Esophageal Varices

For further information, see CMDT Part 15-19: Benign Esophageal Lesions

Essentials of Diagnosis

• Develop secondary to portal hypertension

• Found in 50% of patients with cirrhosis

• Upper gastrointestinal bleeding develops in one-third

• Diagnosis established by upper endoscopy

General Considerations

• Esophageal varices are dilated submucosal veins that develop in patients with underlying portal hypertension and may result in serious upper gastrointestinal bleeding

• Bleeding most commonly occurs in the distal 5 cm of the esophagus

• Approximately 50% of patients with cirrhosis have esophageal varices

• Bleeding from varices occurs in 30% of patients with esophageal varices

• In the absence of any treatment, variceal bleeding spontaneously stops in about 50% of patients

• Patients surviving this bleeding episode have a 60% chance of recurrent variceal bleeding, usually within the first 6 weeks

• Factors that may portend an increased risk of bleeding include

  • Size of the varices

  • Presence at endoscopy of red wale markings on the varix

  • Severity of liver disease (as assessed by Child-Pugh score)

  • Active alcohol abuse—patients with cirrhosis who continue to drink have an extremely high risk of bleeding

Symptoms and Signs

• Acute gastrointestinal hemorrhage, usually severe, resulting in hypovolemia, postural vital signs, or shock

Differential Diagnosis

• Alcoholic gastritis

• Mallory-Weiss syndrome

• Portal hypertensive gastropathy

• Peptic ulcer disease

• Gastric or duodenal varices (rare)

• Vascular ectasias (angiodysplasias), eg, idiopathic arteriovenous malformation, CREST syndrome, hereditary hemorrhagic telangiectasia

Laboratory Tests

• Complete blood count, platelet count, prothrombin time, INR

• Serum liver enzymes

• Creatinine, blood urea nitrogen

• If bleeding, blood type and cross-match

Diagnostic Procedures

• After the patient's hemodynamic status has been stabilized, emergent upper endoscopy is diagnostic

Medications

• Antibiotic prophylaxis reduces the risk of serious infection in hospitalized patients with cirrhosis and upper GI bleeding

• Prophylactic administration of oral or intravenous antibiotics reduces the risk of serious infection to 10–20% as well as in-hospital mortality, especially in patients with Child-Pugh class C cirrhosis

  • Norfloxacin, 400 mg orally twice daily for 5–7 days

  • Ceftriaxone 1 g/d intravenously for 5–7 days

• Vasoactive agents

  • Somatostatin, (250 mcg/h; not available in the United States) or octreotide, (50 mcg intravenous bolus followed by 50 mcg/h intravenously) infusion reduces splanchnic and hepatic blood flow and portal pressures

  • Terlipressin (1–2 mg intravenous every 4 hours; not available in the United States) causes significant reduction in portal and variceal pressures and, where available, may be preferred over octreotide

• Combined vasoactive agents and endoscopic therapy (band ligation or sclerotherapy)

  • Superior to either modality alone in controlling acute bleeding and early rebleeding

  • May improve survival

• Vitamin K, 10 mg subcutaneously

• Lactulose 30 mL orally every 2–3 hours until evacuation occurs, then reduced to 15–45 mL/h every 8–12 hours as needed to promote 2–3 bowel movements daily for hepatic encephalopathy

• After bleeding stops, administer β-blocker to reduce portal pressure

  • Propranolol, 20–60 mg twice daily orally; long-acting propranolol, 60–80 mg once daily orally; or nadolol, 40 mg once daily orally

  • Gradually increase dosage until heart rate falls by 25% or reaches 55–60 beats/min

Surgery

• Transvenous intrahepatic portosystemic shunt (TIPS) has resulted in a significant reduction in recurrent bleeding compared with endoscopic sclerotherapy or band ligation—either alone or in combination with β-blocker therapy

• TIPS reserved for patients who

  • Have recurrent (≥ 2 episodes) bleeding from gastric varices or portal hypertensive gastropathy (for which endoscopic therapies cannot be used)

  • Have not responded to endoscopic or pharmacologic therapies

  • Are noncompliant with other therapies

  • Live in remote locations (without access to emergency care)

• Shunt surgery is seldom performed due to the advent and widespread adoption of TIPS

• Liver transplantation

Therapeutic Procedures

• Initial management involves rapid assessment and acute resuscitation with fluids or blood products

• Transfusion of fresh frozen plasma or platelets to patients with INRs > 1.8–2.0 or platelet counts < 50,000/mcL in the presence of active bleeding

• Mechanical tamponade with nasogastric tubes containing large gastric and esophageal balloons (Minnesota or Sengstaken-Blakemore tubes)

  • Provides initial control of active variceal hemorrhage in 60–90% of patients

  • However, rebleeding occurs in 50%

• Acute endoscopic treatment of the varices generally is performed with banding; in current clinical practice, sclerotherapy is seldom used

  • Banding arrests active bleeding in 80–90% of patients and reduces the chance of in-hospital recurrent bleeding to about 20%

  • Repeat banding at intervals of 2–4 weeks until the varices are obliterated or reduced to a small size

  • Long-term treatment with banding achieves lower rates of rebleeding, complications, and death than sclerotherapy

  • For patients with platelet counts < 50,000/mcL,

    • Administering avatrombopag before the procedure should be considered

    • At a dose of 40–60 mg/day for 5 consecutive days beginning 10–13 days prior to endoscopy, phase III clinical trials results showed that 68% of patients with baseline platelet counts < 40,000/mcL and 88% with baseline counts 40–50,000/mcL achieved platelet counts > 50,000/mcL and avoided periprocedural platelet transfusions

  • Sclerotherapy is occasionally used for actively bleeding patients (in whom visualization for banding may be difficult)

Follow-Up

• Stenosis and thrombosis of the TIPS occur in the majority over time with a consequent risk of rebleeding; monitor shunt periodically with Doppler ultrasonography or hepatic venography

Complications

• Complications of TIPS include

  • Hepatic encephalopathy in 35%

  • Hepatic failure

• Complications of sclerotherapy occur in 20–30% and include

  • Chest pain

  • Fever

  • Bacteremia

  • Esophageal ulceration, stricture, and perforation

• Complications of mechanical tamponade include

  • Esophageal and oral ulcerations

  • Perforation

  • Aspiration

  • Airway obstruction

Prognosis

• With current therapies, the in-hospital mortality rate associated with bleeding esophageal varices is 12%

• Mortality rate within 2 weeks after an acute bleeding episode is 20%

• Mortality rate at 2 years is 60% due to recurrent bleeding or progression of chronic liver disease

Prevention

• Nonselective β-adrenergic blockers (propranolol, nadolol) reduce the risk of rebleeding from esophageal varices to about 40%

• Likewise, long-term treatment with band ligation reduces the incidence of rebleeding to about 30%

When to Refer

• All patients with upper GI bleeding and suspected varices should be evaluated by a physician skilled in therapeutic endoscopy

• Patients with cirrhosis for endoscopic evaluation for varices

• Patients being considered for TIPS procedures or liver transplantation

When to Admit

• All patients with acute upper GI bleeding and suspected cirrhosis should be admitted to an ICU