GI Competency Course Esophagus Pathophysiology of the Esophagus

Esophageal varices

  • Most often caused by portal hypertension.
  • Something in the portal system, often cirrhosis, causes a blockage, resulting in a scarred liver, and the hepatic vein becoming obstructed.
  • The closest place for the excess to flow into is the smaller veins in the GI system.
  • The esophageal veins dilate, and may become large enough to burst, and bleed.
  • This can be an emergency situation, with bright red blood pouring from their mouth, and a who is in shock. Most patients have no pain, and may not even know they have this condition until they present in an emergency.
  • Varices are graded on a scale from I-IV, with grades III-IV being the most likely to bleed.
  • Patients are being treated earlier, as many with liver cirrhosis are being found earlier, and the emergency treatment may be prevented in many cases.
  • Those with liver disease are sent for endoscopy, and if varices are present, they are placed on medications similar to Nadolol (Corgard), a non-specific beta-blocker to lower their blood pressure, and prevent progression of the varices.
  • If, on endoscopy, larger varices are noted, they may be treated with ligating devices (esophageal variceal ligation (EVL)), involving placement of bands around vessels that are large enough to create bleeding.
  • A patient presenting to the emergency room with an emergency bleed needs to be treated immediately with packed red blood cells, albumin, hydration, and fresh frozen plasma.
  • Prognosis for an acute bleed are poor. Approximately one third will die this hospitalization, one third in the first six weeks post bleed, and the last third in the next year.
  • Traditionally, sclerotherapy was used in an acute bleed to inject a medication to stop the bleeding.
  • Unfortunately, there were several complications involved including perforation, inflammation of the surrounding areas, strictures or ulcers formed, and often, they would bleed at a later date.
  • Presently, the use of esophageal variceal ligation is the first choice for treatment.
  • Physicians may choose to include the use of Octreotide (Sandostatin) by IV infusion to help control bleeding, and one must monitor for bradycardia and seizures during its use.
  • Some facilities may not have access to emergency procedures, so prior to sending patients for further care, may place a balloon tamponade (Minnesota tube or Blakemore tube) until more assistance may be obtained. Always keep scissors at the bedside for emergency care for these patients.
  • In trying to prevent long term complications, a TIPS procedure (transjugular intrahepatic portosystemic shunt) may be performed by a radiologist to shunt the blood from the portal system, bypassing the liver.
  • It is important for these patients to alter their lifestyle to offer them the best chance to survive:
    1. Take medications as ordered.
    2. Drink 2-3 cups of coffee a day.
    3. Avoid aspirin, ibuprofen, naproxen, other NSAIDS.
    4. Avoid alcohol and recreational drugs.
    5. Low fat diet (especially for cirrhosis from fatty liver disease).
    6. Treatment for Hepatitis, if applicable.