Oesophageal varices

Oesophageal varicies classification

• Low risk varices

  • Small, minimally elevated with normal mucosa

• High risk

  • Small with red wale markings
  • Medium (<1/3)
  • Large (>1/3)

• Grade

Primary prevention of variceal hemorrhage

• Screening
  • Indication
    • All patients with decompensated сirrhоsis
    • Patients with compensated сirrhοsiѕ and either liver stiffness measurement (LЅМ) >20 kPa by transient elastography or platelet count <150,000/microL
• Findings
  • Low risk varices
    • Screening in 1-2 years
  • High risk
    • NSBB
    • In patients unable to take beta-blockers:
      • Variceal banding
      • This should be done every 2-4 weeks until eradication. After eradication an OGD should be performed every 3-6 months for the first year.  Followed by screening every 2-3 years.

Acute management of variceal bleeding

Pharmacological treatments

• Vasoactive medications (acute variceal hemorrhage)
  • Cause splanchnic vasoconstriction
    • Terlipressin (synthetic analogue of vasopressin)
      • Preferred as has been shown to reduce mortality
    • Somatostatin and Octreotide (somatostatin analog)
• Antibiotics (acute bleed)
  • Gram -ve cover to reduce bacterial infections and decreased early re-bleeding
• PPI not indicated unless associated peptic ulcer disease

Endoscopy

• Can be used as primary prophylaxis if contraindication to beta blockers
• For oesophageal varices, endoscopic band ligation better than sclerotherapy (which is associated with higher rates of re-bleeding, mortality and stricture)
• For gastric varices, sclerotherapy with tissue adhesives such as cyanoacrylate more effective and safer than EBL

Balloon tamponade

• Temporary measure
• Intubate first
• Sengstaken-Blakemore tube
  • Gastric balloon is inflated in the stomach (e.g. with 30 mL of water) and placed on gentle traction against the gastro-oesophageal junction
  • Inflation of the oesophageal balloon should be delayed and only undertaken if bleeding persists as there is an increased risk of necrosis at the gastro-oesophageal junction
  • Oesophageal balloon must be deflated every 12 hours to prevent necrosis, and for similar reasons the gastric balloon should not be inflated for more than 48 hours
• Complications – aspiration pneumonia, oesophageal rupture, asphyxia from balloon migration, oesophageal ulcers, pressure necrosis (tongue or lips), arrhythmia and chest pain
• Self-expandable metal stent may be a better option

TIPSS (Transjugular intrahepatic portosystemic shunt)

• IR guided needle from hepatic vein to intrahepatic branch of portal vein maintained by a stent
• Indications (for various complications of portal hypertension):
  • Refractory ascites
  • Hepatic hydrothorax (pleural effusion)
  • Portal hypertensive gastropathy
  • Hepatorenal syndrome
  • Rescue therapy for treating active variceal bleeding (success rate 95%, rebleeding rate 18%)
• Absolute contraindications:
  • Primary prevention of variceal bleeding
  • Right heart:
    • Severe heart failure
    • Tricuspid regurgitation
    • Severe pulmonary hypertension
  • Intrahepatic:
    • Multiple hepatic cysts
    • Unrelieved biliary obstruction
    • Uncontrolled sepsis
• Relative contraindications:
  • Liver: Centrally placed hepatomas
  • Veins:
    • Obstruction of all hepatic veins
    • Significant portal vein thrombosis
    • Moderate pulmonary hypertension
  • Blood:
    • Severe un-correctable coagulopathy (INR > 5)
    • Thrombocytopenia (plt < 20,000/cm³)
• Complications:
  • Worsening encephalopathy (due to shunting of portal blood without clearance of toxins via liver)
  • Procedure related:
    • Damage to structures - perforation of liver capsule, biliary puncture, hepatic artery injury
    • Intraperitoneal bleeding
    • Hepatic infarction
    • Fistulisation
    • Haemolysis
  • Longer term:
    • Stent infection
    • Stent thrombosis
    • Stent stenosis
    • Stent migration
• MELD score better than Child-Pugh at predicting post-TIPSS mortality

Surgical shunts

• Direct portocaval, selective distal splenorenal and interposition C or H graft portocaval shunt
• Non-selective if uncontrolled bleeding. Encephalopathy risk: related to degree of hepatic dysfunction, i.e. CPS C.
• Selective distal splenorenal shunting compared to TIPSS – comparable re-bleeding rate, 2 year survival, hepatic encephalopathy. Much lower rate of thrombosis, stenosis and need for re-intervention in distal splenorenal shunt compared to TIPSS.
• If transplant candidate – should avoid shunt unless very distant from liver e.g. splenorenal or mesocaval. Higher risk of peritransplant complications. Preferred treatment is TIPSS.
• For uncontrolled bleeding, can perform splenectomy + devascularise short gastrics/greater curve. No need to transect oesophagus.

Figure

• non selective
  • A - end-to-side portocaval
  • B - side-to-side portacaval
  • C - mesocaval
  • D - proximal splenorenal
• Selective
  • E - PTFE H-graft portocaval
  • F - Distal splenorenal (Warren)
  • Left gastric to IVC (Inokuchi)

Secondary prevention

• Main priority after initial haemorrhage controlled
  • If no further therapy given, 70% re-bleed in 2 months
  • Risk of re-bleed highest in hours-to-days after initial bleed
• Medical therapy to prevent rebleed
  • Beta-Blocker (Nadolol)
  • PPI to prevent ulcer
• Endoscopic management
  • Repeat endoscopy and band ligation
  • Every 10-14 days until varices eliminated
  • Need patient compliance
• Consider
  • Treatment of underlying liver disease
  • Referral for transplant
• If recurrent bleeding despite endoscopic/medical management
  • TIPS
  • Liver transplant