Gastroenterological Medicine: Esophageal and Gastric Varices

• Submucosal layer of esophagus and belly has engorged due to increased venous pressure.
• Developed by chronic pancreatitis or liver cancer other than cirrhosis of liver.
• If raptured or led to bleeding, vomiting fresh or dark red blood.
• Arrest hemorrhage by solidify or aspirating varicosity.
• One of the three commonest cause of death by cirrhosis of liver.
• Respond with balancing out the cure for accompanied disease treatment

Submucosal layer of esophagus and belly has engorged due to increased venous pressure.

When lead to cirrhosis of lever, kidney shrunk and hardened and blood to kidney will decrease. Then portal vein (venous), which supply blood and nutrition to kidney, pressure increase (portal hypertension). When vein pressure exceeds 25cmH2O (normally it is 8 to 13cmH2O), collateral blood circulation pathway is developed, then it builds up from upper belly or lower layer of gastroesophageal mucosa, and expand or engorged. This is an Esophageal and Gastric Varices.(Fig: 1 & 2)

Fig.1 ; Esophageal Varices
Fig.2: Gastric Varices

Developed by chronic pancreatitis or liver cancer other than cirrhosis of liver.

The most common disease which develops portal hypertension is cirrhosis of liver. As the cause of cirrhosis of liver, they are hepatitis virus, auto immune disease, or heavy use of alcohol. Others are, idiopathic portal hypertension, budd-chiari syndrome, chronic pancreatic, liver cancer, or pancreatic cancer.

If raptured or led to bleeding, vomiting fresh or dark red blood.

Most of them are no symptom, but there may be a case of recognizing a feeling of knot in stomach. In case of rapture or bleeding by the stimulation of food or gastric fluid, fresh or dark red blood vomiting can be seen.
As an exam, there are Radiographic Contrast Study (Valium Exam), Upper Alimentary Canal Endoscope. When result is positive in Blue color sign, beaded type, red color sign; RC sign, at endoscope exam, there is a risk of bleeding.

Arrest hemorrhage by solidify or aspirating varicosity.

This is grouped in emergency treatment against the bleeding of varicosity, stand-by treatment when bleeding is stabled, preventive treatment applied for nonbleeding sample. Treatments are listed as below, but endoscopic treatment is the most common one.

1. Endoscopic Treatment

   There is sclerosing therapy (EIS) and ligature method (EVL). Sclerosing therapy is the method which taps in using injection needle of endoscope with identifying the varicosity, inject the hardening agent to solidify varicosity with making a clot. (Fig. 3 & 4)

   
   Fig.3: Varicosity Sclerosing Therapy: Inject the hardening agent with verifying adversed blood flow.
   Fig.4: Varicosity Sclerosing Therapy: Confirming the injection of hardening agent by X-ray.

   Ligature method is; Attach rubber band, O-ring, on top of endoscope, and while aspirating varicosity tighten it by O-ring to stop blood flow. Ligature method is used for hemostasis at emergency, it is relatively simple enough but many recurrences are the demerit.

   
   Fig. 5: Varicosity raptures, bleeding
   Fig.6: Emergency endoscopic ligature method: successful arrest hemorrhage

2. Radiation Therapy

   Balloon occluded retrograde trans venous obliteration (B-RTO) which inject hardening agent to gastric varices using catheter, and Transjugular intrahepatic portosystemic shunt (TIPS) which insert stent between hepatic vein and intrahepatic portal vein to lower portal vein pressure, two methods are available.

3. Surgical Treatment

   Esophageal transection which separates and resuture esophageal is available.

4. Medicine Treatment

   There are Vasopressin, β Blockers, Nitrite drugs, and Angiotensin receptor antagonist having an effect to lower portal vein pressure down.

In case of emergency hemorrhage, it is common to perform endoscopic variceal ligation (EVL), but in case entire body condition is unstable, or in case of the circumstance is hard to apply endoscope exam, astriction by S-B Tube is applied.

One of the three commonest cause of death by cirrhosis of liver.

Three commonest cause of cirrhosis of liver are, hepatic failure, liver cancer and varicosity bleeding. Applying to much preventive treatment, burdens to liver increased resulted to lead to hepatic failure (such as; jaundice, ascites fluid, liver encephalopathy). On the contrary, in case if varicosity is left untreated, it may rapture or bleeding so that life becomes under the risk of bleeding to death or choking death by vomiting blood. Even in case if arrest bleeding is successful, because of blood flow to kidney is reduced while bleeding, hepatic failure is advanced or inner-body ammonia concentration due to digestion absorption of bleeding blood, so that there is a risk of developing the liver encephalopathy.

Respond with balancing out the cure for accompanied disease treatment

Fig.7: After Endoscopic treatment: almost no varicosityFor cirrhosis of liver led by alcohol, stop drinking is mandatory requested, and for cirrhosis of liver caused by virus, anti-virus treatment is inevitable. For the treatment of esophageal and gastric varices, it is important to make balanced treatment for co-existing disease like cirrhosis of liver is considered.