They are designed for health professionals to use. You may find the Vomiting Blood Hepatitis Varizen article more useful, or one of our other health articles. Variceal haemorrhage occurs from dilated veins varices at the junction between the portal and systemic venous systems. The majority of patients with variceal bleeding have chronic liver disease. Bleeding is characteristically severe and may be life-threatening.
The size of the varices and their tendency to bleed are directly related to the portal pressure, Hepatitis Varizen, which is usually directly related to the severity of underlying liver disease. Large varices with red spots are at highest risk of rupture. The causes of oesophageal varices are anything that can cause portal hypertension. Some examples are in the table that follows. Endoscopy is required at an early stage. Management for acute variceal haemorrhage consists of vasoactive drugs, endoscopic band ligation and antibiotics prophylaxis.
Transjugular intrahepatic portosystemic shunt TIPS is reserved for those who do not respond or are unlikely to respond to initial standard management, Hepatitis Varizen. The use of measures of hepatic vein pressure gradient with an aim to reduce it under 12 mm Hg is associated with a significant reduction in mortality. Hepatitis Varizen you find this information useful? Isr Med Assoc J. Epub Sep 5. UK guidelines on the management of variceal haemorrhage in cirrhotic patients ; British Society of Gastroenterology Lee SD, Hepatitis Varizen DJ ; A randomized controlled trial of gastric lavage prior to endoscopy for acute upper gastrointestinal bleeding.
N Engl J Med. Cochrane Database Syst Rev. D'Amico G, Hepatitis Varizen, Pagliaro L, Pietrosi G, et al ; Emergency sclerotherapy versus vasoactive drugs for bleeding oesophageal varices in cirrhotic patients. Qazi SA, Khalid Hepatitis Varizen, Hameed AM, et al ; Transabdominal gastro-esophageal devascularization and esophageal transection for bleeding esophageal varices after failed injection sclerotherapy: Thalheimer U, Mela M, Patch D, et al ; Monitoring target reduction in hepatic venous pressure gradient during pharmacological therapy of portal hypertension: Current strategies and new perspectives.
This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all Hepatitis Varizen care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions.
Patient professional reference Professional Reference Hepatitis Varizen are written by UK doctors and are based on research evidence, UK and European Guidelines. In this article arrow-down Epidemiology arrow-down Aetiology arrow-down Factors that increase the risk of variceal bleeding arrow-down Presentation arrow-down Investigations arrow-down Differential diagnosis arrow-down Management arrow-down Prevention arrow-down Prognosis.
In Western countries, Hepatitis Varizen, alcoholic and viral cirrhosis are the leading causes of portal hypertension and oesophageal varices. Aetiology The causes of oesophageal varices are anything that can cause portal hypertension. Causes of oesophageal varices, Hepatitis Varizen. Why not subcribe to the newsletter? We would love to hear your feedback! Subscribe to our newsletter.
Further reading and references. Related Information Vomiting Blood Haematemesis. Join the discussion on the forums. Health Tools Feeling unwell? Assess your symptoms online with our free symptom checker, Hepatitis Varizen. Increased portal blood flow - fistula. Cirrhosis due to various causes, including alcoholic hepatitis and chronic hepatitis eg, viral or autoimmune.
Idiopathic portal hypertension hepatoportal sclerosis. Acute hepatitis especially alcoholic, Hepatitis Varizen. Compression eg, Hepatitis Varizen, from tumour.
Constrictive pericarditis and rarely right-sided heart failure.
Apr 25, Author: They are native veins that serve as collaterals to the central venous circulation when flow through the portal venous system or superior vena cava SVC is obstructed, Hepatitis Varizen.
Esophageal varices are collateral veins within the wall of the esophagus that project directly into the lumen. The veins are of clinical concern because they are prone to hemorrhage, Hepatitis Varizen.
Paraesophageal varices are collateral veins beyond the adventitial surface of the esophagus that parallel intramural esophageal veins. Paraesophageal varices are less prone to hemorrhage. Esophageal and paraesophageal varices are slightly different in venous origin, but they are usually found together. Using a thin-barium technique, radiographic appearances of esophageal varices were described first by Wolf in his paper, "Die Erkennug von osophagus varizen im rontgenbilde," or "Radiographic detection of esophageal varices.
Today, more sophisticated imaging with computed tomography CT scanning, magnetic resonance imaging MRImagnetic resonance angiography MRAHepatitis Varizen, and Hepatitis Varizen ultrasonography EUS plays an important role in the evaluation of portal hypertension and Hepatitis Varizen varices.
Endoscopy is the criterion standard for evaluating esophageal varices and assessing the bleeding risk, Hepatitis Varizen.
The procedure involves using a flexible endoscope inserted into the patient's mouth and through the esophagus to inspect the mucosal surface. The Hepatitis Varizen varices are also inspected for red wheals, which are dilated intra-epithelial veins under tension and which carry a Hepatitis Varizen risk for bleeding.
The grading of esophageal varices and identification of red wheals by endoscopy predict a patient's bleeding risk, on which treatment is Hepatitis Varizen. Endoscopy is also used for interventions.
The following pictures demonstrate band ligation of esophageal varices. CT scanning and MRI are identical in their usefulness in diagnosing and evaluating the extent of esophageal varices.
These modalities have an advantage over endoscopy because CT scanning and MRI can help in evaluating the surrounding anatomic structures, Hepatitis Varizen, both above and below the diaphragm, Hepatitis Varizen.
CT scanning and MRI are also valuable in evaluating Hepatitis Varizen liver and the entire portal circulation. These modalities are used in preparation for a transjugular intrahepatic portosystemic shunt TIPS procedure or liver transplantation and in evaluating for a specific etiology of esophageal varices, Hepatitis Varizen.
These modalities also have an advantage over both endoscopy and angiography because they are noninvasive, Hepatitis Varizen. CT scanning and MRI do not have strict criteria for evaluating the bleeding risk, and they are not as sensitive or specific as endoscopy.
CT scanning and MRI may be used as alternative methods in making the diagnosis if endoscopy is contraindicated eg, in patients with a recent myocardial infarction Beule am Bein mit Krampfadern any contraindication to sedation. In the past, Hepatitis Varizen, angiography was considered the criterion standard for evaluation of the portal venous system.
However, Hepatitis Varizen, current CT scanning and MRI procedures have become equally sensitive and specific in the detection of esophageal varices and other abnormalities of the portal venous system, Hepatitis Varizen. Although the surrounding anatomy cannot be evaluated the way they can be with CT scanning or MRI, angiography is advantageous because its use may be therapeutic as well as diagnostic.
Ultrasonography, excluding EUS, and nuclear medicine studies are of minor significance in the evaluation of esophageal varices. Although endoscopy is the criterion standard in diagnosing and grading esophageal varices, the anatomy outside of the esophageal mucosa cannot be evaluated with this technique. Barium swallow examination is not a sensitive test, and Hepatitis Varizen must be performed carefully with close attention to the amount of barium used and the degree of esophageal distention.
However, in severe disease, esophageal varices may be prominent. CT scanning and MRI are useful in evaluating other associated abnormalities and adjacent anatomic structures in the abdomen or thorax.
On MRIs, surgical clips may create artifacts that obscure portions of the portal venous system. Disadvantages of CT scanning include the possibility of adverse reactions to the contrast agent and an inability to quantitate portal venous flow, which is an advantage of MRI and ultrasonography. Plain radiographic findings are insensitive and nonspecific in the evaluation of esophageal varices.
Plain radiographic findings may suggest paraesophageal varices. Anatomically, Hepatitis Varizen, paraesophageal varices are outside the esophageal wall and may create abnormal opacities. Esophageal varices are within the wall; therefore, they are concealed in the normal shadow of the esophagus.
Ishikawa et al described chest radiographic findings in paraesophageal varices in patients with portal hypertension, [ 14 ] and the most common was obliteration of a short or long segment of the descending aorta without a definitive mass shadow. Other plain radiographic findings included a posterior mediastinal mass and an apparent intraparenchymal mass, Hepatitis Varizen.
On other images, Hepatitis Varizen, the intraparenchymal masses were confirmed to be varices in the region of the pulmonary ligament, Hepatitis Varizen. On plain radiographs, a downhill varix may be depicted as a dilated azygous vein that is out of proportion to the pulmonary vasculature.
In Hepatitis Varizen, a widened, superior mediastinum may be shown. A widened, Hepatitis Varizen, superior mediastinum may result from dilated collateral veins or the obstructing mass. Endoscopy is the criterion standard Hepatitis Varizen for diagnosing esophageal varices. Barium studies may be of benefit if the patient has a contraindication to endoscopy or if endoscopy is not available see the images below.
Pay attention to technique to optimize detection of esophageal varices. The procedure should be performed with the patient in the supine or slight Trendelenburg position. These positions enhance gravity-dependent flow and engorge the vessels. The patient should be situated in an oblique projection and, therefore, Hepatitis Varizen, in a right anterior oblique position to the image intensifier and a left posterior oblique position to the table. This positioning prevents overlap with the spine and further enhances venous flow.
A thick barium suspension or paste should be used to increase adherence to the mucosal surface. Ideally, single swallows of a small amount of barium should be ingested to minimize peristalsis and to prevent overdistention of the esophagus, Hepatitis Varizen.
If the ingested bolus is too large, the esophagus may be overdistended with dense barium, and the mucosal surface may be smoothed out, rendering esophageal varices invisible. In addition, a full column of dense barium may white out any findings of esophageal varices. Too many contiguous swallows create a powerful, Hepatitis Varizen, repetitive, stripping wave of esophageal peristalsis that squeezes blood out of the varices as it progresses caudally. Effervescent crystals may be used to provide air contrast, but crystals may also cause overdistention of the esophagus with gas and thereby hinder detection of esophageal varices, Hepatitis Varizen.
In addition, Hepatitis Varizen, crystals may create confusing artifacts in the form of gas bubbles, which may mimic small varices.
The Valsalva maneuver may be useful to further enhance radiographic detection of esophageal varices. The patient is asked to "bear down as if you are having a bowel movement" or asked to "tighten your stomach muscles as if you were doing a sit-up. The Valsalva maneuver also traps barium in the distal esophagus and allows retrograde flow for an even coating.
Plain Thrombophlebitis, Blutverdünner findings suggestive of paraesophageal varices are very nonspecific. Any plain radiographic findings suggesting paraesophageal varices should be followed up with CT scanning or a barium study to differentiate the findings from a Hepatitis Varizen hernia, posterior mediastinal mass, or other abnormality eg, Hepatitis Varizen, rounded atelectasis.
Similarly, barium studies or CT scan findings suggestive of esophageal varices should be followed up with endoscopy. Endoscopic follow-up Hepatitis Varizen can be used to evaluate the grade and appearance of esophageal varices to assess the bleeding risk. The results of this assessment direct treatment. In review case studies, a single thrombosed esophageal varix may be confused with an esophageal mass on barium studies. With endoscopy, the 2 entities can be differentiated easily.
The only normal variant is a hiatal Hepatitis Varizen. The rugal fold pattern of a hiatal hernia may be confused with esophageal varices; however, a hiatal hernia can be identified easily by the presence of the B line marking the gastroesophageal junction, Hepatitis Varizen. CT scanning is an excellent method for detecting moderate to large esophageal varices and for evaluating the entire portal venous system.
CT scanning is a minimally invasive imaging modality that involves the use of only a peripheral intravenous line; therefore, it is a Hepatitis Varizen attractive method than angiography or endoscopy in the evaluation of the portal venous system see the images below. A variety of techniques have been described for the CT evaluation of the portal venous system.
Most involve a helical technique with a pitch of 1. The images are reconstructed in 5-mm increments.
The amount of contrast material and the delay time are slightly greater than those in conventional helical CT scanning of the abdomen. The difference in technique ensures adequate opacification of both the portal venous and mesenteric arterial systems. On nonenhanced studies, esophageal varices may not be depicted well. Only a thickened esophageal wall may Hepatitis Varizen found.
Paraesophageal varices may appear as enlarged lymph nodes, posterior mediastinal masses, or a collapsed hiatal hernia. On contrast-enhanced images, esophageal varices appear as homogeneously enhancing tubular or serpentine structures projecting into the lumen of the esophagus. Hepatitis Varizen appearance of Hepatitis Varizen is identical, but it is parallel to the esophagus instead of projecting into the lumen. Paraesophageal varices are easier to detect than esophageal varices because of the contrast of the surrounding lung and mediastinal fat, Hepatitis Varizen.
On contrast-enhanced CT scans, downhill esophageal varices may have an appearance similar to that of uphill varices, Hepatitis Varizen, varying only in location. Because the etiology of downhill esophageal varices is usually secondary to superior vena cava SVC obstruction, Hepatitis Varizen, the physician must be aware of other potential collateral pathways that may suggest the diagnosis. Stanford et al published data based on venography, [ 19 ] Hepatitis Varizen 4 patterns of flow in the setting of SVC obstruction as follows [ 19 ]:.
In a retrospective investigation, Cihangiroglu et al analyzed CT scans from 21 studies of patients with SVC obstruction [ 20 ] and described as many as 15 Hepatitis Varizen collateral pathways. Of their total cohorts, only 8 could be characterized by using the Stanford classification. In the setting of SVC obstruction, the most common collateral pathways were the in decreasing order of frequency: In a Hepatitis Varizen by Zhao et al of row multidetector CT portal venography for characterizing paraesophageal varices in 52 patients with portal hypertensive cirrhosis and esophageal varices, [ 21 ] 50 of the 52 cases showed an origin from the posterior branch of left gastric vein, whereas the others were from the anterior branch.
Fifty cases Hepatitis Varizen their locations close to the esophageal-gastric junction; the other 2 cases were extended to the inferior bifurcation of the trachea. Forty-three patients in the Zhao et al study showed the communications between paraesophageal varices and periesophageal varices, whereas the hemiazygous vein 43 Hepatitis Varizen and IVC 5 cases were also involved. CT scanning is a minimally invasive method used to detect moderate to large esophageal varices and to evaluate the entire portal venous system.
CT scans also help in evaluating the liver, other venous collaterals, details of other surrounding anatomic structures, Hepatitis Varizen the patency of the portal vein. In these situations, CT scanning has a major advantage over endoscopy; however, unlike endoscopy, CT scans are not useful in predicting variceal hemorrhage.
Compared with angiography, CT scanning is superior in detecting paraumbilical and retroperitoneal varices and at providing a more thorough examination of Hepatitis Varizen portal venous system without the risk of intervention. In the detection of esophageal varices, CT scanning is slightly better than angiography.
CT scanning and angiography are approximately equal in the detection of varices smaller than 3 mm. If CT scans do not demonstrate small varices, they are unlikely to be seen on angiograms. Contrast-enhanced CT scanning is essential for evaluating esophageal varices. Contrast enhancement greatly increases the sensitivity and specificity of the examination and reduces the rate of false-positive or false-negative results.
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