Here we have varices.
Esophageal varices to you, first, first
place that you’re going to turn to
for pathology in the origin of esophageal
varices would be the liver, okay?
Now, before we get there, what’s going on and
what you’re going to find in your esophagus?
Varices means dilation of
the veins, esophageal veins.
They’re known as the cardiac veins and… make sure that
you know from anatomy your portocaval anastomosis.
Three different and I like the
pneumonic, it’s cute: Head-Butt-Caput.
Head - esophageal varices;
region, obviously not the head.
Head region, esophageal varices.
Butt - hemorrhoids.
Caput - caput medusa.
These are the three major areas of porto - portal
vein, caval - inferior vena cava, anastomosis.
These will be the areas in which, if your patient,
in the liver, results in portal hypertension.
Close your eyes, think
about the portal vein.
The portal vein - the splenic vein and the
superior mesenteric vein will come together.
These two veins form the portal
vein draining into the liver.
At any point in time, if there is obstruction of
the portal vein draining into the liver such as
cirrhosis, such as Budd-Chiari with hepatic vein
thrombosis backing up or portal vein thrombosis.
You call this pre-hepatic portal hypertension,
portal hypertension - hepatic, or
post-hepatic portal hypertension.
Are you with me?
From henceforth, portal hypertension,
there are many differentials.
Don’t always think that
it’s always cirrhosis.
Any time the journey of your portal vein to the liver, if it’s
been impeded or result in portal hypertension, what happens?
You increase your hydrostatic pressure in
three different places - Head-Butt-Caput.
Are you with me now?
Of all the three places,
which one’s the emergency?
It ain’t the hemorrhoids.
Its esophageal varices.
If this ruptures, your patient actually
may suffocate on his or her blood.
This is an emergency.
So all jokes aside, let’s get serious.
Portal hypertension is your point; most common cause of
massive upper GI bleeding, high mortality, 30% within 2 weeks.
noted in 70%, one year.
Early endoscopy for diagnosis and treatment and beta-blockers,
beta-blockers, beta-blockers, reduced
the recurrent bleeding by 50%.
That is pretty impressive.
We’ll do an upper endoscopy
here yet once again.
This time you’ll notice the following, you’ll notice
that here that the esophagus not nice and smooth.
You got these bulges.
You could find a little bit of bleeding,
that means that this is dangerous
isn’t it because with the varices,
it’s what’s actually happening here.
Why do you find the bulges?
Because the esophageal veins, secondary
to portal hypertension resulting in
that increased hydrostatic pressure,
is causing engorgement of the veins.
Hence the hemorrhoids, hence the caput
medusa, hence the esophageal varices.
Here you can actually notice
it on upper endoscopy.
This is an emergency.
Acute episode, resuscitation and
correction of coagulopathy is important.
for airway protection.
Endoscopic band ligation
IV octreotide to
decrease portal pressure.
Now, that portal pressure which is going to be for the most
part, the next set of… the next couple of bullet points here,
become important because remember the problem began at the
level of the liver or in the region with the portal vein.
There’s something called the tube
placement, known as the Blakemore.
And then you have TIPSS, which literally
you’re going to bypass the liver.
You’re creating a
portocaval type of shunt.
Okay, so it’s a transhepatic
type of portal shunt.
So you’re going to shunt-- if for
example your patient had overdose
in acetaminophen and therefore causes damage to your liver.
Liver’s dead, you’re worried about
portal hypertension, esophageal varices.
You bypass the liver by providing
TIPSS or implementing TIPSS.
When you… transhepatic and you create a
shunt, you are directly going into the head.
The major, major, major side effect
that you’re worried about with TIPSS is
that when you bypass the liver which is
heavily, heavily involved with proper
metabolism, metabolism of your ammonia
that you are directly introducing
ammonia into the head resulting in your
encephalopathy - major side effect.
But you really… lack of a better term here,
catch 22 situation, because if it is liver
damage and you’re going to cirrhosis and such,
you’re worried about esophageal varices.
You have to bypass it but at the same time
beware that the patient may then at some point
start having this, right; encephalopathy, I’m
doing asterixis - resting flapping tremors.
Good information here.
Emergency esophageal varices,
acute episode, pay attention.
And at the very end here, when I talk to you about
TIPSS, I’ve given you few things about complications.
You are, you are
Band ligation for those that cannot tolerate the
medication, such as maybe perhaps your patient has asthma.
Why would you want to
Or be very cautious about