Esophageal varices

A direct consequence of portal hypertension as a progressive complication of cirrhosis.

The development of bleeding carries significant morbidity and mortality.

Nonselective beta-blockers and/or endoscopic ligation can prevent the development of variceal bleeding.

Acute hemorrhage can be managed with resuscitation, a vasoactive drug or a somatostatin analog, and endoscopic ligation. Additional management may include transjugular intrahepatic shunt therapy and prophylactic antibiotics.

Diagnosis and surveillance by endoscopy is an important aspect of management.

Esophageal varices are dilated collateral blood vessels that develop as a complication of portal hypertension, usually in the setting of cirrhosis. They can be seen on endoscopy. In the US and Europe, the major cause of cirrhosis is alcoholic liver disease. Worldwide, hepatitis B virus infection and hepatitis C virus infection are the major causes of cirrhosis.[1]Alter MJ. Epidemiology of hepatitis B in Europe and worldwide. J Hepatol. 2003;39 Suppl 1:S64-9. https://www.journal-of-hepatology.eu/article/S0168-8278(03)00141-7/fulltext http://www.ncbi.nlm.nih.gov/pubmed/14708680?tool=bestpractice.com [2]Kim WR, Brown RS Jr, Terrault NA, et al. Burden of liver disease in the United States: summary of a workshop. Hepatology. 2002 Jul;36(1):227-42. http://www.ncbi.nlm.nih.gov/pubmed/12085369?tool=bestpractice.com Once cirrhosis has developed, increasing hepatic vein pressure gradient and deteriorating liver function may result in the formation of esophageal varices.

Rupture of esophageal varices can cause life-threatening bleeding. The most important predictor of variceal hemorrhage is the size of varices, with the highest risk of first hemorrhage occurring in patients with large varices (15% per year).[3]North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med. 1988 Oct 13;319(15):983-9. http://www.ncbi.nlm.nih.gov/pubmed/3262200?tool=bestpractice.com [4]Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010 Mar 4;362(9):823-32. http://www.ncbi.nlm.nih.gov/pubmed/20200386?tool=bestpractice.com Other important predictors of hemorrhage are decompensated cirrhosis (Child-Pugh B/C) and the endoscopic finding of red wale marks.[3]North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med. 1988 Oct 13;319(15):983-9. http://www.ncbi.nlm.nih.gov/pubmed/3262200?tool=bestpractice.com [5]Garcia-Tsao G, Abraldes JG, Berzigotti A, et al. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2017 Jan;65(1):310-35. https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/hep.28906 http://www.ncbi.nlm.nih.gov/pubmed/27786365?tool=bestpractice.com