From the Guidelines
Esophageal varices are abnormally enlarged veins in the lower esophagus that develop when blood flow to the liver is blocked, most commonly due to cirrhosis, and are managed with a combination of endoscopic variceal ligation (EVL) and non-selective beta-blockers (NSBBs) as the primary treatment for esophageal variceal bleeding, as recommended by the KASL clinical practice guidelines 1.
Anatomical Relationship to Splanchnic Circulation and Portal Vein
Esophageal varices are anatomically related to the splanchnic circulation and portal vein, as they develop due to increased pressure in the portal vein, which causes blood to be diverted into smaller veins that swell and become varices. The splanchnic circulation, which includes the blood flow to the stomach, small intestine, and spleen, plays a crucial role in the development of esophageal varices.
Management of Esophageal Varices
The management of esophageal varices includes both prevention and treatment of bleeding episodes. For primary prevention in patients with medium to large varices, non-selective beta-blockers like propranolol (20-40mg twice daily) or nadolol (20-40mg daily) are recommended to reduce portal pressure. Endoscopic band ligation may be used for patients who cannot tolerate beta-blockers. Acute variceal bleeding is a medical emergency requiring immediate intervention with blood product resuscitation, antibiotics, and vasoactive medications like octreotide or terlipressin. Urgent endoscopic band ligation or sclerotherapy should be performed within 12 hours.
Treatment Options
- Combination therapy with EVL and NSBBs is the most effective treatment for esophageal variceal bleeding, as shown in a study by Lo et al 1.
- TIPS placement may be considered as a rescue therapy in cases where primary treatment fails, as recommended by the KASL clinical practice guidelines 1.
- Liver transplantation may be considered in patients with recurrent variceal rebleeding, as recommended by the KASL clinical practice guidelines 1.
Key Points
- Esophageal varices are a serious complication of liver disease and require prompt treatment to prevent bleeding and improve outcomes.
- Combination therapy with EVL and NSBBs is the most effective treatment for esophageal variceal bleeding.
- TIPS placement and liver transplantation may be considered in refractory cases or recurrent variceal rebleeding.
From the Research
Definition and Pathophysiology of Esophageal Varices
- Esophageal varices are dilated submucosal veins in the distal esophagus that are prone to bleeding, often associated with portal hypertension and chronic liver disease 2, 3.
- Portal hypertension is characterized by increased pressure in the portal venous system, which can lead to the development of portosystemic collaterals, including esophageal varices 3.
- The pathophysiology of esophageal varices involves increased vascular resistance in the portal circulation, leading to increased portal blood flow and pressure, which can cause varices to form and bleed 2.
Anatomical Relationship to Splanchnic Circulation and Portal Vein
- The splanchnic circulation, which includes the portal vein, plays a crucial role in the development of esophageal varices, as increased portal blood flow and pressure can lead to variceal formation 2, 4.
- The portal vein is a key structure in the splanchnic circulation, and its increased pressure and flow can contribute to the development of esophageal varices 4, 5.
- Portosystemic collaterals, including esophageal varices, can develop as a result of portal hypertension, allowing blood to flow from the portal circulation to the systemic circulation 2, 3.
Management of Esophageal Varices
- Management of esophageal varices involves a comprehensive approach, including prevention, primary prophylaxis, and treatment of acute bleeding episodes 6.
- Non-selective beta-blockers, such as propranolol, can be used as primary prophylaxis to reduce portal pressure and prevent variceal bleeding 4, 6.
- Endoscopic variceal ligation (EVL) and sclerotherapy are effective treatments for esophageal varices, and can be used as primary or secondary prophylaxis to prevent bleeding episodes 2, 6.
- Transjugular intrahepatic portosystemic shunt (TIPS) may be considered in cases where bleeding is refractory to endoscopic treatment, to effectively reduce portal pressure and prevent rebleeding 3, 6.