Oesophageal varices

Question 1

Describe gastro-oesophageal varices?

Answer 1

• Submucosal venous dilatation
  
  • Secondary to elevated portal pressures
• Suspect if alcohol history

Question 2

What are the different categories of portal hypertension?

Answer 2

• Pre-hepatic
• Intra-hepatic
• Post-hepatic

Question 3

Pre-hepatic causes of portal hypertension?

Answer 3

Thrombosis (portal or splenic vein)

Question 4

Intra-hepatic causes of portal hypertension?

Answer 4

• Cirrhosis
• Schistosomiasis
• Myeloproliferative diseases

Question 5

Post-hepatic causes of portal hypertension?

Answer 5

• Budd-chiari syndrome
• Right heart failure
• Constrictive pericarditis

Question 6

Risk factors for variceal bleeds?

Answer 6

• Raised portal pressure
• Variceal size
• Advanced liver disease

Question 7

Describe the immediate management of GO varices?

Answer 7

• Endoscopic banding (oesophageal)
• Scleropathy (gastric)

Question 8

Prophylaxis of GO varices?

Answer 8

• Beta-blocker (propanolol)
• Repeat endoscopic banding
• Resistant varices: TIPS
  
  • Transjugular intrahepatic porto-systemic shunt

Question 9

Draw the full treatment pathway for variceal bleeding

Answer 9

Question 10

Describe the special management of patients with cirrhosis and upper GI bleeding?

Answer 10

• Should be given prophylactic broad spectrum antibiotics
  
  • eg IV Cephalosporin

Question 11

Describe the use of Terlipressin in variceal bleeding?

Answer 11

• Synethtic vasopressin analogue
• Aims to reduce portal venous pressure
• Reduces portal blood flow and hepatic resistance
• (Octreotide can be used as an alternative if Terlipressin unavailable)

Question 12

Describe variceal ligation (banding)?

Answer 12

• Ligation involes varices being suck into cap on endoscope, allowing them to be occluded with a tight rubber band
  
  • Repeated every 2 weeks until all varices are obliterated
• Prophylactic PPIs to reduce risk of bleeding banding-induced ulceration

Question 13

Describe the use of variceal scleropathy?

Answer 13

• Gastric fundal varices
• Thrombin/cryoacrylate injected directly into varix to induce thrombus
• Cryoacrylate can cause glue embolism to the lungs

Question 14

Describe the use of balloon tamponade?

Answer 14

• Employs a Sengstaken-blakemore tube
• Two balloons attached which compress lower oesophagus and the fundus .
• Endotracheal intubation prior to tube insertion reduces risk of pulmonary aspiration

Question 15

Describe TIPSS?

Answer 15

• Stent placed between the portal vein and heptatic vein in the liver to provide a portosystemic shunt
  
  • Reduces portal pressure
• Radiological pressure, entry through the internal jugular vein
• Hepatic encephalopthy may occur following TIPSS
  
  • Treatment by reduced shunt diameter