Esophageal varices 702254 220791087 2008-06-21T16:23:54Z DOI bot 6652755 Citation maintenance. You can [[WP:DOI|use this bot]] yourself! Please [[User:DOI_bot/bugs|report any bugs]]. {{Infobox_Disease | Name = Esophageal varices | Image = Esophageal varices - wale.jpg| Caption = Gastroscopy image of esophageal varices with prominent red wale spots | DiseasesDB = 9177 | ICD10 = {{ICD10|I|85||i|80}} | ICD9 = {{ICD9|456.0}}-456.2 | ICDO = | OMIM = | MedlinePlus = 000268 | eMedicineSubj = med | eMedicineTopic = 745 | eMedicine_mult = {{eMedicine2|radio|269}} | MeshID = D004932 | }} In [[medicine]] ([[gastroenterology]]), '''esophageal varices''' are extremely [[dilation|dilated]] sub-mucosal [[vein]]s in the [[esophagus]]. They are most often a consequence of [[portal hypertension]], such as may be seen with [[cirrhosis]]; patients with esophageal varices have a strong tendency to develop [[bleeding]]. Esophageal varices are diagnosed with [[endoscopy]].<ref name=Biecker_2005>{{cite journal |author=Biecker E, Schepke M, Sauerbruch T |title=The role of endoscopy in portal hypertension |journal=Dig Dis |volume=23 |issue=1 |pages=11–7 |year=2005 |pmid=15920321 |doi=10.1159/000084721}}</ref> ==Pathogenesis== The majority of blood from the [[esophagus]] is drained away via the [[esophageal veins]], which drain deoxygenated blood from the esophagus to the [[azygos vein]] which in turn, directly drains into the [[superior vena cava]]. These veins have no part in the development of esophageal varices. The remaining blood from the esophagus is drained away via the superficial veins lining the esophagus interior, which drain into the [[coronary vein]] ([[left gastric vein]]) which in turn, drains directly into the [[portal vein]]. These superficial veins lining the esophagus interior (normally only approximately 1mm in diameter) become distended up to 1-2 cm in diameter in association with portal hypertension. Normal portal pressure is approximately 9 mmHg compared to an inferior vena cava pressure of 2-6 mmHg. This creates a normal pressure gradient of 3-7 mmHg. If the portal pressure rises above 12mmHg, this gradient rises to 7-10 mmHg.<ref name=Arguedas_2003>{{cite journal |author=Arguedas M |title=The critically ill liver patient: the variceal bleeder |journal=Semin Gastrointest Dis |volume=14 |issue=1 |pages=34–8 |year=2003 |pmid=12610853}}</ref> A gradient greater than 10 mmHg is considered [[portal hypertension]]. At gradients greater than 10 mmHg, blood flow though the hepatic portal system is redirected from the liver into areas with lower venous pressures. This means that collateral circulation develops in the lower [[esophagus]], abdominal wall, [[stomach]] and [[rectum]]. The small blood vessels in these areas become distended, becoming more thin-walled, and appear as varicosities. In addition, these vessels are poorly supported by other structures, as they are not designed for high pressures. In situations where portal pressures increase, such as with [[cirrhosis]], there is dilation of veins in the [[anastomosis]], leading to esophageal varices. Varices can also form in other areas of the body, including the [[stomach]] ('''[[gastric varices]]'''), [[duodenum]] ('''[[intestinal varices|duodenal varices]]'''), and [[rectum]] ('''[[rectal varices]]'''). Treatment of these types of varices may differ. ==Treatment and the role of endoscopy== [[Image:esophageal varices - post banding.jpg|thumb|right|250px|Esophageal varices seven days post [[banding (medical)|banding]], showing ulceration at the site of banding.]] In emergency situations, the care is directed at stopping blood loss, maintaining plasma volume, correcting disorders in coagulation induced by cirrhosis, and appropriate use of [[antibiotics]] (as infection is either concomitant, or a precipitant). Therapeutic [[endoscopy]] is considered the mainstay of urgent treatment. Two main therapeutic approaches exist: * Variceal ligation, or [[banding (medical)|banding]] * [[sclerotherapy]] In cases of refractory bleeding, [[balloon tamponade]] may be necessary, usually as a bridge to further [[endoscopy]] or treatment of the underlying cause of bleeding (usually portal hypertension). Methods of treating the portal hypertension include: [[transjugular intrahepatic portosystemic shunt]] (TIPS), or a [[distal splenorenal shunt procedure]] or a [[liver transplantation]]. Nutritional supplementation is not necessary if the patient is not eating for four days or less.<ref name="pmid9073135">{{cite journal |author=de Lédinghen V, Beau P, Mannant PR, ''et al'' |title=Early feeding or enteral nutrition in patients with cirrhosis after bleeding from esophageal varices? A randomized controlled study |journal=Dig. Dis. Sci. |volume=42 |issue=3 |pages=536–41 |year=1997 |pmid=9073135 |doi=}}</ref> ==Prevention== Ideally, patients with known varices should receive treatment to reduce their risk of bleeding.<ref name=Lebrec_1981>{{cite journal | author=Lebrec D, Poynard T, Hillon P, Benhamou J-P | title=Propranolol for prevention of recurrent gastrointestinal bleeding in patients with cirrhosis: a controlled study | journal=N Engl J Med | year=1981 | volume=305 | issue= | pages=1371&ndash;1374 | url= | pmid=7029276}}</ref> The non-selective [[beta-blocker|β-blocker]]s (e.g., [[propranolol]], [[timolol]] or [[nadolol]]) and nitrates have been evaluated for secondary prophylaxis. The effectiveness of this treatment has been shown by a number of different studies.<ref name=Talwalkar_2004>{{cite journal | author=Talwalkar JA, Kamath PS | title=An evidence-based medicine approach to beta-blocker therapy in patients with cirrhosis | journal=Am J Med | year=2004 | volume=116 | issue= | pages=759&ndash;766 | url= | pmid=15144913 | doi=10.1016/j.amjmed.2004.03.006}}</ref> Unfortunately, non-selective [[beta-blocker|β-blocker]]s do not prevent the ''formation'' of esophageal varices.<ref name=Groszmann _2005>{{cite journal | author=Groszmann RJ, Garcia-Tsao G, Bosch J, ''et al.'' | title=Beta-Blockers to Prevent Gastroesophageal Varices in Patients with Cirrhosis | journal=N Engl J Med | year=2005 | volume=353 | issue=21 | pages=2254&ndash;2261 | url= | pmid=16306522 | doi=10.1056/NEJMoa044456}}</ref> ==See also== *[[Portal hypertensive gastropathy]] ==References== <!-- --------------------------------------------------------------- See http://en.wikipedia.org/wiki/Wikipedia:Footnotes for a discussion of different citation methods and how to generate footnotes using the <ref> & </ref> tags and the {{Reflist}} template -------------------------------------------------------------------- --> {{Reflist|2}} ==See also== * [[gastric varices]] * [[intestinal varices]] * [[esophagitis]] * [[Mallory-Weiss syndrome]] * [[peptic ulcer]] ==External links== *[http://www.worldgastroenterology.org/18_treatment_e_varices_en.pdf.html Treatment of Esophageal Varices] - World Gastroenterology Organisation (WGO) {{Gastroenterology}} {{Vascular diseases}} [[Category:Gastroenterology]] [[de:Ösophagusvarizen]] [[nl:oesofagusvarices]] [[ja:食道静脈瘤]] [[pt:Varizes esofágicas]]