Oesophageal Varices

Question 1

Blood supply to the liver

Answer 1

The portal vein comes from the superior mesenteric vein and the splenic vein and delivers blood to the liver.

Question 2

What does liver cirrhosis result in?

Answer 2

Liver cirrhosis increases the resistance of blood flow in the liver. As a result, there is increased back-pressure into the portal system. This is called “portal hypertension”.

Question 3

what does portal hypertension result in?

Answer 3

This back-pressure causes the vessels at the sites where the portal system anastomoses with the systemic venous system to become swollen and tortuous. These swollen, tortuous vessels are called varices.

Question 4

Where do varices occur at?

Answer 4

Gastro oesophageal junction
Ileocaecal junction
Rectum
Anterior abdominal wall via the umbilical vein (caput medusae)

Question 5

Presentation of varices

Answer 5

Varices do not cause symptoms or problems until they start bleeding. Due to the high blood flow through varices, once they start bleeding patients can exsanguinate (bleed out) very quickly.

Question 6

Treatment of stable varices

Answer 6

Propranolol reduces portal hypertension by acting as a non-selective beta blocker
Elastic band ligation of varices
Injection of sclerosant (less effective than band ligation)

Question 7

What is TIPS?

Answer 7

Transjugular Intra-hepatic Portosystemic Shunt (TIPS) is a technique where an interventional radiologist inserts a wire under xray guidance into the jugular vein, down the vena cava and into the liver via the hepatic vein. They then make a connection through the liver tissue between the hepatic vein and the portal vein and put a stent in place. This allows blood to flow directly from the portal vein to the hepatic vein and relieves the pressure in the portal system and varices. This is used if medical and endoscopic treatment of varices fail or if there are bleeding varices that cannot be controlled in other ways.

Question 8

Treating Bleeding Oesophageal Varices (RESUS)

Answer 8

Vasopressin analogues (i.e. terlipressin) cause vasoconstriction and slow bleeding in varices
Correct any coagulopathy with vitamin K and fresh frozen plasma (which is full of clotting factors)
Giving prophylactic broad spectrum antibiotics has been shown to reduce mortality
Consider intubation and intensive care as they can bleed very quickly and become life threateningly unwell

Question 9

Treating oesophageal varices (ENDO)

Answer 9

Injection of sclerosant into the varices can be used to cause “inflammatory obliteration” of the vessel
Elastic band ligation of varices

Question 10

If endo fails?

Answer 10

Sengstaken-Blakemore Tube is an inflatable tube inserted into the oesophagus to tamponade the bleeding varices. This is used when endoscopy fails.