ESOPHAGEAL VARICEAL Mamata Gurung

Pariksha Gurung
BLEEDING Riya Agrawal
PORTAL HYPERTENSION
Sustained elevation of portal venous pressure >10 mmHg.
Normal – (5–10) mmHg.
>12 mmHg – risk for variceal bleeding increases (often ~ 20
mmHg in bleeding esophageal varices).
SITES OF
PORTO-
SYSTEMIC
ANASTOMOSIS
ESOPHAGEAL VARICES
May be asymptomatic.
Varices begin to bleed when portal pressure exceeds 12 mmHg.
 When present with severe hematemesis or recurrent bleeding,
shows features of shock.
 Mortality in bleeding varices is 25–30%.
TYPES OF VARICES
1. Oesophageal
• 80%
• Lower 1/3rd of oesophagus
• Graded as I, II, III, IV (based on gastroscopic findings)
2. Gastric
• 20%
• Fundal or upper part of stomach
INVESTIGATIONS
Haemoglobin
Liver function tests,
Blood grouping and crossmatching,
Prothrombin time, platelet count,
Blood urea, serum creatinine.
 Endoscopy
ENDOSCOPIC FINDING
Signs of impending/predicting ruptures;
Cherry red spots
Red wale marks
Blue varices
Varices upon varices
Erosions
Ulcerations
Endoscopy —Grading of varices:
I – Minimal varices without luminal prolapse, visible on Valsalva,
non-tortuous
II – Moderate varices, with luminal prolapse and with minimal
obscuring of O-G junction — occupy <25% of lumen, non-
protuding
III – Large varices, with luminal prolapse and with moderate
obscuring of O-G junction — occupy 25–50% of lumen, protruding
but normal mucosa in between
IV – Very large varices, with luminal prolapse and with complete
obscuring of O-G junction — obliterate lumen and no normal
mucosa in between
MANAGEMENT OF
BLEEDING ESOPHAGEAL
VARICES
General resuscitation
Volume replace using crystalloids (avoid sudden overload- ascites, pulmonary
edema, hyponatremia
Blood transfusion
Correction of coagulopathy
• By administration of fresh frozen plasma
• Vitamin K 10 mg IV and tranexamic acid 1 gm IV
 Thrombocytopenia (50 x 10^9 /L) – treated with splanchnic vasoconstrictor
(terlipression).
Prophylactic antibiotics
PHARMACOTHERAPY
Injection vasopressin 0.4 units for 24 hours- constricts splanchnic vessels and control
bleeding
Octreotide- agent of choice in acute bleed, 100-200ug iv bolus followed by infusion
50ug/hour for 5 days
Propanolol- later for prophylaxis to prevent bleeding
ENDOSCOPIC THERAPY
(Standardtreatment for acute variceal bleeding –
vasoconstrictor combined with endoscopic therapy)
 Endoscopic variceal banding
Gold standard and ideal
Banded varices thrombose and slough off
Technically easier, less chance of rebleeding, less chance of
perforation or stricture
ENDOSCOPIC THERAPY
Endoscopic variceal sclerotherapy
Sclerosant- ethanolamine oleate, polidocanol, sodium tetradecyl
sulphate
Intravaiceal or paravariceal injections of sclerosant is given
Rate of rebleeding is higher
Complication- perforation, massive bleed, retrosternal pain
OESOPHAGEAL
BALLOON TAMPONADE
- Balloon is inflated with 300 ml of
air and retracted to gastric fundus
where varices at esophago-gastric
junction are tamponaded by
subsequent inflation of
esophageal balloon to pressure of
40 mmHg
- Position of tube – confirmed
radiologically
- Balloon temporarily deflated after
12 hours to prevent pressure
necrosis.
TIPSS (TRANSJUGULAR INTRAHEPATIC
PORTOSYSTEMIC STENT SHUNTS)
Non-surgical, inerventional
radiological method
Stent is placed between
hepatic venule and portal
venule through a guidewire
Complication-
encephalopathy, bleeding,
bile leak, stenosis
Acts as a bridge for future
transplantation
Management of recurrent variceal bleeds secondary to
splenic or portal vein thrombosis- Splenectomy and gastro-
oesophageal devascularisation
Surgery
 Portosystemic shunts
 Oesophageal transactions
 Splenectomy and gastric devascularization
Orthotropic liver transplantation
REFERENCES
•Bailey and love’s Short practice of surgery, 27th edition
•SRB’s manual of surgery, 5th edition
THANK YOU