COMMENTARY

The Clinical Management of Gastroesophageal Varices

Rowen K. Zetterman, MD

Disclosures

January 20, 2012

In This Article

Screening for Varices

The presence of portal hypertension is defined by a portal venous pressure of greater than 10 mm Hg. The practice guideline from the American College of Gastroenterology (ACG) and the American Association for the Study of Liver Disease (AASLD) for gastroesophageal varices suggests that all patients with hepatic cirrhosis should be screened for varices at least every other year.[8] Of those screened following a diagnosis of cirrhosis, approximately 50% will have gastroesophageal varices and roughly one third will have varices sufficiently large to require prophylaxis.[9] Screening at endoscopy should determine the size of esophageal varices[8]because patients with varices ≥ 5 mm in diameter are at the greatest risk for bleeding and should receive prophylaxis. Red wales are also an indicator of bleeding risk. Even varices that are < 5 mm in diameter with red wales are more likely to bleed and should receive drug prophylaxis.

Endoscopy remains the best screening method for gastroesophageal varices in patients with known or suspected cirrhosis.[10]If initial screening endoscopy fails to identify varices, upper endoscopy should be repeated at 2 yearly intervals. For those with decompensated cirrhosis, more frequent screening endoscopy may be warranted. Wedged hepatic vein pressure measurement is the best predictor of varix development,[10] and those with pressures > 20 mm Hg have the highest risk for hemorrhage.[11]

Noninvasive techniques to look for significant portal hypertension or varices are of limited value.[12] Thrombocytopenia,[13]splenomegaly,[14]and liver function tests can all be abnormal in the absence of esophageal varices. Estimates of liver stiffness using tissue elastography assist in identifying cirrhosis but are limited in their ability to identify significant portal hypertension.[15]Capsule endoscopy with a dual camera capsule has been tested in patients who have had both capsule endoscopy and esophagogastroduodenoscopy on the same day.[16] The sensitivity was 76% and specificity 82% for esophageal varices with capsule endoscopy, as compared with conventional endoscopy. Computed tomography is 65%-100 % sensitive and 50%-100% specific for large esophageal varices.[17,18]Other noninvasive markers such as the Model for End-Stage Liver Disease (MELD), Child-Pugh score, and aspartate aminotransferase (AST) to platelet count index appear to lack sufficient sensitivity to screen for high-risk varices.[1,19]

Clinical factors associated with variceal hemorrhage have been studied in 240 patients with bleeding varices and compared with 240 nonbleeding patients matched for cirrhosis and degree of decompensation. Constipation, vomiting, severe coughing, and excessive ethanol consumption all were associated with the risk of variceal hemorrhage.[12]

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....