ESOPHAGEAL VARICES The presence of varicose veins in the esophagus constitutes a serious condition which is potentially life-threatening. It is an entity which is readily discovered by Video-endoscopy. Amonst the causes of esophageal varices one must consider liver cirrhosis as the most frequent, but also portal hypertension and thrombosis of the portal or splenic veins can be made responsible in some cases. For this reason a Video-endoscopic procedure should be performed on all patients in which liver cirrhosis is suspected. Although the definite diagnosis of liver cirrhosis can only be made with a liver biopsy, the presence of esophageal varices in itself constitutes an indirect sign of liver cirrhosis with a 95% accuracy. The potentially life-threatening aspect of esophageal varices lies in the danger of their profuse bleeding , considered to be one of the severest hemorrhages of the whole g.i. tract. The pátient presents with bloody vomiting and black stools (melena). If this condition is not treeated promptly hypotension (fall in blood pressure) will set in and patient may succumb.

Esophageal varices are dilated blood vessels within the wall of the esophagus. Patients with
cirrhosis develop Portal Hypertension. When Portal Hypertension occurs, blood flow through
the liver is diminished. Thus, blood flow increases through the microscopic blood vessels within
the esophageal wall. As this blood flow increases, the blood vessels begin to dilate. This
dilation can be profound. The original diameter of the blood vessels is measured in
millimeters while the final, fully established, esophageal varix may be 0.5 to 1.0 cm or larger in
diameter.
Bleeding varices are a life-threatening complication of portal hypertension (increased blood
pressure in the portal vein caused by liver disease). Increased pressure causes the veins to
balloon outward. The vessels may rupture, causing vomiting of blood and bloody stools or
tarry black stools. If a large volume of blood is lost, signs of shock will develop. Any cause of
chronic liver disease can cause bleeding varices.

A 83 year-old, non-alcoholic female that had an upper gastrointestinal hemorrhage. For more endoscopic details download the video clip by clicking on the image. Esophageal varices are dilated blood vessels within the wall of the esophagus. Patients with cirrhosis develop Portal Hypertension. When Portal Hypertension occurs, blood flow through the liver is diminished. Thus, blood flow increases through the microscopic blood vessels within the esophageal wall. As this blood flow increases, the blood vessels begin to dilate. This dilation can be profound. The original diameter of the blood vessels is measured in millimeters while the final, fully established, esophageal varix may be 0.5 to 1.0 cm or larger in diameter. Bleeding varices are a life-threatening complication of portal hypertension (increased blood pressure in the portal vein caused by liver disease). Increased pressure causes the veins to balloon outward. The vessels may rupture, causing vomiting of blood and bloody stools or tarry black stools. If a large volume of blood is lost, signs of shock will develop. Any cause of chronic liver disease can cause bleeding varices. For more endoscopic details, download the video clip by clicking on the endoscopic image. Wait to be downloaded complete then Press Alt and Enter for full screen.

Acute Variceal Bleed Endoscopic Sequence 1 of 10. Severe upper gastrointestinal hemorrhage due to esophageal varices. 40 year-old, alcoholic male that has been drinking continuously for 3 months a bottle of alcoholic beverage every day, came to emergency room presenting severe hematemesis, patient presented Hypovolemic shock his average of arterial blood pressure was 70/40. Acute bleeding from esophageal varices requires an endoscopic evaluation and aggressive therapeutic intervention. Endoscopy in a patient with massive bleeding demands attention to details. Adequate volume and blood replacement before and during endoscopy is vital, so is protection of the airway in a patient that is liable to aspiration. This may be achieved with endotracheal intubation. More details download the video clips of this endoscopic sequence.

Endoscopic Sequence 2 of 10. This image displays the exactly site of the bleeding at the cardias, actve variceal bleeding is appreciated. DIAGNOSIS OF THE BLEEDING SOURCE, Endoscopy is an essential step in the diagnosis and treatment of acute variceal bleeding. For more endoscopic details download the video clip by clicking on the endoscopic image.

Endoscopic Sequence 3 of 10. The image and the video display active variceal bleeding that is appreciated through the banding apparatus.

Endoscopic Sequence 4 of 10. Endoscopic variceal ligation (banding) Endoscopic variceal ligation is based on the widely used technique of rubber-band ligation of hemorrhoids. The esophageal mucosa and the submucosa containing varices are ensnared, causing subsequent strangulation, sloughing, and eventual fibrosis, resulting in obliteration of the varices. Endoscopic ligation requires placement of an opaque cylinder over the end of the endoscope. This decreases the endoscopic field of view and may allow pooling of blood. Thus, in patients with active bleeding, visualization may be impaired more with ligation than with sclerotherapy. Recent trials have demonstrated that ligation and sclerotherapy achieved similar rates of initial hemostasis in patients whose varices were actively bleeding at the time of treatment. Local complications are less common with ligation compared to sclerotherapy. For example, esophageal strictures were found to be less common with ligation compared to sclerotherapy. Systemic complications, such as pulmonary infections and bacterial peritonitis, were not significantly different in the 2 groups. However, a trend was observed toward a decrease in these 2 complications in patients treated with ligation. Endoscopic Sequence 5 of 10. The next day, 8 varices were banding, the image and the video display a esofageal varix that has been ligated. Patients who have had one variceal bleed are at high risk of rebleeding. Since its introduction, endoscopic variceal banding has been shown to be superior to needle sclerotherapy.

Endoscopic Sequence 6 of 10. The image as wellas the video clip displays the cardias with varix ligated. Variceal banding or sclerotherapy. Endoscopic therapy, particularly variceal banding (also called ligation), may be used to treat and prevent variceal bleeding in the esophagus. In the past, sclerotherapy was the main treatment to stop a first episode of variceal bleeding, but it has fallen out of favor. Most doctors now prefer variceal banding because it works as well as sclerotherapy to stop bleeding and has fewer complications.

Endoscopic Sequence 7 of 10. More images and videos of same case. Technique uses a device attached to the tip of the endoscope that allows the varix to be suctioned into a banding chamber, whereupon an elastic band is then deployed around the base of the captured varix. After 3 to 7 days the ligated tissue sloughs, leaving a shallow ulceration with scar tissue.

Endoscopic Sequence 8 of 10. Some more ligated varices. More bands have been placed on the varices, resulting in spherical blebs. Note the colored elastic bands strangulating each varix at the base.

Endoscopic Sequence 9 of 10. The video displays multiple varices that have been banding. Mortality due to variceal bleeding secondary to portal hypertension has decreased significantly in the past 2 decades. Endoscopic therapy has been the mainstay of treatment for acute variceal bleeding. Variceal banding ligation has superceded injection sclerotherapy as the most popular treatment modality for acute bleeding. Multiple banding ligators are widely used with high success in restoring hemostasis. The combination of banding and sclerotherapy may be useful in preventing the early recurrence of varices and rebleeding after initial obliteration of varices.

Endoscopic Sequence 10 of 10. Seven days after banding a new endoscopy was performed the image and the video exhibit the post banding status All varices are in necrotic stage.

Esophageal Varices. 61 year old female, living in the U.S., who, being a salvadorean national, had come to visit El Salvador on vacation. While still in the airport, patient developed upper g.i. tract hemorrhage and was admitted to the Centro de Emergencias Hospital. Patient had history of liver cirrhosis and was awaiting liver transplant in the U.S The image shows various reddish maculae where it is presumed the hemorrhage started

Patient was initially treated with Minnesota tube and various varices were later on sclerosed. Patient was able to return to the U.S. a few weeks later.

Gastric Varices.
The retroflexed endoscopic view shows various nodules at the gastric fundus.

Hemorrhage from esophageal varices constitues a real emergency which must be promtly and vigorously treated. Eesophageal tamponade by the implementation of the Senstaken-Blakemore or the Minnesota tube is utilized. Variceal sclerosing is another form of treatment which utilizes the fibre-optic endoscope to inject a special substance into the varicose veins of the esophagus, in order to obliterate (sclerose) them. The endoscope is fitted with a special device known as varices injector, which consists of a special cable, which displays a needle-shaped injector on one end and a syringe adapter on the other (external) end. Another method sometimes used to treat bleeding esophageal varices involves the ligation of the varicose veins by means of special rubber bands. It is a method similar to the one employed in the treatment of rectakl hemorrhoids, and relatively easy to implement.

Sub-epithelial gastric varix. 67 year old female who presented with various esophageal varices. This image is readily confused with a gastric polyp, a fact which one must always bear in mind when planning to perform a polypectomy mainly at the fundus and cardias. When the diagnosis is doubtful, one should resort to the endoscopic ultrasound to differentiate between a gastric polyp and gastric varices.