Esophageal varices

Esophageal varices are varicose veins ( varices ) of the gullet (esophagus ). They are usually caused by portal hypertension. Bleeding from esophageal varices are a life-threatening complication and is a medical emergency.

• 5.1 Treatment of acute bleeding
• 5.2 therapy for relapse or prophylaxis of bleeding

Causes

The nutrient- rich but oxygen-poor venous blood from the spleen, stomach, intestine and gall bladder normally flows through the portal vein ( portal vein ) by the liver and from there into the inferior vena cava. Is this restricted blood outflow (eg liver cirrhosis ), creates a portal hypertension ( increased blood pressure in the portal vein ). In this case, the liver via the portocaval anastomoses ( connections between the portal vein and the upper and lower vena cava ) is bypassed, the blood then flows directly into the vena cava.

There are several such portocaval anastomoses: in the rectum, in the abdominal wall, in the stomach and in the esophagus. The latter extend to the elevated blood pressure in the portal vein to esophageal varices. Bleeding from these varices can be life-threatening.

Epidemiology (frequency )

In severe portal hypertension, for example, in the context of cirrhosis, have about half of those on esophageal varices. The mortality rate of bleeding is also used to treat up to 30 %. The probability that a first esophageal varices relapse occurs is approximately 70%.

Complications

The dilated veins in the lower end of the esophagus, just the esophageal varices, since they are very thin, easy to tear and cause severe bleeding. Blood loss leads unless strong enough to shock and is life-threatening. In addition, hepatic coma may in the patient with cirrhosis regardless of the bleeding may occur. Such hemorrhages are often complicated by an existing blood disorder that is caused by liver cirrhosis. Minor bleeding lead to melena ( melena ), in acute life- threatening hemorrhage typically comes vomiting of blood ( hematemesis ) to do so.

Diagnosis

The diagnosis is made endoscopically by gastroscopy. During a gastroscopy can also, if bleeding is an attempt hemostasis are made. The gastroscopy particularly serves to answer the question of whether other sources of bleeding are made. Clinically important esophageal varices are in fact in all primarily as a source of bleeding. As more sources of bleeding in the stomach or in the esophagus, the Mallory- Weiss syndrome, ulcer bleeding and gastric erosions come into question.

Staging

After appearance and properties during endoscopy, a clinical stage classification in grade I - IV done:

• Stage I: There are extensions before the submucosal veins, but the pass after air insufflation through the endoscope.
• Stage II: There are some excellent into the lumen of the esophagus varices, which remain with air insufflation.
• Stage III: The lumen of the esophagus is narrowed by excellent Varizenstränge. As signs of epithelial damage (erosion ) to reddish patches ( "cherry spots" ) are made on the mucosa.
• Stage IV: The Varizenstränge have misplaced the esophageal lumen, there are usually numerous erosions of the mucous membrane.

In some of the patients are in addition to esophageal varices and gastric varices and a Gastropathia hypertensive.

Therapy

In the therapy is to differentiate between acute measures occurred bleeding or haemorrhage prophylaxis and relapse prevention.

Treatment of acute bleeding

In an emergency, the affected patient should be placed directly on an intensive care unit. Primary goal is to hemostasis. This can best be achieved by a rubber band ligation of bleeding varices, injection of Histoacryl or varices by means of injections.

Is not possible endoscopic Varizenbehandlung, a balloon probe should be used for hemostasis by compression, eg Sengstaken - Blakemore probe or the Linton - Nachlas probe. Thereafter, the patient should be transferred as soon as possible for further endoscopic therapy. Up to the sclerotherapy or tamponade by probes of the portal venous blood flow can be reduced by the administration of terlipressin, vasopressin or somatostatin.

More general measures are:

• Monitoring of vital signs
• Endotracheal intubation ( risk of aspiration)
• Volume loading on large bore peripheral venous access

Therapy for recurrence or bleeding prophylaxis

As a causal therapy, the underlying cause of portal hypertension is to treat. However, not all causes of portal hypertension treatable, so that often only symptomatic and hinauszögernde therapy takes place.

Drug therapy includes the administration of beta-blockers, nitrates, and spironolactone to reduce pressure in the portal circulation. The Ligaturbehandlung is the method of choice as rare serious complications.

Interventional and surgical procedures are aimed generally at the creation of a shunt between the portal circulation and the systemic venous circulation. Current methods are:

• TIPS ( transjugular intrahepatic portosystemic shunt)
• Shuntoperationen: Portacaval shunt ( Portocaval end-to -side anastomosis, PCA)
• Splenorenaler shunt