Zdravniški Vestnik (May 2005)
Therapy and prevention of esophageal varices hemorrhage
Abstract
Background: Bleeding from esophageal varices is a life threatening situation for a patient with portal hypertension. Esophageal varices are dilated veins in the submucosal layer of the esophagus. The dilatation of submucosal veins is the consequence of elevated pressure in the portal vein. Portal hypertension mostly stems from liver cirrhosis. The mortality rate of patients with bleeding esophageal varices is high. Therefore, primary-prevention of the first episode of bleeding is very important. Patients with a bleeding esophageal varice must be admitted to hospital. It is very important that loss in blood volume is substituted with IV infusions even before the admission to hospital. If the patient is bleeding from the upper part of the gastrointestinal tract and has clinical signs of liver cirrhosis and portal hypertension due to the larger probability that the source of the bleeding is the esophageal varix, then even before admission to hospital one can start with IV application of medications for lowering portal vein pressure. This may diminish or even stop the bleeding. After admission an urgent diagnostic esophago-gastro-duodenoscopy should be done as soon as possible in order to determine the source of bleeding. If it is possible, the bleeding should be stopped with endoscopic therapy. After successful endoscopic therapy we continue with the substitution of the loss in blood volume with IV infusion and transfusion and also with IV applications of the medications for lowering portal vein pressure in order to prevent an early re-occurence in bleeding. In cases where the bleeding cannot be stopped with endoscopic therapy, the patient needs urgent Transjugular Intrahepatic Portosystemic Shunt placement or urgent surgical shunt formation. While organizing the above mentioned procedures, we can try to stop the bleeding using a balloon tamponade and IV application of medications for lowering portal vein pressure. After the first bleeding from esophageal varices the patient needs secondary-prevention in order to prevent repeated episodes of variceal hemorrhage.Conclusions: Esophageal varice hemorrhaging worsens the prognosis of the patient with portal hypertension. Primaryprevention of the initial variceal hemorrhage, good selection and application of the right therapy on-time when the varice is bleeding and secondary-prevention of repeated episodes of variceal hemorrhage can improve the prognosis of patients with portal hypertension.
