Oesophageal/gastric varices

Venous collaterals (dilated submucosal veins) in the stomach or oesophagus

Epidemiology

• Developed by 5-10% of patients with cirrhosis per year
• Present in 60% of patients with decompensated cirrhosis
• Varices account for 70% of UGIB in cirrhotics
  • 70% oesophageal, 30% gastric
• One third of patients with varices will lead to haemorrhage per year

Classification

• Gastric varices
  • Type 1 - isolated gastric varices in the fundus
  • Type 2 - isolated ectopic varices anywhere in the stomach

Pathophysiology

• Can develop from either:
  • Portal hypertension, in conjunction with oesophageal varices
    • Transmitted by the left gastric vein to oesophageal varices, and then drain through azygos system
    • Transmitted by the short and posterior gastric veins to the fundic plexus and cardia veins
  • Sinistral hypertension from splenic vein thrombosis
    • Tends to cause isolated gastric varices
    • SVT is most commonly secondary to pancreatitis
    • Splenic blood flows retrograde through the short and posterior gastric veins into the varices and then through the coronary vein into the portal vein
    • Ectopic varices can form from retrograde flow through the gastroepiploic vein to the SMV
• Need a pressure gradient >12mmHg across liver to develop varices
• Veins may pathologically dilate up to 2cm with increased wall tension stressing the overlying mucosa. The mucosa can breach, causing catastrophic bleeding

Risk factors for bleeding

• Increasing size of varices
• Decompensated cirrhosis

Investigation

• Gastroscopy
  • Stigmata of recent bleeding - red wale markings, erythematous raised spots/cherry red spots, patients with decompensated cirrhosis
  • Grading - modified Paquet classification:
    • Grade I: varices extending just above the mucosal level
    • Grade II: varices projecting by one-third of the luminal diameter that cannot be compressed with air insufflation
    • Grade III: varices projecting up to 50% of the luminal diameter and in contact with each other

Management

Bleeding varices

• • See separate topic

Long-term management of varices

• • Medical management
    • Compensated cirrhosis: carvedilol - prevents bleeding, possible survival benefit
    • Decompensated cirrhosis: propanolol - less reduction in SBP
  • Endoscopic surveillance
    • Scope every 1-3 years in stable patients without known varices
    • Once varices have been identified, repeat scope and band ligation every 2-4 weeks until varices are down to grade I, then every three months for a year, then annually
    • Reduces risk of bleeding and mortality
  • Continue chronic endoscopic therapy until patient develops an indication for further treatment (TIPS, shunt, liver transplant):
    • Uncontrolled haemorrhage
    • Multiple major episodes of re-bleeding
    • Hypertensive gastropathy

Gastric varices in the setting of splenic vein thrombosis

• • Splenectomy is effective
  • Need to carefully consider whether splenic vein thrombosis is truly the sole cause, and document the thrombosis with imaging; gastric varices are more commonly associated with generalised portal hypertension

Nasogastric tube in patients with varices

• • Low-risk for causing bleeding, but the risk exists
  • See 'Enteric tube placement in patients with oesophageal varices: Risks and predictors of postinsertion gastrointestinal bleeding'. 11/75 patients (14.6%) had evidence of an UGIB within 48 hours of placement, although none of these were 'clinically significant'. Decompensated patients were more likely to have bleeds.

Procedures for patients with refractory varices

TIPS (Transjugular Intrahepatic Portosystemic Shunt)

• • See Portal HTN page under HPB for full procedure info
  • Covered metal stent between right hepatic and portal veins

Surgical shunts

• • Reserved for chronic or recurrent variceal haemorrhage in patients in whom TIPS have thrombosed repeatedly
  • Can also be a salvage procedure in the acute setting
  • Classification
    • Selective - decompression of portal/azygous system while preserving portal inflow into liver
      • Distal splenorenal shunt - anastomosis of distal splenic vein to left renal vein and ligation of collaterals, coronary vein and gastroepiploic veins. Liver still gets perfused through SMV.
        • Contraindications - intractable ascites - it can get worse.
        • Technically difficult procedure
        • Pancreatic collaterals sometimes develop
    • Nonselective - divert all portal flow away from the liver
      • End-to-side portacaval shunt - diverts all blood away from liver, so you get very high rates of hepatic encephalopathy -> not done any more.
      • Side-to-side portacaval shunt - discouraged if patient is a potential liver transplant recipient as there is too much porta hepatis dissection
      • Interposition shunt
      • Conventional splenorenal shunt
    • Rates of survival and recurrent bleeding are similar between the two, but incidence of post-op hepatic encephalopathy is obviously lower with selective.