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Gastrointestinal (GI) System

Esophageal varices

Extremely dilated sub-mucosal veins in the lower-third of the oesophagus.

Extremely dilated sub-mucosal veins in the lower-third of the oesophagus.

History:

Timeline of historical events in classification and grading of oesophageal and gastric varices. | Abby Philips, C., & Sahney, A. (2016). Oesophageal and gastric varices: historical aspects, classification and grading: everything in one place. Gastroenterology report, 4(3), 186–195. https://doi.org/10.1093/gastro/gow018

Pathophysiology

The Calgary Guide | http://calgaryguide.ucalgary.ca/

Diagnosis

Esophagogastroduodenoscopy (EGD):

Esophageal varices seven days after banding, showing ulceration at the site of banding | Samir – Public Domain, https://commons.wikimedia.org/w/index.php?curid=3003643

Imaging:

Baveno classification of esophageal varices.:

  • Small: Minimally elevated varices above esophageal mucosal surface
  • Medium: Varices occupy < ⅓ esophageal surface
  • Large: Varices occupy > ⅓ esophageal surface

Histopathology:

  • Dilated submucosal veins (M/prominent histologic feature)

BLEED criteria:

Applied at initial emergency department evaluation and before admission, predicts hospital outcomes for patients with acute upper or lower GI hemorrhage.
Kollef MH, O’Brien JD, Zuckerman GR, Shannon W. BLEED: a classification tool to predict outcomes in patients with acute upper and lower gastrointestinal hemorrhage. Crit Care Med. 1997 Jul;25(7):1125-32. doi: 10.1097/00003246-199707000-00011. PMID: 9233736.

Forrest classification:

Endoscopic scoring system used in initial endoscopic investigation for evaluation of bleeding lesion, for the prediction of rebleeding.
Hadžibulić, E. (2008). Significance of Forrest Classification , Rockall ’ S and Blatchford ’ S Risk Scoring System in Prediction of Rebleeding in Peptic Ulcer Disease.

Rockall scoring:

Pre-endoscopic scoring system to assess the risk of re-bleeding and/or death in case of acute upper gastrointestinal bleeding
Kumar & Clark’s Clinical Medicine 9e (2016); page: 385; Box no: 13.14 and 13.15
Dr Khaled El. (2021) What is the Rockall score?. Retrieved March 03, 2021, from https://www.umqaa.com/2020/07/rockall-score.html

Glasgow-Blatchford bleeding score (GBS):

Screening tool to assess the likelihood that a person with an acute upper gastrointestinal bleeding (UGIB) will need to have medical intervention such as a blood transfusion or endoscopic intervention. The tool may be able to identify people who do not need to be admitted to hospital after a UGIB. Advantages of the GBS over the Rockall score, which assesses the risk of death in UGIB, include a lack of subjective variables such as the severity of systemic diseases and the lack of a need for oesophagogastroduodenoscopy (OGD) to complete the score, a feature unique to the GBS.
Lu Y, Barkun AN. Endoscopic Management of Acute Non Variceal Upper Gastrointestinal Bleeding. Journal of Gastroenterology and Hepatology Research 2015; 4(3): 1515-1523 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/1122

Management

Prevention & secondary prophylaxis:

Non-selective β-blockers (but not cardioselective β-blockers like atenolol)
  • Preferred because:
    • β1 blockade: ↓ cardiac output
    • β2 blockade: ↓ Vasodilation (β2 action) → ↓ Splanchnic blood flow
    • However, they do not prevent the formation of oesophagal varices.
  • Drugs:
    • Propranololtimolol or nadolol

Nitrates

  • Isosorbide mononitrate (IMN)

Endoscopic management:

Esophageal varices seven days after banding, showing ulceration at the site of banding | Samir – Public Domain, https://commons.wikimedia.org/w/index.php?curid=3003643
  • Therapeutic endoscopy (mainstay of urgent treatment)
    • Therapeutic approaches:
      • Variceal ligation
      • Banding & sclerotherapy
  • Refractory bleeding:
    • Balloon tamponade (with a Sengstaken-Blakemore tube or Minnesota tube or Linton tube)
      • Usually as a bridge to further endoscopy or treatment of the underlying cause of bleeding (usually portal hypertension)
  • Complicated variceal bleeding:
    • Esophageal devascularization operations: Sugiura procedure

Surgical management:

  • Transjugular intrahepatic portosystemic shunt (TIPS): Non-selective shunt (entire bowel blood is shunted from right portal vein to right hepatic vein)
  • Warren shunt (distal splenorenal shunt): Selective shunt (only splenic blood is shunted to left renal vein)
  • Linton shunt (proximal splenorenal shunt): Non-selective shunt (entire bowel blood shunted from portal vein to left renal vein)
  • Eks fistula shunt (portocaval shunt): Non-selective shunt (portal vein-IVC)
  • Inokuchi shunt (splenorenal shunt): Selective shunt
  • Liver transplantation

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