Oesophageal Varices

Definition and Pathogenesis

• Robbins Basic Pathology, p. 546 - "The increased blood flow enlarges and dilates subepithelial and submucosal venous plexi within the distal esophagus."
• Grainger & Allison's Diagnostic Radiology - uphill varices appear as serpentine filling defects at fluoroscopy or CT.

Aetiology

Epidemiology and Natural History

• Varices are present in ~40% of all cirrhotic patients and up to 60% of cirrhotics with ascites.
• In cirrhotics without varices at initial endoscopy, new varices develop at ~5% per year.
• Small varices progress to large at ~10% per year, related to degree of liver dysfunction.
• Up to 25% of patients with newly diagnosed varices will bleed within 2 years.
• Risk of bleeding by 2 years: 7% for varices <5 mm; 30% for varices >5 mm.
• The hepatic venous pressure gradient (HVPG) is the most important predictor: bleeding is virtually absent when HVPG <12 mmHg.

• ~80-90% of episodes are controlled with initial treatment.
• ~1/3 of patients who stop bleeding will rebleed within 6 weeks.
• Mortality: 5-8% at 1 week, ~20% at 6 weeks.
• Among survivors, up to 60% will have additional haemorrhage episodes, each potentially fatal.

Classification

• Grade I - Small, straight, collapse with insufflation
• Grade II - Enlarged, tortuous, do not collapse fully
• Grade III - Large, coil-shaped, occupy >1/3 of lumen

• Red wale marks
• Cherry-red spots
• Hematocystic spots
• White fibrin plugs or blood clots over a varix

• GOV1 - Extending 2-5 cm below gastro-oesophageal junction, continuous with oesophageal varices (most common, 70%)
• GOV2 - In cardia/fundus, continuous with oesophageal varices
• IGV1 - Isolated fundal varices (absent oesophageal varices; often splenic vein thrombosis)
• IGV2 - Isolated varices in body, antrum, or pylorus

Clinical Features

• Often asymptomatic until rupture
• Rupture presents as sudden, large-volume haematemesis - a life-threatening emergency
• Associated features of chronic liver disease: jaundice, spider naevi, palmar erythema, caput medusae, splenomegaly, ascites, hepatic encephalopathy
• Variceal bleeding accounts for 59% of upper GI bleeds in cirrhotic patients; in-hospital mortality for GI bleeding in cirrhotic patients is essentially double that of non-cirrhotics

Diagnosis

• Diagnosis of active variceal bleed requires: active bleeding from varices OR signs of recent haemorrhage (white fibrin plug, red clot) OR risk stigmata (cherry-red spot, red wale) in the absence of another lesion

• HVPG >12 mmHg required for varices to form
• HVPG >20 mmHg: high risk of treatment failure and rebleeding
• Target of pharmacotherapy: reduce HVPG to <12 mmHg or by ≥20%

• Doppler ultrasound - assess portal vein patency, direction of flow, splenomegaly
• CT with IV contrast - demonstrates varices, shunts, portal vein thrombosis, cirrhotic liver morphology
• Barium swallow - shows serpentine filling defects (largely superseded by endoscopy)

Management

1. Primary Prophylaxis (Prevention before first bleed)

• Propranolol (long-acting): start 60 mg once daily at night; titrate to target HR 25% below baseline or 55-60 bpm; max 160 mg/day
• Nadolol: start 20 mg once daily; similar titration
• Carvedilol: start 6.25 mg daily; max 25 mg daily (used in hypertension or CAD)
• Target: systolic BP >90 mmHg at all times
• Absolute risk reduction ~10%; NNT to prevent 1 bleed = ~10
• Mortality reduction: 28.4% → 23.9%
• ~15% need to discontinue due to side effects
• Treatment should be continued indefinitely

• Used when contraindication/intolerance to beta-blockers, target HVPG not reached, or patient preference
• Banding sessions every 2-4 weeks until variceal obliteration

2. Control of Acute Variceal Bleeding

• Two large-bore IV lines
• Restrictive transfusion strategy: transfuse RBCs only when Hgb drops below 7 g/dL (improved survival vs. <9 g/dL threshold in Child-Pugh A/B)
• Protect airway - endotracheal intubation for active bleeding
• Correct coagulopathy

• Norfloxacin 400 mg orally twice daily × 7 days (preferred)
• If unavailable: ciprofloxacin 500 mg orally bd × 7 days
• IV ciprofloxacin 400 mg q12h or ceftriaxone 1 g q24h × 7 days if oral intake impossible
• Failure to control infection → significantly increased mortality and rebleeding risk

• Continue for up to 5 days to prevent early rebleeding
• Pharmacological + endoscopic combination is superior to pharmacological alone

• Performed as soon as patient is haemodynamically stabilised
• EVL is the preferred method - bleeding controlled in 85-90% with combined pharmacological + endoscopic treatment
• Ligation begins at/below bleeding site, then other large varices banded
• If active bleeding obscures view: circumferential bands at gastro-oesophageal junction

• TIPS (Transjugular Intrahepatic Portosystemic Shunt) - salvage therapy if 2 endoscopic sessions within 24 hours fail
• Early TIPS (within 72 hours): indicated in high-risk patients: Child-Pugh class C, Child-Pugh class B with active bleeding, or MELD >18 requiring >4 units RBCs - associated with reduced mortality and treatment failure
• Oesophageal stents - to stabilise until definitive treatment (preferred over balloon tamponade when available)
• Balloon tamponade (Sengstaken-Blakemore or Minnesota tube) - only when oesophageal stents unavailable; temporising measure
• Surgical portosystemic shunts - largely abandoned due to high mortality

3. Prevention of Rebleeding (Secondary Prophylaxis)

• Combined therapy reduces rebleeding risk in Child-Pugh A patients compared to NSBB alone
• Combination + beta-blocker reduces mortality in Child-Pugh B and C patients compared to EVL alone
• EVL performed every 2-4 weeks until variceal obliteration, then surveillance EGD at 3 months, then every 6-12 months

• Patient adherent to therapy → TIPS (or distal splenorenal shunt in Child-Pugh A; equally effective)
• Patient non-adherent → add missing component (EVL or beta-blocker)
• Liver transplantation - definitive treatment for end-stage liver disease

Summary of Key Management Principles

Pathology (Morphology)

• Sleisenger & Fordtran's Gastrointestinal and Liver Disease, Chapter 92 - detailed natural history, pharmacology, and management algorithms
• Bailey & Love's Short Practice of Surgery, 28th Ed., Chapters 66 & 69 - surgical management
• Robbins & Kumar Basic Pathology - pathogenesis and morphology
• Grainger & Allison's Diagnostic Radiology - imaging features
• Tintinalli's Emergency Medicine - acute bleeding in the ED context