Oesophageal varice
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Transcript of Oesophageal varice
OESOPHAGEAL VARICES
Sunil Kumar Daha
Portal Hypertension• Normal pressure of portal vein is 5-8 mmHg
• When it is >7-8mmHg, then called as portal hypertension
• Symptoms and complications occur when the portal pressure is more than 12 mmHg.
Causes
Site CausesPre-hepatic Obstructive thrombosis
Narrowing of portal veinMassive splenomegaly with increased blood flow
Hepatic CirrhosisFatty liver diseaseSchistosomiasisDiffuse fibrosing granulomatous disease(sarcoidosis)Nodular regenerative hyperplasia
Post-hepatic Right sided heart failureConstricted pericarditisHepatic vein outflow obstruction
Pathophysiology
• Increased resistance to portal flow:
At the level of sinusoids
• Increase in portal venous blood flow:
Resulting from hyper-dynamic circulation
Clinical features
Esophageal varices
• Esophageal varices are portosystemic collaterals that dilate when portal pressure exceeds 12mm Hg.
• It is the 2nd most commom cause of upper GI bleeding.
Management of Esophageal varices
Management
1. Primary Prevention of variceal bleeding in patient who
have never bleed and control of acute variceal bleeding
For all patients with larger varices (diameter greater than 5mm)
2. Secondary Prevention of rebleeding in patients who have
survived in initial bleeding episodes
Algorithm for primary prophylaxis of esophageal variceal hemorrhage
Algorithm for secondary prophylaxis
General Resuscitation• Varices generally present with acute onset
of large volume hematemesis• Diagnosis may be suspected if patient is
known to have chronic liver diseases• Liver function test and coagulation profile • Vitamin K (10 mg IV), Correction Of
coagulopathy
Drug Treatment Octreotide• Long acting somatostatin analogue• Reduces hepatic blood flow• 50- μg bolus and 50- μg/h IV infusion for 2–5 days
Vasopressin• Potent vasoconstrictor• For the initial control of variceal haemorrhage• S/E- Myocardial ischemia, arythmia, mesenteric and limb
ischemia
Endoscopic TreatmentUse of vasoconstrictor + endoscopic therapy
Standard medical treatment for acute variceal bleed
• Endoscopic Band ligation– By placing constricting rubber bands at
the base of Varix.– Better in preventing rebleeding
• Endoscopic Scleropathy: by injecting sclerosant (Such as Polidocanol 1-3% or Ethanolamine 5%) into or around the varix.
Transjugular intrahepatic porto-systemic stent shunts(TIPSS)
• Variceal hemorrhage not responded to drug treatment and endoscopic therapy
• Using fluoroscopic guidance and USG
• Internal jugular vein to SVC to hepatic vein to hepatic parenchyma to branch of the portal vein
TIPSS
Surgical shunt for variceal hemorrhages
• Reduces pressure in portal circulation• Indication:
– Patients with child’s grade A cirrhosis in whom initial bleed has been controlled by sclerotherapy
• Commonly used shunts are:– Selective( eg. Splenorenal)– Non-selective(eg. Portocaval)
• Alternatives - long term β- blockers (Propanolol, Nadolol), chronic sclerotherapy or banding
side-to-side portocaval end-to-side portocaval
mesocaval splenorenal
Oesophageal stapled transection• Uses the circular stapling device for stapling
and resection of doughnut ring of the lower oesophagus
• High perioperative mortality
Recurrent variceal bleeds secondary to splenic or portal vein thrombosis• Splenectomy • Gastro esophageal devascularisation
Orthotopic liver transplantation• Only therapy which will treat portal hypertension
and and liver disease.
The end
References
• Bailey and Love’s Short Practice of Surgery; 26th Edition
• SRB’s manual of surgery; 5th edition