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.
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
millimeters while the final, fully established, esophageal varix may be
0.5 to 1.0 cm or larger in
Bleeding varices are a life-threatening complication of portal hypertension
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.
83 year-old, non-alcoholic female that had an upper gastrointestinal
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
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 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
|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
| Endoscopic Sequence 5 of 10.
The next day, 8
varices were banding, the image and the video display a esofageal
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
|Endoscopic Sequence 6 of 10.
The image as wellas the video clip displays the cardias with varix
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
|Endoscopic Sequence 7 of 10.
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.
more ligated varices. More bands have been placed on the varices,
spherical blebs. Note the colored elastic bands strangulating each
varix at the base.
| Endoscopic Sequence 9 of 10.
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
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
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
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.