Gastrointestinal varices overview: Difference between revisions
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==Classification== | ==Classification== | ||
Gastrointestinal varices may be further classified into [[esophageal]] and [[gastric]] varices. [[Gastrointestinal varices|Esophageal varices]] may be further divided according to various classification systems such as the Dagradi classification, Conn's classification, Pachquet classification, Westaby classification, Soehendra classification and Cales classification. [[Gastrointestinal varices|Gastric varices]] may be classified according to Hoskins and Johnson’s classification, Mathur’s classification, Hashizume classification and Sarin's classification system. These classificatication systems are based on morphological features, [[anatomical]] location, size and color of the varices. | |||
==Pathophysiology== | == Pathophysiology == | ||
Varices arise from [[Hemodynamics|hemodynamic]] disturbance between the systemic and [[portal venous system]]. The majority of [[venous]] drainage of the [[gastrointestinal system]] occurs via the [[portal venous system]]. Whenever there is an interruption of drainage through the [[Portal venous system|portal system]] (for example due to [[cirrhosis]]), the [[Blood vessel|vessels]] contributing to the [[Portocaval anastomoses|porto-caval shunts]]<nowiki/>become more prominent due to increased pressure gradient. The interruption in [[blood flow]] leads to the creation collateral [[Blood vessel|vessels]] that involve [[veins]] of the [[esophagus]], [[stomach]], [[pelvis]] ([[hemorrhoids]]), [[retroperitoneum]], [[liver]], [[abdominal wall]], and other areas. | |||
==Causes== | ==Causes== | ||
Causes of gastointestinal varices include all the causes of increased [[Portal venous system|portal venous pressure]], which may be divided into [[Cirrhosis|cirrhotic]] and non-[[Cirrhosis|cirrhotic]] causes. | |||
==Differentiating Gastrointestinal varices from other Diseases== | ==Differentiating Gastrointestinal varices from other Diseases== | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
Gastroesophageal varices are present in approximately 50000 per 100,000 patients with [[cirrhosis]], depending upon the clinical stage of the disease. The annual [[incidence]] of gastrointestinal varices ranges from a low of 7000 per 100,000 individuals to a high of 8000 per 100,000 individuals. Variceal [[hemorrhage]] occurs at a rate of around 10%-15% per year and depends on the severity of liver disease, size of varices, and presence of red wale marks (areas of thinning of the variceal wall). | |||
==Risk Fators== | ==Risk Fators== | ||
The most potent [[risk factor]] for the development of gastrointestinal varices is increased [[Portal venous system|portal venous]] pressure. Conditions that predispose an individual to development of increased [[Portal venous system|portal venous]] pressure and consequently leading to varices can be divided into those leading to development of varices, those involved in progression of varices from small to large size and those leading to variceal [[hemorrhage]]. | |||
==Screening== | ==Screening== | ||
[[Screening (medicine)|Screening]] [[esophagogastroduodenoscopy]] ([[Esophagogastroduodenoscopy|EGD]]) for the diagnosis of esophageal and gastric varices is recommended after the diagnosis of [[cirrhosis]] is made. | |||
==Natural History, Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
If untreated, recurrent variceal hemorrhage occurs in 60% of patients, usually within 1-2 years of the initial [[hemorrhage]]. Gastrointestinal varices are an indication of increased [[Portal venous system|portal venous]] pressure, especially in [[Cirrhosis|cirrhotic]] patients. The progressive increase in [[portal]] pressure leads to a progressive increase in size of the varices and an increased [[vascular]] wall tension. Variceal [[hemorrhage]] resulting from rupture occurs when the expanding force exceeds the maximal wall tension. Complications include, transient [[dysphagia]], [[chest pain]], [[esophageal]] [[ulceration]], ulcerogenic bleeding, post-therapeutic [[hemorrhage]], [[esophageal]] [[strictures]], [[Pleural effusion|pleural effusions]], [[pericarditis]] and [[portal vein thrombosis]]. Factors associated with a poor [[prognosis]] of presence of [[bacterial]] infections, HVPG >20 mm Hg, [[alcohol]] intake and [[obesity]]. The AIMS65 score is the best predictor of [[mortality]] in patients with variceal [[bleeding]]. | |||
==Diagnosis== | ==Diagnosis== | ||
===Diagnostic study of choice=== | ===Diagnostic study of choice=== | ||
[[Esophagogastroduodenoscopy]] ([[Esophagogastroduodenoscopy|EGD]]) is the [[Gold standard (test)|gold standard]] test for the [[diagnosis]] of gastrointestinal varices. [[Esophagogastroduodenoscopy|EGD]] should be performed once the [[diagnosis]] of [[cirrhosis]] is established | |||
===History and symptoms=== | ===History and symptoms=== | ||
Patients suffering from gastrointestinal varices may present with other [[Comorbidity|co-morbid]] conditions which lead to [[portal hypertension]]. [[Chronic liver disease]] and [[portal vein thrombosis]]<nowiki/>commonly lead to the development of gastrointestinal varices. Patients with a [[family history]] of venous abnormalities, [[Hypercoagulable state|hypercoaguable states]], [[autosomal recessive polycystic kidney disease]] (may lead to [[hepatic fibrosis]]), [[Nephronophthisis|nephronophthisis 1]], [[Joubert syndrome]] and related disorders 5, cranioectodermal dysplasia (Sensenbrenner syndrome), [[Ellis-van Creveld syndrome]], [[Jeune's disease|Jeune asphyxiating thoracic dystrophy]], [[renal]]-[[hepatic]]-[[pancreatic]] [[dysplasia]], [[autosomal dominant polycystic kidney disease]] have an increased risk of developing gastrointestinal varices. Non-[[bleeding]] gastrointestinal varices do not produce any [[symptoms]], however [[bleeding]] gastrointestinal varices may lead to [[hematemesis]], [[abdominal pain]], [[lightheadedness]], [[loss of consciousness]], [[melena]], [[bloody stools]] (in severe cases), [[shock]] (in case of loss of a large volume of [[blood]]). | |||
===Physical examination=== | ===Physical examination=== | ||
[[Physical examination]] of patients with gastrointestinal varices is usually remarkable for [[ascites]], [[pallor]], [[jaundice]], [[tachycardia]], low [[blood pressure]] in case of [[shock]], [[hepatomegaly]]<nowiki/>or shrunken [[liver]] (in case of [[cirrhosis]]), [[spleenomegaly]], [[altered mental status]], [[palmar erythema]], [[cyanosis]] and [[clubbing]]. | |||
===Laboratory findings=== | ===Laboratory findings=== | ||
[[Cirrhosis]] of the [[liver]] is the most common cause of portal hypertension worldwide. A range of laboratory values may be obtained in the evaluation of [[cirrhosis]], in order to determine [[disease]] severity and [[Causality|causation]]. [[Liver function tests]], [[complete blood count]], [[basic metabolic panel]] and [[coagulation factors]] are standard in the evaluation of [[cirrhosis]]. More specific testing for markers and serum [[enzymes]] may be performed when certain [[Etiology|etiologies]] are suspected. | |||
===Electrocardiogram=== | ===Electrocardiogram=== | ||
[[Electrocardiogram]] ([[The electrocardiogram|EKG]]) in case of variceal [[bleeding]] after rupture may show [[sinus tachycardia]]. | |||
===Echocardiography/Ultrasound=== | |||
[[Doppler echocardiography|Echo-Doppler]] may be helpful in the diagnosis of [[portal hypertension]]. Findings on an [[Doppler echocardiography|echo-doppler]] suggestive of [[portal hypertension]] include lack of increase in [[portal vein]]<nowiki/>diameter in response to meals, increased portal [[blood flow]] velocity, and decreased [[portal vein]] cross-sectional area. [[Doppler ultrasonography|Color-Doppler ultrasound]] may be helpful in the diagnosis of [[portal hypertension]]. Findings on an [[Doppler ultrasonography|color-doppler ultrasound]] suggestive of [[portal hypertension]] include increased diameter of [[left gastric vein]], increased diameter of [[portal vein]], and increased flow velocity in [[left gastric vein]]. [[Biphasic]] and reverse flow in [[portal vein]] along with re-canalization of [[umbilical vein]] are [[pathognomonic]] for [[portal hypertension]]. | |||
===X-Ray=== | ===X-Ray=== | ||
There are no abnormal [[X-rays|x-ray]] findings associated with gastrointestinal varices | |||
===CT scan=== | ===CT scan=== | ||
===MRI=== | ===MRI=== | ||
===Other imaging findings=== | ===Other imaging findings=== | ||
[[Upper endoscopy]] may be helpful in the [[diagnosis]] of [[Esophageal varices|gasteroesophageal varices]]. Findings on an [[upper endoscopy]] diagnostic of [[esophageal varices]] include visible [[submucosal]]<nowiki/>tortuous veins, congested [[veins]] without compression during air [[insufflation]], and grape-like [[Varicose veins|varicose]] veins that may occlude the [[lumen]]. Three dimensional [[portal]] [[venography]] may be helpful in the diagnosis of [[Esophageal varices|gasteroesophageal varices]]. Findings on a [[portal]] [[venography]] diagnostic of [[esophageal varices]] include reverse flow in [[Portocaval anastomoses|porto-systemic shunts]], [[collateral]] [[Vein|veins]] draining into [[Inferior vena cava|inferior vena cava (IVC)]], and other [[collateral]] [[veins]]. | |||
===Other diagnostic studies=== | ===Other diagnostic studies=== | ||
Hepatic venous pressure gradient (HVPG) is the difference between [[Hepatic vein|hepatic venous]] [[wedge pressure]] (HVWP) and free [[Hepatic vein|hepatic venous]] pressure (FHVP). HVPG reflects the intra-[[sinusoidal]] [[pressure]]. HVPG is measured through insertion of a [[catheter]] in right [[internal jugular vein]]. | |||
==Treatment== | ==Treatment== | ||
===Medical therapy== | ===Medical therapy=== | ||
Medical therapy in cases of gastrointestinal varices includes goal-directed management of the cause of [[portal hypertension]] along with specific management of varices after their development. The treatment is aimed at optimizing [[Portal venous system|portal venous]] inflow, portal pressure and portal resistance. The pharmacological therapy includes [[vasoconstrictors]] ([[beta blockers]]) and [[Venodilator|venodilators]] ([[nitrates]]). These therapies may be employed alone or in combination with endoscopic variceal ligation/[[sclerotherapy]] and [[Transjugular intrahepatic portosystemic shunt|transjugular intrahepatic shunt]] ([[Transjugular intrahepatic portosystemic shunt|TIPS]]) therapy depending upon the condition of the patient. | |||
===Surgery=== | ===Surgery=== | ||
Revision as of 18:12, 4 January 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]
Overview
Historical Perspective
Classification
Gastrointestinal varices may be further classified into esophageal and gastric varices. Esophageal varices may be further divided according to various classification systems such as the Dagradi classification, Conn's classification, Pachquet classification, Westaby classification, Soehendra classification and Cales classification. Gastric varices may be classified according to Hoskins and Johnson’s classification, Mathur’s classification, Hashizume classification and Sarin's classification system. These classificatication systems are based on morphological features, anatomical location, size and color of the varices.
Pathophysiology
Varices arise from hemodynamic disturbance between the systemic and portal venous system. The majority of venous drainage of the gastrointestinal system occurs via the portal venous system. Whenever there is an interruption of drainage through the portal system (for example due to cirrhosis), the vessels contributing to the porto-caval shuntsbecome more prominent due to increased pressure gradient. The interruption in blood flow leads to the creation collateral vessels that involve veins of the esophagus, stomach, pelvis (hemorrhoids), retroperitoneum, liver, abdominal wall, and other areas.
Causes
Causes of gastointestinal varices include all the causes of increased portal venous pressure, which may be divided into cirrhotic and non-cirrhotic causes.
Differentiating Gastrointestinal varices from other Diseases
Epidemiology and Demographics
Gastroesophageal varices are present in approximately 50000 per 100,000 patients with cirrhosis, depending upon the clinical stage of the disease. The annual incidence of gastrointestinal varices ranges from a low of 7000 per 100,000 individuals to a high of 8000 per 100,000 individuals. Variceal hemorrhage occurs at a rate of around 10%-15% per year and depends on the severity of liver disease, size of varices, and presence of red wale marks (areas of thinning of the variceal wall).
Risk Fators
The most potent risk factor for the development of gastrointestinal varices is increased portal venous pressure. Conditions that predispose an individual to development of increased portal venous pressure and consequently leading to varices can be divided into those leading to development of varices, those involved in progression of varices from small to large size and those leading to variceal hemorrhage.
Screening
Screening esophagogastroduodenoscopy (EGD) for the diagnosis of esophageal and gastric varices is recommended after the diagnosis of cirrhosis is made.
Natural History, Complications and Prognosis
If untreated, recurrent variceal hemorrhage occurs in 60% of patients, usually within 1-2 years of the initial hemorrhage. Gastrointestinal varices are an indication of increased portal venous pressure, especially in cirrhotic patients. The progressive increase in portal pressure leads to a progressive increase in size of the varices and an increased vascular wall tension. Variceal hemorrhage resulting from rupture occurs when the expanding force exceeds the maximal wall tension. Complications include, transient dysphagia, chest pain, esophageal ulceration, ulcerogenic bleeding, post-therapeutic hemorrhage, esophageal strictures, pleural effusions, pericarditis and portal vein thrombosis. Factors associated with a poor prognosis of presence of bacterial infections, HVPG >20 mm Hg, alcohol intake and obesity. The AIMS65 score is the best predictor of mortality in patients with variceal bleeding.
Diagnosis
Diagnostic study of choice
Esophagogastroduodenoscopy (EGD) is the gold standard test for the diagnosis of gastrointestinal varices. EGD should be performed once the diagnosis of cirrhosis is established
History and symptoms
Patients suffering from gastrointestinal varices may present with other co-morbid conditions which lead to portal hypertension. Chronic liver disease and portal vein thrombosiscommonly lead to the development of gastrointestinal varices. Patients with a family history of venous abnormalities, hypercoaguable states, autosomal recessive polycystic kidney disease (may lead to hepatic fibrosis), nephronophthisis 1, Joubert syndrome and related disorders 5, cranioectodermal dysplasia (Sensenbrenner syndrome), Ellis-van Creveld syndrome, Jeune asphyxiating thoracic dystrophy, renal-hepatic-pancreatic dysplasia, autosomal dominant polycystic kidney disease have an increased risk of developing gastrointestinal varices. Non-bleeding gastrointestinal varices do not produce any symptoms, however bleeding gastrointestinal varices may lead to hematemesis, abdominal pain, lightheadedness, loss of consciousness, melena, bloody stools (in severe cases), shock (in case of loss of a large volume of blood).
Physical examination
Physical examination of patients with gastrointestinal varices is usually remarkable for ascites, pallor, jaundice, tachycardia, low blood pressure in case of shock, hepatomegalyor shrunken liver (in case of cirrhosis), spleenomegaly, altered mental status, palmar erythema, cyanosis and clubbing.
Laboratory findings
Cirrhosis of the liver is the most common cause of portal hypertension worldwide. A range of laboratory values may be obtained in the evaluation of cirrhosis, in order to determine disease severity and causation. Liver function tests, complete blood count, basic metabolic panel and coagulation factors are standard in the evaluation of cirrhosis. More specific testing for markers and serum enzymes may be performed when certain etiologies are suspected.
Electrocardiogram
Electrocardiogram (EKG) in case of variceal bleeding after rupture may show sinus tachycardia.
Echocardiography/Ultrasound
Echo-Doppler may be helpful in the diagnosis of portal hypertension. Findings on an echo-doppler suggestive of portal hypertension include lack of increase in portal veindiameter in response to meals, increased portal blood flow velocity, and decreased portal vein cross-sectional area. Color-Doppler ultrasound may be helpful in the diagnosis of portal hypertension. Findings on an color-doppler ultrasound suggestive of portal hypertension include increased diameter of left gastric vein, increased diameter of portal vein, and increased flow velocity in left gastric vein. Biphasic and reverse flow in portal vein along with re-canalization of umbilical vein are pathognomonic for portal hypertension.
X-Ray
There are no abnormal x-ray findings associated with gastrointestinal varices
CT scan
MRI
Other imaging findings
Upper endoscopy may be helpful in the diagnosis of gasteroesophageal varices. Findings on an upper endoscopy diagnostic of esophageal varices include visible submucosaltortuous veins, congested veins without compression during air insufflation, and grape-like varicose veins that may occlude the lumen. Three dimensional portal venography may be helpful in the diagnosis of gasteroesophageal varices. Findings on a portal venography diagnostic of esophageal varices include reverse flow in porto-systemic shunts, collateral veins draining into inferior vena cava (IVC), and other collateral veins.
Other diagnostic studies
Hepatic venous pressure gradient (HVPG) is the difference between hepatic venous wedge pressure (HVWP) and free hepatic venous pressure (FHVP). HVPG reflects the intra-sinusoidal pressure. HVPG is measured through insertion of a catheter in right internal jugular vein.
Treatment
Medical therapy
Medical therapy in cases of gastrointestinal varices includes goal-directed management of the cause of portal hypertension along with specific management of varices after their development. The treatment is aimed at optimizing portal venous inflow, portal pressure and portal resistance. The pharmacological therapy includes vasoconstrictors (beta blockers) and venodilators (nitrates). These therapies may be employed alone or in combination with endoscopic variceal ligation/sclerotherapy and transjugular intrahepatic shunt (TIPS) therapy depending upon the condition of the patient.