Esophageal Varices

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

• Variceal bleeding 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

• Serum 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

• Prophylactic administration of intravenous antibiotics (eg, ceftriaxone 1 g/day intravenously for 5–7 days) in hospitalized patients with cirrhosis and upper GI bleeding

  • Reduces the risk of serious infection to 10–20%

  • Reduces in-hospital mortality, especially in patients with Child-Pugh class C cirrhosis

• Vasoactive agents

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

  • Terlipressin (1–2 mg intravenously 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

• Combination of vasoactive agent infusion plus endoscopic therapy (band ligation)

  • 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 a beta-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 beta-blocker therapy

• TIPS is 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 now 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

• Fresh frozen plasma should not be administered routinely in patients with an elevated INR, if stable

• In patients with decompensated cirrhosis and active severe upper gastrointestinal bleeding, platelet transfusion is recommended for a platelet count < 50,000/mcL and fresh frozen plasma may be considered for those with INRs > 1.8

• Mechanical tamponade with nasogastric tubes containing large gastric and esophageal balloons (Minnesota or Sengstaken-Blakemore tubes) may provide initial control of hemorrhage in 60–90% of patients

• Acute endoscopic treatment of the varices generally is performed with banding

  • 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

  • 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

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 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 beta-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