Varices

Esophageal varices are most often the result of portal hypertension. Patients with esophageal varices are often prone to gastrointestinal bleeding that may be life threatening. In trying to control varices and variceal bleeding, both local and systemic therapies may be employed. Medications that result in the lowering of portal venous hypertension (nonselective b-adrenergic blockers or oral nitrates) may be used, especially for long-term control [102]. More recently, transjugular intrahepatic portosystemic shunts (TIPS) have been of considerable help in lowering portal venous pressures, often replacing operative shunts. However, elevated serum ammonia levels with resultant hepatic encephalopathy and/or reduced flow through the shunts reduce the overall efficacy and clinical usefulness of these procedures.

Alternatively, local therapies are of value, especially in the short-term management of variceal bleeding. The oldest therapy is that of balloon tamponade via a Sengstaken-Blakemore tube. This tube has multiple components. First is a long proximal balloon that lies within the esophagus. A second balloon, rounder and larger in diameter, is located distally. The longitudinal balloon is used to compress esophageal varices, while the distal round balloon compresses gastric fundal varices. Care must be taken to insufflate the distal balloon in the capacious stomach, not in the limited diameter of the esophagus (Figs. 2.30 and 2.31). Improper inflation can lead to esophageal disruption with dire consequences for the patient (Fig. 2.32).

Other, more permanent methods of control include esophageal variceal sclerotherapy or variceal banding. Less likely to be used, especially in the United States is esophageal devascularization (Sugiura-Futagawa procedure). In sclerotherapy, small amounts of sclerosant are injected directly into, or immediately adjacent to the esophageal varices [102-106]. Sodium morrhuate (5%) [104,105], ethanolamine oleate [106], and tetradecyl sulfate have all been used to produce a local

Figure 2.30. Malpositioned Sengstaken-Blakemore tube. Anteroposterior film of the chest following inadvertent inflation with air of the gastric balloon of a Sengstaken-Blakemore tube in the esophagus.
Figure 2.31. Malpositioned Sengstaken-Blakemore tube. Anteroposterior film of the chest shows a large gastric balloon of a Sengstaken-Blakemore tube filled with contrast medium while still in the patient's esophagus.
Figure 2.32. Esophageal perforation secondary to malpostioned Sen-gstaken-Blakemore tube. Film from a water-soluble contrast esophagogram following attempted placement of a Sengstaken-Blakemore tube shows marked disruption of the esophagus with multiple mediastinal tracts.

inflammatory reaction that obliterates the varices. Sodium morrhuate, a mixture of unsaturated fatty acids found in cod liver oil [105], includes oleic and linoleic acids. Early on in the postinjection period, the overlying mucosa may ulcerate. These ulcers are usually focal and related to the injection site [104]. Following extensive injection therapy, the ulceration may become more diffuse and confluent, even leading to sinus tract and fistula formation. A double-barreled appearance may result from extensive intramural tracking [104]. When the ulcerations are deep, perforation may ensue [104].

The local inflammatory response may lead to esophageal luminal narrowing. If the region of injection therapy was circumferential, the resultant narrowing may also be circumferential, mimicking an annular carcinoma [104]. When less extensive, the perivariceal inflammatory and hemorrhagic response produces mucosal or extramucosal defects that may vary in size and shape [104]. These local defects secondary to edema usually regress in a few days.

In patients in whom the inflammatory response was more marked, or deeper in extent, esophageal strictures may develop over time (Fig. 2.33). Therefore, patients with deep ulcers or sinus tracts early on in

Figure 2.33. Sclerotherapy-induced esophageal changes. Postsclerotherapy esophagogram reveals multiple ulcerations in the proximal to middle thirds, and a long stricture distally.

their course are more prone to develop a stricture [104]. Most strictures are short and may be at the site of a previous ulceration. Contour defects noted in the early post-procedure period may persist as nodules or even plaques on later follow-up examinations. Stiffening of the injected portions of the esophageal wall may also result. Dysmotility in the area, perhaps secondary to neuromuscular damage, has been reported as well.

A new, and now widely used therapy for the control and prevention of variceal hemorrhage is that of endoscopic variceal ligation (or banding) [102,107,108]. Reportedly, this procedure has several advantages over sclerotherapy, including fewer complications, fewer treatments necessary, lower rebleeding rates, and an overall lower mortality [107]. In esophageal variceal ligation, the varix is snared with endo-scopic suction and drawn into the ligator. A small O-ring ligature is then placed around the base of the varix and released. The placement of the rubber ligature results in strangulation of the varix, with eventual thrombosis, sloughing, and fibrosis [109].

When a varix sloughs, an ulceration of the mucosa may result. If deep enough, the ulcer may heal with stricturing [108]. When studied in the immediate postprocedure period, patients with esophageal variceal ligation show smooth rounded nodules that range in size from 5 to 10 mm. Because blood does not flow into or out of the ligated varix, the vein does not change in size or shape as opposed to a nontreated varix. Ulcerations may also be seen in these patients, but these are usually healed within 2 weeks of the initial insult [108].

Esophageal devascularization is another, and more controversial method of controlling esophageal varices [110]. As the procedure is commonly performed, the esophagus is devascularized distal to the level of the inferior pulmonary vein. The greater and lesser curvatures of the stomach are also devascularized, with the ligation of the short gastric veins along the greater curvature and the left gastric veins along the high lesser curvature. The esophagus is then transected and reanas-tomosed by means of a stapling device. A splenectomy is performed along with the esophagogastric surgery. Truncal vagotomy and pyloro-plasty are concomitantly performed in most patients. If a selective vagotomy is performed, there may not be a need for the pyloroplasty.

Initial results from Japan, in nonalcoholic cirrhotic patients, showed 66% 5-year survival and recurrent hemorrhage in less than 10% of patients [111]. A more recent study from France replicated these results [112]. In North America, the results have been significantly worse, and the procedure is usually reserved for emergencies.

There is little written about the radiographic appearance of the esophagus following the Sugiura procedure (Fig. 2.34). One series of 11 patients showed a significant number of complications including pleural effusions, ascites, ileus, and pneumonia [113]. Esophageal varices were either markedly reduced in size or absent altogether on

Figure 2.34. Sugiura procedure. Innumerable surgical clips outline the esophagus in this patient, who has undergone a devascularization procedure. A long segment of narrowing is noted distally.

postoperative studies. A less striking reduction in gastric varices was also seen. Two patients had dysphagia with stricture formation. One resolved spontaneously and the other required bougienage. One patient developed gastroesophageal reflux symptoms postoperatively, and esophagitis was noted on endoscopy. Some irregularity to the esophageal wall was noted, but it was difficult to differentiate esophagitis from postprocedure deformity. Two cases of anastomotic leakage were noted, one with fatal consequences. The surgical literature notes that fistulization or frank dehiscence of the anastomotic line is not unheard of [114,115]. A new modification of the procedure involves a submucosal interruption of the esophageal wall, leaving the mucosa intact. This measure reportedly has decreased the incidence of these two serious complications [116].

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