Oesophageal Varices

Introduction

Oesophageal varices are enlarged submucosal veins that can develop in patients with portal hypertension.
They can cause life-threatening oesophageal bleeding presenting in the form of massive hematemesis.

Liver cirrhosis makes it harder for blood to move through the portal vein. Remember this is the vein that carries blood from the gastrointestinal tract to the liver.

Cirrhosis does this by causing structural narrowing of the vessel and by contracting portal venules. This results in the backup of blood in the portal vein and its branches. This is also known as portal hypertension.

As this extra pressure wants to escape, our body forms porto-systemic shunts. These help by returning blood back into the circulation and releasing pressure. One escape route is through the collateral oesophageal veins which blow up and turn into varices.

Think about treatment options in terms of 4 drugs and 4 interventions.

The medications can be remembered like the coagulation test APTT and the interventions rhyme with this: E triple T.

The drugs include prophylactic antibiotics, as this reduced risk of recurrent bleeding and mortality.

Proton pump inhibitors, especially if a bleeding peptic ulcer is a potential differential

Terlipressin or octreotide, which reduces portal pressure and splanchnic blood flow.

And finally, thiamine because there’s probably a high likelihood the patient is at risk of Wernicke Korsakoff syndrome, especially if its from alcoholic liver disease.

The main interventions include endoscopy, to find and stop the bleeding, a balloon tamponade if this fails, an emergency TIPS procedure which stands for a transjugular intrahepatic portosystemic shunt, which is basically a temporary way for the portal vein to bypass the liver in order to reduce backed up pressure, and finally, a liver transplant after doing the tips at some point down the line.

The presentation of varices is most often asymptomatic - until they rupture.

Rupturing causes life-threatening catastrophic upper gastrointestinal bleeding in the form of haematemesis (or vomiting blood).

Everything can be remembered in fours for varices - haematemesis has a really specific set of 4 differentials:

Peptic ulcers

Mallory Weiss tears

Oesophagitis

Non-GI bleeds (for example a posterior nose bleed that drips into your stomach).

There are 4 key signs that might indicate someone has asymptomatic varies. Think the ABCDs of liver cirrhosis:

Ascites, jaundice causing bumblebee coloured skin, caput medusae, and a patient with drinking issues.

4 mnemonics of 4.

There are 4 differentials of hematemesis other than varies: peptic ulcers, Mallory Weiss tears, Oesophagitis, and non-GI bleeds

There are there are the 4 signs of liver cirrhosis which could indicate varices. ABC and D which stands for ascites, bumblebee coloured skin, caput medusae, and a history of drinking

There are 4 drugs to treat varices: APTT which stands for antibiotics,

PPI, terlipressin, and thiamine.

There are 4 interventions to consider: E triple T which stands for endoscopy, tamponade, TIPS and Transplant.