Varices, esophageal

Hepatobiliary disease occurs due to bile duct obstruction from abnormal bile composition and flow. Hepatomegaly, splenomegaly, and cholecystitis may be present. Hepatic steatosis may also be present due to effects of malnutrition. The progression from cholestasis (impaired bile flow) to portal fibrosis and to focal and multilobar cirrhosis, esophageal varices, and portal hypertension takes several years. Many patients are compensated and asymptomatic but maybe susceptible to acute decompensation in the event of extrinsic hepatic insult from viruses, medications, or other factors.7... 

Chronic hepatitis (disease lasting longer than 6 months) is usually associated with hepatitis B, C, and D. Chronic viral hepatitis may lead to the development of cirrhosis, which may induce end-stage liver disease (ESLD). Complications of ESLD include ascites, edema, jaundice, hepatic encephalopathy, infections, and bleeding esophageal varices. Therefore, prevention and treatment of viral hepatitis may prevent ESLD. 

Esophageal varices Dilated blood vessels in the esophagus. 

Cirrhosis results in elevation of portal blood pressure because of fibrotic changes within the hepatic sinusoids, changes in the levels of vasodilatory and vasoconstrictor mediators, and an increase in blood flow to the splanchnic vasculature. The pathophysiologic abnormalities that cause it result in the commonly encountered problems of ascites, portal hypertension and esophageal varices, HE, and coagulation disorders. 

EBL is the recommended form of endoscopic therapy for acute esophageal variceal 1A... 

Other Systemic Effects. No studies were located regarding other effects in humans following inhalation exposure to 1,4-dichlorobenzene. Ascites, esophageal varices, hemorrhoids, and tarry stools are all secondary effects of subacute, yellow atrophy and cirrhosis of the liver (Cotter 1953). 

Drugs that block j32-receptors generally have a calming effect and are prescribed for anxiety, migraine, esophageal varices, and alcohol withdrawal syndrome, among others. 

Esophageal varices IV (Sandostatin) Bolus of 25-50 meg followed by IV infusion of 25-50 mcg/hrfor48 hr. 

Unlabeled Uses Control of bleeding esophageal varices, treatment of AIDS-associated secretory diarrhea, chemotherapy-induced diarrhea, insulinomas, small-bowel fistulas, control of bleeding esophageal varices... 

G. Other applications Octreotide has been reported to be effective in treating noninfectious diarrhea and diarrhea in patients with AIDS, and as an adjunct to endoscopic variceal ligation, to reduce recurrent bleeding from esophageal varices. Micromedex lists many other potential uses. 

Vasopressin and desmopressin are treatments of choice for pituitary diabetes insipidus. The dosage of desmopressin is 10-40 meg (0.1-0.4 mL) in two to three divided doses as a nasal spray or, as an oral tablet, 0.1-0.2 mg two to three times daily. The dosage by injection is 1-4 meg (0.25-1 mL) every 12-24 hours as needed for polyuria, polydipsia, or hypernatremia. Bedtime desmopressin therapy, by intranasal or oral administration, ameliorates nocturnal enuresis by decreasing nocturnal urine production. Vasopressin infusion is effective in some cases of esophageal variceal bleeding and colonic diverticular bleeding. 

Vasopressin Available for treatment of diabetes insipidus and sometimes used to control bleeding from esophageal varices ... 

Portal hypertension most commonly occurs as a consequence of chronic liver disease. Portal hypertension Is caused by Increased blood flow within the portal venous system and increased resistance to portal flow within the liver. Splanchnic blood flow is increased in patients with cirrhosis due to low arteriolar resistance that is mediated by increased circulating vasodilators and decreased vascular sensitivity to vasoconstrictors. Intrahepatic vascular resistance is increased in cirrhosis due to fixed fibrosis within the spaces of Disse and hepatic veins as well as reversible vasoconstriction of hepatic sinusoids and venules. Among the consequences of portal hypertension are ascites, hepatic encephalopathy, and the development of portosystemic collaterals—especially gastric or esophageal varices. Varices can rupture, leading to massive upper gastrointestinal bleeding. 

Corley DA, Cello JP, Adkisson W, Ko WF, Kerhkowske K. Octreotide for acute esophageal variceal bleeding a metaanalysis. Gastroenterology 2001 120(4) 946-54. 

Although vasopressin and its analogues have been used in the acute management of bleeding esophageal varices, they do not reduce mortality (2,3) and the rate of adverse effects is higher than with octreotide (3). 

Avgerinos A. Approach to the management of bleeding esophageal varices role of somatostatin. Digestion 1998 59(Suppl l) l-22. 

Bruha R, Marecek Z, Spicak J, Hulek P, Lata J, Petrtyl J, Urbanek P, Taimr P, Volfova M, Dite P. Double-blind randomized, comparative multicenter study of the effect of terlipressin in the treatment of acute esophageal variceal and/or hypertensive gastropathy bleeding. Hepatogastroenterology 2002 49(46) 1161-6. 

Beta-receptor antagonists have been found to diminish portal vein pressure in patients with cirrhosis. There is evidence that both propranolol and nadolol decrease the incidence of the first episode of bleeding from esophageal varices and decrease the mortality rate associated with bleeding in patients with cirrhosis. Nadolol in combination with isosorbide mononitrate appears to be more efficacious than sclerotherapy in preventing re-bleeding in patients who have previously bled from esophageal varices. 

Vasopressin and desmopressin are the alternative treatments of choice for pituitary diabetes insipidus. Bedtime desmopressin therapy ameliorates nocturnal enuresis by decreasing nocturnal urine production. Vasopressin infusion is effective in some cases of esophageal variceal bleeding and colonic diverticular bleeding. 

Vasopressin [vay soe PRESS in] (antidiuretic hormone, ADH), is structurally related to oxytocin (Figure 25.5). The chemically-synthesized nonapeptide has replaced that extracted from animal posterior pituitaries. Vasopressin has both antidiuretic and vasopressor effects. In the kidney it binds to the V2 receptor to increase water permeability and resorption in the collecting tubules. Thus the major use of vasopressin is to treat diabetes insipidus. It also finds use in controlling bleeding due to esophageal varices or colonic diverticula. Other effects of vasopressin are mediated by the Vi receptor, found in vascular smooth muscle, liver and other tissues. As might be expected the major toxicity is water intoxication and hyponatremia. Headache, bronchoconstriction and tremor also can occur. Caution must be used in treating patients with coronary artery disease, epilepsy and asthma. 

A 44-year-old man with hepatitis C and cirrhosis, esophageal varices, and poorly controlled hypertension, who was also a chronic alcoholic and crack cocaine abuser, had his varices injected at endoscopy and... 

ACUTE HEMORRHAGE FROM ESOPHAGEAL VARICES Octreotide Acetate... 

Nonselective )3-blockers should be initiated in patients with medium or large esophageal varices... 

EBL is the recommended form of endoscopic therapy for acute esophageal variceal bleeding and should be used in conjunction with vasoactive drug therapy Secondary prophylaxis of variceal bleeding... 

Boyer TD, Henderson JM. Portal hypertension and bleeding esophageal varices. In Zakim D, Boyer TD, eds. Hepatology A textbook of liver disease. 4th ed. Philadelphia WB Saunders 2003. p.581-629. 

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