Gastroenterology is the branch of medicine whereby the digestive system and its disorders are studied. Etymology, the name is a combination of three Ancient Greek words gastros , enteron , and logos ....
), esophageal varices are extremely dilated
Dilation

Dilation or dilatation may refer to:In physiology:* Pupillary response, dilation of the pupil of the eye* Cervical dilation, the widening of the cervix in childbirth, miscarriage etc....
 sub-mucosal vein
Vein

In the circulatory system, veins are blood vessels that carry blood toward the heart. Most veins carry deoxygenated blood from the tissues back to the heart; exceptions are the pulmonary vein and umbilical veins, both of which carry oxygenated blood....
s in the esophagus
Esophagus

The esophagus or oesophagus , sometimes known as the gullet, is an Organ in vertebrates which consists of a Muscle tube through which food passes from the pharynx to the stomach....
. They are most often a consequence of portal hypertension
Portal hypertension

In medicine, portal hypertension is hypertension in the portal vein and its tributaries.It is often defined as a portal pressure gradient of 5 mm Hg or greater....
, such as may be seen with cirrhosis
Cirrhosis

Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver Tissue by fibrous scar tissue as well as regenerative Nodule , leading to progressive loss of liver function....
; patients with esophageal varices have a strong tendency to develop bleeding
Bleeding

Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood from the circulatory system. Bleeding can occur internally, where blood leaks from blood vessels inside the body or externally, either through a natural opening such as the vagina, Mouth , nose, or anus, or through a break in the skin....
.

Esophageal varices are diagnosed with endoscopy
Endoscopy

Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an instrument called an endoscope....
.

Pathogenesis


The majority of blood from the esophagus
Esophagus

The esophagus or oesophagus , sometimes known as the gullet, is an Organ in vertebrates which consists of a Muscle tube through which food passes from the pharynx to the stomach....
 is drained away via the esophageal veins
Esophageal veins

The esophageal veins drain blood from the esophagus to the inferior thyroid vein.In the abdomen, some drain to the left gastric vein....
, which drain deoxygenated blood from the esophagus to the azygos vein
Azygos vein

The azygos vein is a vein running up the right side of the thoracic vertebral column. It can also provide an alternate path for blood to the superior vena cava....
 which in turn, directly drains into the superior vena cava
Superior vena cava

The superior vena cava is a large, yet short vein that carries deoxygenated blood from the upper half of the body to the heart's right atrium....
. These veins have no part in the development of esophageal varices. The remaining blood from the esophagus is drained away via the superficial veins lining the esophagus interior, which drain into the coronary vein (left gastric vein
Left gastric vein

The Left gastric vein derives tributaries from both surfaces of the stomach; it runs from right to left along the lesser curvature of the stomach, between the two layers of the lesser omentum, to the esophageal opening of the stomach, where it receives some esophageal veins....
) which in turn, drains directly into the portal vein. These superficial veins lining the esophagus interior (normally only approximately 1mm in diameter) become distended up to 1-2 cm in diameter in association with portal hypertension.

Normal portal pressure is approximately 9 mmHg compared to an inferior vena cava pressure of 2-6 mmHg. This creates a normal pressure gradient of 3-7 mmHg. If the portal pressure rises above 12mmHg, this gradient rises to 7-10 mmHg. A gradient greater than 5 mmHg is considered portal hypertension
Portal hypertension

In medicine, portal hypertension is hypertension in the portal vein and its tributaries.It is often defined as a portal pressure gradient of 5 mm Hg or greater....
. At gradients greater than 10 mmHg, blood flow though the hepatic portal system is redirected from the liver into areas with lower venous pressures. This means that collateral circulation develops in the lower esophagus
Esophagus

The esophagus or oesophagus , sometimes known as the gullet, is an Organ in vertebrates which consists of a Muscle tube through which food passes from the pharynx to the stomach....
, abdominal wall, stomach
Stomach

In most mammals, the stomach is a hollow muscular organ of the gastrointestinal tract involved in the second phase of digestion, following mastication....
 and rectum
Rectum

The rectum is the final straight portion of the large intestine in some mammals, and the Gastrointestinal tract in others, terminating in the anus....
. The small blood vessels in these areas become distended, becoming more thin-walled, and appear as varicosities. In addition, these vessels are poorly supported by other structures, as they are not designed for high pressures.

In situations where portal pressures increase, such as with cirrhosis
Cirrhosis

Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver Tissue by fibrous scar tissue as well as regenerative Nodule , leading to progressive loss of liver function....
, there is dilation of veins in the anastomosis
Anastomosis

An anastomosis is a network of streams that both branch out and reconnect, such as blood vessels or leaf veins. The term is used in medicine, biology, mycology and geology....
, leading to esophageal varices.

Varices can also form in other areas of the body, including the stomach
Stomach

In most mammals, the stomach is a hollow muscular organ of the gastrointestinal tract involved in the second phase of digestion, following mastication....
 (gastric varices
Gastric varices

Gastric varices are dilated submucosal veins in the stomach, which can be a life-threatening cause of upper gastrointestinal hemorrhage. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis....
), duodenum
Duodenum

The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms anterior intestine or proximal intestine may be used instead of duodenum....
 (duodenal varices
Intestinal varices

Intestinal varices are dilated submucosal veins in the intestine....
), and rectum
Rectum

The rectum is the final straight portion of the large intestine in some mammals, and the Gastrointestinal tract in others, terminating in the anus....
 (rectal varices). Treatment of these types of varices may differ.

Treatment and the role of endoscopy

In emergency situations, the care is directed at stopping blood loss, maintaining plasma volume, correcting disorders in coagulation induced by cirrhosis, and appropriate use of antibiotics (as infection is either concomitant, or a precipitant).

Therapeutic endoscopy
Endoscopy

Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an instrument called an endoscope....
 is considered the mainstay of urgent treatment. Two main therapeutic approaches exist:

  • Variceal ligation, or banding
  • sclerotherapy
    Sclerotherapy

    Sclerotherapy is a procedure used to treat blood vessels or blood vessel malformations and also those of the lymphatic system. The term was coined in the 1940's by United States physician H....


In cases of refractory bleeding, balloon tamponade
Balloon tamponade

Balloon tamponade refers to the use of mercury weighted balloons instilled into typically the esophagus or stomach, and inflated to stop refractory bleeding from vascular structures -- including esophageal varices and gastric varices -- in the upper gastrointestinal tract....
 may be necessary, usually as a bridge to further endoscopy
Endoscopy

Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an instrument called an endoscope....
 or treatment of the underlying cause of bleeding (usually portal hypertension). Methods of treating the portal hypertension include: transjugular intrahepatic portosystemic shunt
Transjugular intrahepatic portosystemic shunt

A transjugular intrahepatic portosystemic shunt_, also TIPS, is an artificial channel in the liver from the portal vein to a hepatic vein ....
 (TIPS), or a distal splenorenal shunt procedure
Distal splenorenal shunt procedure

In medicine, a distal splenorenal shunt procedure , also splenorenal shunt procedure and Warren shunt, is a List of surgical procedures in which the distal splenic vein is attached to the left renal vein ....
 or a liver transplantation
Liver transplantation

Liver transplantation or hepatic transplantation is the replacement of a diseased liver with a healthy liver allograft. The most commonly used technique is orthotopic transplantation, in which the native liver is removed and the donor organ is placed in the same anatomic location as the original liver....
.

Nutritional supplementation is not necessary if the patient is not eating for four days or less.

Prevention

Ideally, patients with known varices should receive treatment to reduce their risk of bleeding. The non-selective ß-blockers (e.g., propranolol
Propranolol

Propranolol is a non-selective beta blocker mainly used in the treatment of hypertension. It was the first successful beta blocker developed. It is the only drug proven effective for the prophylaxis of migraines in children....
, timolol
Timolol

Timolol maleate is a non-selective beta blocker. In its oral form , it is used to treat hypertension and prevent myocardial infarctions, and occasionally to prevent migraine headaches....
 or nadolol
Nadolol

Nadolol is a non-selective beta-blocker used in the treatment of hypertension, Migraine, and angina pectoris....
) and nitrates have been evaluated for secondary prophylaxis. The effectiveness of this treatment has been shown by a number of different studies.

Unfortunately, non-selective ß-blockers do not prevent the formation of esophageal varices.

See also

  • Portal hypertensive gastropathy
    Portal hypertensive gastropathy

    Portal hypertensive gastropathy refers to changes in the mucosa of the stomach in patients with portal hypertension; by far the most common cause of this is cirrhosis of the liver....


See also


  • gastric varices
    Gastric varices

    Gastric varices are dilated submucosal veins in the stomach, which can be a life-threatening cause of upper gastrointestinal hemorrhage. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis....
  • intestinal varices
    Intestinal varices

    Intestinal varices are dilated submucosal veins in the intestine....
  • esophagitis
    Esophagitis

    Esophagitis is inflammation of the esophagus....
  • Mallory-Weiss syndrome
    Mallory-Weiss syndrome

    Mallory-Weiss syndrome refers to bleeding from tears in the mucosa at the junction of the stomach and esophagus, usually caused by severe retching, coughing, or vomiting....
  • peptic ulcer
    Peptic ulcer

    A peptic ulcer, also known as ulcus pepticum, PUD or peptic ulcer disease, is an ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful....


External links

  • - World Gastroenterology Organisation (WGO)