From the Guidelines
Esophageal varices are primarily caused by portal hypertension, which is abnormally high blood pressure in the portal vein system, most commonly resulting from cirrhosis of the liver. This condition occurs when scarring blocks blood flow through the liver, causing blood to back up into smaller vessels, including those in the esophagus, leading to swelling and fragility. The development of varices is associated with the rise in portal pressure, which leads to the formation of collateral circulation, allowing portal blood to be diverted into the systemic circulation 1. The two factors that appear to determine the development of varices are continued hepatic injury and the degree of portosystemic shunting 1.
Causes of Esophageal Varices
- Cirrhosis of the liver, often due to alcoholic liver disease, hepatitis B or C, or fatty liver disease
- Blood clots in the portal vein (portal vein thrombosis)
- Schistosomiasis (a parasitic infection)
- Budd-Chiari syndrome (hepatic vein obstruction)
Importance of Early Detection
Early detection through endoscopy is crucial for patients with liver disease, as bleeding from esophageal varices has a high mortality rate if not promptly treated 1. The frequency of surveillance endoscopies in patients with no or small varices depends on their natural history, with recommendations for repeat endoscopy at 2-3 year intervals for patients with compensated cirrhosis and no varices, and 1-2 year intervals for those with small varices 1.
Management and Treatment
Treatment with beta-blockers is widely recommended because these drugs lower the portal pressure and prevent life-threatening bleedings 1. Transjugular intrahepatic portal systemic shunts (TIPS) creation is a well-established treatment for esophageal variceal hemorrhage resulting from portal hypertension, although it comes with a significant incidence of resulting hepatic encephalopathy and risk of hepatic decompensation 1.
From the Research
Causes of Esophageal Varices
Esophageal varices are a major complication of portal hypertension, which is often caused by liver cirrhosis 2. The development of esophageal varices is associated with an elevated portal pressure, measured by hepatic venous pressure gradient, exceeding 10 mm Hg 3.
Risk Factors
Several risk factors contribute to the development of variceal hemorrhage, including:
- Variceal size
- Endoscopic features on the variceal wall, such as red wales
- Child-Pugh class 3
- Presence of very large varices with red spots 4
Pathophysiology
The pathophysiology of esophageal varices involves the expansion of the submucosal venous plexus in the lower esophagus due to permanently increased portal venous pressure, usually caused by infectious or ethyltoxic liver cirrhosis 5. Alcoholic cirrhosis is a common cause of portal hypertension, leading to the development of varices 6.
Underlying Causes
The underlying causes of portal hypertension, such as:
- Alcoholic cirrhosis
- Infectious liver cirrhosis
- Other liver diseases contribute to the development of esophageal varices 2, 6.
Key Points
- Esophageal varices are a complication of portal hypertension
- Elevated portal pressure is a key factor in the development of variceal hemorrhage
- Various risk factors contribute to the development of variceal hemorrhage
- The pathophysiology of esophageal varices involves the expansion of the submucosal venous plexus
- Underlying causes of portal hypertension, such as liver cirrhosis, contribute to the development of esophageal varices 2, 3, 4, 5, 6