Oesophageal varices Flashcards
What is the pathophysiology of oesophageal varices
Increased resistance to portal blood flow. This leads to formation of collateral vessels and dilation of porto-ststemic anastamosis in the oesophagus
What are the mechanisms which lead to portal hypertension?
Increased resistence - Portal/splenic vein occlusions, sarcoidosis, schistosomiasis, cirrhosis, alcoholic hepatitis, budd chiari syndrome, constrictive pericarditis.
Increased flow - myeloproliferative changes
What is the endoscopic classification of oesophageal varices?
Grade 1 - small, straight vessels.
Grade 2 - Enlarged tortuous varices occupying less than one third of lumen.
Grade 3 - Large coil shapped varices occupying more than one third of the lumen
When should you suspect oesophageal variceal bleeding?
Patients with signs and symptoms of decompensated liver failure - Jaundice, ascites or hepatic encephalopathy.
Psychical signs of chronic liver disease - splenomegaly, spider angioma and ascites.
Deranged liver function tests or heavy prolonged alcohol misuse.
What are the investigations for oesophageal varices?
Gastroscopy + banding,
FBC, U&Es, coagulation, G&S and cross matching
What are the signs and symptoms of bleeding varices?
Haematemesis, melena, haemodynamic instability on the background of liver disease/signs of liver disease
What are the signs of liver disease?
Ascites, spider angioma, caput medusa, jaundice,
What are the contraindications for terlipressin?
Arterial disease, hyponatraemia, myocardial ischaemia, heart failure and prolonged QTC.
What can be used to prevent variceal bleeding?
Propanolol (non-selective beta blocker)
Band ligation
What are the absoloute contraindications for a TIPS proceedure?
Severe pulmonary hypertension,
Severe tricuspid regurgitation,
Congestive heart failure,
Severe liver disease,
Active sepsis,
Polycystic liver
What are the complications of oesophageal varices?
Haemorrhage,
SBP or other infections.
Oesophageal stricture
What drugs can prolong the QTc?
Antipsychotics
Antiarrhythmics - Amiodarone, flecanide,
Tricyclic antidepressants and SSRIs (citalopram, venlafaxine)
Antihistamines - Loratidine
Antibiotics - macrolides, quinolones
Antimalarials - quinine, chloroquine and hydroxychloroquine
Ondansetron,
Methodone.
What is alcoholic ketoacidosis?
Non diabetic ketoacidosis. Alcoholics often in starvation and after alcohol binge body breaks down fat producing ketones
What is the presentation of alcoholic ketoacidosis and treatment?
Presentation - Metabolic acidosis, elevated anion gap, high ketones and normal to low glucose.
Treat - saline and thiamine
