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AIP: Gastrointestinal bleed > Oesophago-gastric varices > Flashcards

Oesophago-gastric varices Flashcards

1
Q

What causes oesophageal varices?

A

arise through portal hypertension, commonly secondary to cirrhosis

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2
Q

Why are oesophageal varices prone to bleeding?

A

tend to be more fragile and dilated, more likely to bleed because of high portal pressures

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3
Q

When should patients with liver cirrhosis be screened for varices?

A

at time of diagnosis and repeated every 2 years

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4
Q

In addition to screening for varices, what other disease should patients with liver cirrhosis undergo regular screening for?

A

hepatocellular carcinoma

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5
Q

What are 7 causes of portal hypertension?

A
  1. Portal vein thrombosis (due to sepsis/procoagulopathy/cirrhosis)
  2. Abdominal trauma including surgery
  3. Drugs
  4. Cirrhosis
  5. Polycystic liver disease
  6. Veno-occlusive disease
  7. Budd-Chiari syndrome
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6
Q

What is the most common cause of portal hypertension worldwide and which regions is it common in?

A

schistosomiasis - infrequent outside endemic areas such as Egypt

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7
Q

What are 6 findings on clinical examination of portal hypertension?

A
  1. Splenomegaly
  2. Caput medusae - collateral vessels on anterior abdominal wall radiating from umbilicus
  3. Venous hum on auscultation - large umbilical collateral vessel with high blood flow aka Cruveilhier-Baumgarten syndrome
  4. Oesophageal/gastric varices
  5. Rectal varices
  6. Fetor hepaticus - musty breath smell due to sulfate in blood from liver disease
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8
Q

What are 7 complications of portal hypertension?

A
  1. Variceal bleeding: oesophageal, gastric, other (rare)
  2. Congestive gastropathy
  3. Hypersplenism
  4. Ascites
  5. Iron deficiency anaemia
  6. Renal failure
  7. Hepatic encephalopathy
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9
Q

What is the pathophysiology of varices?

A

increased portal vascular resistance leads to a gradual reduction in the flow of portal blood to the liver and simultaneously to the development of collateral vessels, allowing portal blood to bypass the liver and enter the systemic circulation directly

more than half of portal blood flow may be shunted to systemic circulation

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10
Q

In what 9 places can porto-systemic shunting occur?

A
  1. distal oesophagus
  2. stomach
  3. retum
  4. anterior abdo wall
  5. renal
  6. lumbar
  7. ovarian
  8. testicular vasculature
  9. (also stomal at ileostomy site)
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11
Q

Why is thrombocytopenia common in association with varices?

A

due to the hypersplenism associated with portal hypertension

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12
Q

What is the most useful investigation to determine whether gastro-oesophageal varices are present?

A

endoscopy

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13
Q

What is a treatment that can be used as primary prevention of variceal bleeding (non-bleeding varices)? 2 options

A
  1. daily beta blockers e.g. propranolol, nadolol or carvedilol, to lower portal pressure
  2. if unable to tolerate or adhere to beta blockers - prophylactic banding
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14
Q

What are 7 aspects of the management of emergency variceal bleeding?

A
  1. IV fluids
  2. Terlipressin
  3. Prophylactic antibiotics e.g. cephalosporin IV
  4. Emergency endoscopy (make NBM)
  5. Variceal band ligation
  6. IV PPI
  7. Phosphate enema and/or lactulose to prevent hepatic encephalopathy
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15
Q

What are the 2 initial options for management of bleeding oesophageal varices on endoscopy?

A
  1. Band ligation
  2. Sclerotherapy
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16
Q

What are 3 types of medical management to give in bleeding oesophageal varices?

A
  1. Terlipressin
  2. IV antibiotics - prophylactic to reduce mortality
  3. IV PPI
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17
Q

What are 3 options if initial endoscopic therapy does not achieve haemostasis in bleeding varices?

A
  1. Further endoscopic therapy
  2. Balloon tamponade
  3. Emergency TIPSS (transhepatic intrajugular portosystemic shunt)
18
Q

If haemostasis is achieved with initial endoscopic therapy for bleeding varices, what are 3 aspects of ongoing management?

A
  1. Continue terlipressin to 72 hours
  2. Introduce beta blockers as secondary prophylaxis e.g. propranolol
  3. Enter patient into endoscopic banding programme to obliterate varices
19
Q

For how long should terlipressin be continued following successful endoscopic therapy for bleeding varices?

A

72 hours

20
Q

How does terlipressin work?

A

synthetic vasopressin analogue that can be given by intermittent injection rather than continuous infusion

reduces portal blood flow and/or intrahepatic resistance and hence brings down portal pressure

21
Q

What dose of terlipressin is given in variceal bleeding?

A

2mg IV QDS until bleeding stops, then 1mg QDS for up to 72h

22
Q

For which patients should terlipressin be used with caution and why?

A

patients with severe ischaemic heart disease or peripheral vascular disease because of the drug’s vasoconstrictor properties

23
Q

What is an alternative to terlipressin that is used in some countries where terlipressin isn’t available?

A

octreotide

24
Q

In what proportion of patients does variceal band ligation and sclerotherapy stop the bleeding?

A

80%

25
Q

What does variceal banding involve?

A
  • varices being sucked into a cap placed on the end of the endoscope, allowing them to be occluded with a tight rubber band
  • occluded varix subsequently sloughs with variceal obliteration
  • banding is repeated every 2–4 weeks until all varices are obliterated.
  • regular follow-up endoscopy is required to identify and treat any recurrence of varices
26
Q

Over what time period should variceal band ligation be performed/ repeated?

A
  • banding is repeated every 2–4 weeks until all varices are obliterated.
  • regular follow-up endoscopy is required to identify and treat any recurrence of varices
27
Q

Why is band ligation preferred to sclerotherapy?

A

associated with fewer side effects e.g. lower risk of oesophageal perforation or stricturing

28
Q

How does sclerotherapy work to treat variceal bleeding?

A

varices injected with scerlsoing agent

29
Q

For which type of varices is band ligation best?

A

oesophageal varices

30
Q

What type of therapy is best for gastric fundal varices?

A

injection of agents such as thrombin or cyanoacrylate glue directly into varix to induce thrombosis

31
Q

What is a possible complication of cyanoacrylate injection treatment for gastric varices?

A

glue embolism to the lungs

32
Q

Why should the patient have an endotracheal tube in situ during endoscopy for bleeding varices?

A

protection of airway aids endoscopist, facilitating therapy and significantly reducign risk of pulmonary aspiration

33
Q

What does balloon tamponade for bleeding varices involve?

A

Sengstaken-Blakemore tube, two balloons that exert pressure in fundus of stomach and lower oesophagus, respectively

gastric balloon inflated initially, then oesophageal too if continued bleeding

puts pressure on varices to stop bleeding

34
Q

How effective is balloon tamponade at controlling varices?

A

will almost always stop oesophageal and gastric fundal variceal bleeding, but is only a bridge to more definitive therapy

35
Q

What must be done to prevent necrosis from balloon tamponade to the gastric/oesophageal mucosa?

A

deflate every 3 hours for 10 min

36
Q

What does TIPSS involve?

A

transhepatic intrajugular portosystemic shunting: stent placed between portal vein and hepatic vein within liver to provide portosystemic shunt and reduce portal pressure

carried out under radiological control via internal jugular vein

37
Q

What may occur following TIPSS and how is this managed?

A

hepatic encephalopathy - reduce the shunt diameter

38
Q

What are the outcomes of variceal bleeds like following TIPSS?

A

although TIPSS associated with less rebleeding than endoscopic therapy, survival not improved

39
Q

What are 2 types of surgery that may be required if other methods have not worked ot manage variceal bleeding?

A
  1. Portosystemic shunt surgery
  2. Oesophageal transection
40
Q

What secondary prevention of variceal bleeding is provided after a bleed? 2 things

A
  1. beta blockers
  2. oesophageal banding programme with repeated sessions of therapy at 12-24 week intervals until varices obliterated

AIP: Gastrointestinal bleed (11 decks)

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