Epidemiology

• xxx

Etiology

• End-Stage Liver Disease (ESLD) (see End-Stage Liver Disease, [[End-Stage Liver Disease]])

Physiology

• Portal Hypertension

Clinical Manifestations

• Upper Gastrointestinal Bleeding (UGI) Bleeding: may be precipitous and life-threatening

Treatment

Proton Pump Inhibitor (PPI) (see Proton Pump Inhibitors, [[Proton Pump Inhibitors]])

• Indications
  • Esophageal Varices with Active Bleeding
• Pantoprazole (Protonix) Drip (see Pantoprazole, [[Pantoprazole]])

Octreotide Drip (see Octreotide, [[Octreotide]])

• Indications
  • Esophageal Varices with Active Bleeding
• Contraindications
  • xxx

Correction of Coagulopathy

• Indications
  • Esophageal Varices with Active Bleeding

Transfusion Strategy

• Avoid over-transfusion, as this may further distend varices and increase risk of bleeding (or re-bleeding)

Esophagogastroduodenoscopy (EGD) with Banding or Sclerotherapy

Variceal Banding

• Indications
  • Esophageal Varices with/without Active Bleeding
• Endoscopic U/S can be used to visualize paraesophageal and gastric varices after sclerotherapy or banding ligation
• Paraesophageal varices were more frequently noted in patients undergoing ligation
• The presence of paraesophageal varices may predict the recurrence of esophageal varices and recurrent bleeding

Variceal Sclerotherapy

• Technique: usually, about 1 mL of the agent is injected in and around a varix -> total of 15-20 injections during a single procedure
  • Agents
    • Sodium Morrhuate
    • Sodium Tetradecyl Sulfate
    • Ethanolamine Oleate
• Incidence of Adverse Effects: CXR was abnormal in 85% of cases post-procedure in one series (but these were rarely clinically significant)
• Adverse Effects
  • Pleural Effusion (see Pleural Effusion-Exudate, [[Pleural Effusion-Exudate]])
    • Epidemiology
      • Occurs in approximately 25% of cases (range reported in literature: 0-50% of cases)
      • More common with larger number of injections and larger amount per injection
    • Diagnosis
      • CXR/Chest CT: pleural effusion
    • Clinical: usually asymptomatic
    • Treatment/Prognosis: effusion usually resolves spontaenously
  • Mediastinal Widening/Mediastinitis (see Mediastinitis, [[Mediastinitis]])
    • Mediastinal widening occurs in 33% of cases
  • Atelectasis (see Atelectasis, [[Atelectasis]]): occurs in 12% of cases
  • Pulmonary Infiltrates (see Pneumonia, [[Pneumonia]]): occurs in 9% of cases
  • Fever (see Fever, [[Fever]]): rarely significant
  • Chest Pain (see Chest Pain, [[Chest Pain]]): rarely significant
  • Odynophagia (see Odynophagia, [[Odynophagia]]): rarely significant
  • Esophageal Perforation (see Esophageal Perforation, [[Esophageal Perforation]])
  • Acute Lung Injury-ARDS (see Acute Lung Injury-ARDS, [[Acute Lung Injury-ARDS]])
    • Epidemiology: occurs in <1% of patients

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

• Indications
  • xxx
• Successful TIPS: reduction of hepatic wedge pressure to <12 or at least 20% reduction
• Contraindications
  • Portal Vein Thrombosis (see Portal Vein Thrombosis, [[Portal Vein Thrombosis]])
• Complications
  • Worsened Hepatic Encephalopathy (see Hepatic Encephalopathy, [[Hepatic Encephalopathy]])
  • Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]])

Sengstaken-Blakemore Tube

• Indications
  • Esophageal Varices with Active Bleeding: vascular supply to esophageal varices originates from stomach and traverses the gastroesophageal (GE) junction -> this allows mechanical compression of variceal blood supply
  • Mallory-Weiss Tear with Active Bleeding: use of Sengstaken-Blakemore or Minnesota tube has been reported in some cases to control active bleeding
• Tube Structure: 3-lumen with gastric aspiration port (may require additional NG tube placement, is esophageal aspiration is required)
• Directions for Tube Placement
  • Intubate patient for airway protection
  • Place patient supine or in left lateral decubitus position
  • Place hockey helmet
  • Remove white pegs from esophageal and gastric balloon ports -> test balloons with air
  • Deflate balloons completely, lubricate tube, and insert to at least 50 cm
  • Using 60 ml catheter-tip syringe and blue tubing clamps, inflate gastric balloon with 200 ml of air
  • Tug tube back -> should feel resistance, if gastric balloon is properly in stomach
  • Secure tube to rung of hockey helmet using chest tube white tie, keeping tension (take note of the tube marking at the rung)
  • Add additional 250 ml of air to gastric balloon -> total volume = 450 ml of air
  • Keep clamped and place white peg back into gastric balloon port
  • Optionally (though usually not necessary), inflate esophageal balloon using manometer to 25-40 mm Hg
  • Connect esophageal/gastric aspiration ports to low-intermittent suction
  • Obtain CXR and KUB to confirm placement and confirm ETT positioning
  • Deflate esophageal balloon for 10 min out of every 2 hrs -> esophageal balloon inflation should not be used for >12-24 hrs in total duration
• Complications
  • Migration of Gastric Balloon into Esophagus: causes abrupt tracheal compression and high peak inspiratory pressure (PIP) on ventilator
  • Esophageal Necrosis: in cases where esophageal balloon is not periodically deflated

Minnesota Tube

• Indications: same as above for Sengstaken-Blakemore tube
• Tube Structure: 4-lumen with esophageal gastric aspiration ports (does not require additional NG tube placement)
  • Also, Minnesota tube has larger gastric balloon than Sengstaken-Blakemore tube
• Directions for Tube Placement: same as above for Sengstaken-Blakemore tube
• Complications: same as above for Sengstaken-Blakemore tube

References

• Prevalence of paraesophageal varices and gastric varices in patients achieving variceal obliteration by banding ligation and by injection sclerotherapy. Gastrointest Endosc. 1999 Apr;49(4 Pt 1):428-36