Pathophysiology of oesophageal varices

Liver disease causes an increase in portal vascular resistance. The increased portal
vascular resistance causes an increase in portal pressure and this condition is known as
portal hypertension. Portal hypertension contributes to the development of a collateral
circulation. This circulation diverts the portal blood into the systemic veins through the
portosystemic anastomoses. Oesophago-gastric junction is one of the sites where the
portal and systemic veins join. Thus, varices develop between the oesophageal branch of
the left gastric vein and the oesophageal veins at the junction.
Management of oesophageal varices
A) Primary prophylaxis
1. Propranolol / nadolol / isosorbide mononitrate
2. Endotherapy:
- Endoscopic variceal banding/ligation (EVB/EVL)
- Endoscopic variceal sclerotheraoy (EVS)
B) Secondary prophylaxis (after one or more episodes of bleeding)
1. Endotherapy: EVB
2. Shunt surgeries
3. Propranolol
My conclusion:
1. Grade 1 or small varices: no primary prophylactic therapy + screening for enlargement
of varices every 1-2 years.
2. Large varices (Grade 3) or medium varices (Grade 2) with endoscopic red signs or
Childs C cirrhosis: treatment either by propranolol or endoscopic variceal banding
(EVB).
3. Non-selective beta-blocker (propranolol) is considered the best modality for primary
prophylaxis at present because it shows survival benefit and its cost-effectiveness.
Treatment of oesophageal varices can be divided into two arms:
1. Emergency management
2. Definitive management
Emergency management
1. Resuscitation
2. Pharmacotherapy: octreotide
3. Endoscopic banding/sclerotherapy
4. Balloon tamponade
5. TIPSS
6. Devascularisation surgical procedures
1. Resuscitation

1. Haemodynamic monitoring
2. Large bore IV line or central venous access for volume
replacement

3. Blood: group and cross-matched for blood transfusion

4. Correct coagulopathy
5. Consider intubation for airway protection if severe
uncontrollable bleeding, encephalopathic, inability to maintain
O2 saturation adequately and to prevent aspiration
6. ICU bed and facilities should be made available
7. Antibiotic prophylaxis in patients with cirrhosis
- Antibiotic treatment should be continued for 7 days
Norfloxacin 400mg bd
OR
Ciprofloxacin 500mg bd OR IV 200mg bd
OR
Third generation cephalosporins (e.g. Ceftriaxone 1g daily)
2. Pharmacotherapy
- Octreotide is the
choice

- IV Terlipressin/Octreotide/Somatostatin for 2-5 days to prevent

early rebleeding.
1. Terlipressin: 2mg bolus and 1mg every 6 hours for 2-5 days.
2. Somatostatin: 250mcg bolus followed by 250mcg/hour
infusion for 5 days.
3. Octreotide: 50mcg bolus followed by 50mcg/hour for 5 days.

3. Endoscopic
therapy (banding /
sclerotherapy /
glueing)

A) Endoscopic variceal banding (EVB)

- Gold standard
- Controls bleeding in 90% of cases and less complications
B) Endoscopic variceal sclerotherapy (EVS)
- 70-80% control of bleeding
- Higher rate of re-bleed
- Complications such as perforation and stricture oesophagus
- Have to be done weekly for 6-8 sessions until varices are
obliterated
C) Endoscopic gluing using tissue adhesives
- Commonly used for gastric varices
D) Endoscopic thrombin / dilute adrenaline injection into the
varices

4. Balloon tamponade

Consider balloon tamponade if:

1. Endoscopy is unavailable and there is presence of active
bleeding.
2. Persistent active bleeding after banding, sclerotherapy or
gluing.
- It is only a rescue procedure and should be followed by
definitive procedures like banding or sclerotherapy.

5. TIPSS

- It is used if all other methods mentioned have failed.

- Controls the uncontrolled acute bleeding.

6. Surgeries for acute

bleeding varices

- Not commonly used to control bleeding in acute stage.

My conclusion:
1. Resuscitation (especially volume replacement) is always the first step, followed by
measures to control acute bleeding.
2. Pharmacotherapy is often combined with endotherapy.
3. Endoscopic variceal banding (EVB) is the gold standard and ideal for oesophageal
varices.
4. If bleeding does not stop by banding, sclerotherapy or gluing, the next step should be
balloon tamponade.
5. If all other methods mentioned have failed, TIPSS should be the next step to control
the uncontrolled acute bleeding.
6. Shunt surgeries are not commonly performed to control bleeding.
Definitive management
1. Sclerotherapy
2. Shunt surgery
- Selection of patients by Childs grading. Surgery is contraindicated in Child C.
- Prophylactic shunt surgery should not be done.
- 3 types: non-selective shunts, selective shunts and partial shunts.
3. Splenectomy
- Liver is normal. This is only done to correct segmental portal hypertension / sinistral
portal hypertension due to splenic vein thrombosis.
4. TIPSS (transjugular intrahepatic portosystemic stenting/shunt)
- A non-surgical, interventional radiological method.
5. Liver transplant
- It is the ideal, final and best option.
My conclusion:
1. Sclerotherapy is used as the definitive treatment of varices in our setting (HTJS).
2. In our setting (HTJS), shunt surgery, TIPSS and liver transplant are not possible
because:
- We do not have interventional radiologist.
- We do not have hepatobiliary surgeon.
- Liver transplantation is usually done in Hospital Selayang. Furthermore, donor

availability and cost are always the problems for liver transplantation to be done.
3. Splenectomy is only indicated in the case of portal hypertension due to splenic vein
thrombosis.