9.10 : Esophageal Varices-II: Clinical Features and Management

Esophageal varices often manifest as gastrointestinal bleeding episodes, presenting symptoms like hematemesis (vomiting of blood), hematochezia (passing fresh blood via the rectum), and melena (black, tarry stools). Other signs can include weight loss, anorexia, abdominal discomfort, jaundice, pruritus, altered mental status, and muscle cramps.

In the initial assessment, a thorough review of the patient's medical history is vital to identify risk factors such as liver disease, alcohol abuse, or viral hepatitis. Hemodynamic stability assessment is essential to detect active bleeding, focusing on signs like hypotension and tachycardia. Physical examination may involve:

1. Liver palpation/percussion.
2. Checking for splenomegaly or ascites.
3. Observing visible abdominal collateral circulation.

Laboratory tests should assess anemia, thrombocytopenia, liver enzyme levels, prothrombin time, albumin levels, and blood urea nitrogen (BUN).

Imaging studies, including upper endoscopy (EGD) and CT or MRI scans, are critical for visualizing varices, grading them, and evaluating liver and portal vein abnormalities.

Portal hypertension measurement, often associated with liver conditions, can be done indirectly by inserting a catheter into a hepatic vein under fluoroscopy and then inflating a balloon for pressure measurements. A hepatic venous pressure gradient (HVPG) exceeding 10 mmHg indicates significant portal hypertension. Direct measurement methods involve catheter placement in the portal vein or its branches.

Medical management typically involves transferring patients to the intensive care unit for close monitoring. IV fluids, electrolytes, and volume expanders are administered to stabilize fluid volume and electrolytes. Pharmacologic therapy for suspected variceal bleeding includes vasoactive drugs like octreotide or vasopressin, administered as soon as possible and before endoscopy.

Endoscopic therapies include:

1. Balloon Tamponade Therapy: A balloon applies pressure and controls bleeding.
2. Endoscopic Variceal Ligation: Ties off varices using an endoscope, reducing bleeding risk.
3. Transjugular Intrahepatic Portosystemic Shunt (TIPS): Creates a shunt to divert blood flow and reduce portal vein pressure.
4. Surgical Bypass Procedures: Create alternative blood pathways to bypass the liver.

Nurses are crucial in monitoring mental status and vital signs, administering medications, educating patients, and coordinating care. They also monitor for complications like hepatic encephalopathy and infections, administering antibiotic prophylaxis as necessary. Discharge preparation includes ensuring bleeding cessation and stable hemodynamics.