eMedicine Specialties > Radiology > Gastrointestinal

Esophageal Varices: Follow-up

Author: Cenon Buencamino, MD, Department of Medical Imaging, St. Mary's Hospital and Medical Center
Contributor Information and Disclosures

Updated: Nov 5, 2008

Intervention

On the detection of esophageal varices before the first occurrence of hemorrhage, medical therapy with propranolol or other nonselective beta-blockers is attempted as the initial treatment method. If the esophageal varices are of higher endoscopic grade, sclerotherapy or variceal ligation may be performed. In the setting of acute esophageal variceal hemorrhage, control of bleeding can be accomplished endoscopically in 80-90% of patients. Radiologic interventions in the treatment and management of esophageal varices include placement of a TIPS, embolization of the esophageal varices, or both.

TIPS is a minimally invasive procedure performed through the jugular vein (preferably the right), in which a shunt between the hepatic and portal veins is created to provide decompression of the portal venous system. The procedure is performed in the setting of acute or recurrent esophageal variceal bleeding that cannot be controlled medically or endoscopically.

Other indications for TIPS, other than control of esophageal variceal hemorrhage, include refractory ascites, cirrhotic hydrothorax, or portal gastropathy. TIPS can be performed as a bridge to eventual liver transplantation. To date, no significant data have demonstrated a benefit of TIPS in the prevention of refractory or recurrent hemorrhage in patients with Child class A esophageal varices or in the prevention of initial variceal hemorrhage.

Contraindications to TIPS include right- or left-sided heart failure, cardiac valve insufficiency, fulminate hepatic failure, unrelieved biliary obstruction, polycystic liver disease, hepatic malignancy, and portal vein thrombosis.

TIPS entails venous access through the right jugular vein with a micropuncture catheter set. The left internal jugular vein or right external jugular vein may be used if the right internal jugular vein is occluded.

  • A long 10-12F catheter is advanced down the SVC and into the right hepatic vein. The right hepatic vein is preferred because of its size and proximity to the portal vein.
  • A TIPS needle (16-gauge [16G] Colapinto, 21G Angiodynamics, or 14G Rosch-Uschida needle) is directed caudally and anteriorly toward the right portal vein. The right portal vein is approximately 0.5-1.5 vertebral-body widths to the right of the lateral margin of the spine between the 10th and 12th ribs.
  • A small amount of contrast material may be injected into the periportal region to further aid localization.
  • Once the portal vein is accessed, a floppy tip guidewire is advanced into the splenic or superior mesenteric vein, over which a 5F catheter is inserted into the main portal vein.
  • The portosystemic gradient can be measured at this time by retrieving the sheath to the level of the right atrium. The central venous pressure can be measured in relation to portal venous pressure.
  • A portal venogram may be obtained at this time.
  • Then, the catheter can be exchanged for an 8-mm balloon for angioplasty of the parenchymal segment.
  • A wall stent is deployed over the balloon. Commonly used stents include the self-expanding Nitinol, Smart, and Symphony stents, which have minimal or no shortening once they are deployed and which can create high amounts of radial force.

The goal of the TIPS procedure is to reduce the portosystemic gradient to less than 12 mm Hg. TIPS is successful in controlling esophageal variceal hemorrhage in approximately 97% of patients; however, a significant rebleeding rate of 5-32% is seen at 2 years. Most of the hemorrhage recurrence is within the first 6 months; this observation is comparable to recurrence after endoscopic therapy. Early complications include stent migration, thrombosis, or shunt dysfunction, as demonstrated by slow flow secondary to a competing shunt. Later complications include hepatic vein stenosis and pseudointimal hyperplasia within the stent lumen. The criterion standard method for detecting shunt stenosis is venography.

Stenosis is defined as a greater than 50% reduction of the shunt diameter. The preferred method for follow-up imaging after a TIPS procedure is Doppler ultrasonography. Doppler ultrasonography is an excellent noninvasive method for evaluating TIPS patency and flow. A baseline study should be performed the day after the procedure and then at 1 month, 3 months, 6 months, and then every 6 months.

TIPS patency is evaluated by measuring the shunt velocity in the proximal, distal, and middle portions. Direction of portal venous flow should be evaluated. The 1-year patency rate of TIPS is 20-66%. TIPS is associated with a morbidity rate of 10-20%, with a mortality rate of 1-2% immediately after the procedure. Major morbidities include portosystemic encephalopathy (17-36%), right- or left-sided heart failure, and intraperitoneal bleeding secondary to transcapsular puncture (up to 30%). Most morbidity is related to changing postprocedural flow dynamics and to bypassing the liver to clear metabolic toxins.

The role of embolization in acute esophageal variceal hemorrhage is controversial. Variceal embolization may be performed at the time of the TIPS procedure, or it may be performed by a percutaneous/transhepatic procedure to control bleeding. Embolization materials include ethanol, stainless steel coils, or bucrylate. Embolic agents are deployed or injected after selective catheterization of the left gastric vein.

In a study by L'Herminé et al involving 400 patients with variceal embolization, bleeding was controlled in 83%.24 Recurrence occurred in almost 60% of patients in the first 6 months and 80% in 2 years. The study was performed before the TIPS procedure; therefore, data are from patients with uncorrected underlying portal hypertension. Theoretically, performing the TIPS procedure before embolization therapy may decrease the risk of rebleeding; however, no strong clinical data suggest that TIPS and embolization versus TIPS alone is better in preventing recurrent hemorrhage.

Medicolegal Pitfalls

  • Misdiagnosis and failure to diagnose esophageal varices are the only major medical-legal issues.
  • Russo et al compared the cost effectiveness of TIPS procedure versus endoscopic therapy for recurrent variceal hemorrhage. The group analyzed costs of the procedure and hospitalizations of patients undergoing TIPS, sclerotherapy, or ligation at 2 medical centers. The authors concluded that, in patients with recurrent hemorrhage, the TIPS procedure has lower recurrent variceal bleeding rates and is more cost-effective in the short-term than endoscopic therapy.

See also the Medscape topic Medical Malpractice and Legal Issues.

Special Concerns

  • In children, esophageal varices are a consequence of extrahepatic obstruction of the portal vein rather than parenchymal liver disease.
    • Portal venous thrombosis may result from dehydration, sepsis, umbilical vein catheterization, and abdominal infection.
    • The diagnosis of esophageal varices is difficult, because all clinical laboratory, physical examination, and biopsy results may be normal.
    • Esophageal varices may be seen on images such as barium studies, CT scans, or MRIs.
  • Detection is important because esophageal varices are a major cause of upper gastrointestinal bleeding in children.
    • After detection, sclerotherapy and variceal ligation have been shown to be superior treatment modalities.
    • TIPS and surgical shunts may also be considered, although success rates are not as promising.
 


More on Esophageal Varices

Overview: Esophageal Varices
Imaging: Esophageal Varices
Follow-up: Esophageal Varices
Multimedia: Esophageal Varices
References
Further Reading
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Further Reading

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. American Association for the Study of Liver Diseases - Private Nonprofit Research Organization
American College of Gastroenterology - Medical Specialty Society.  1997 (revised 2007 Sep).  17 pages.  NGC:005907

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Keywords

esophageal varices, esophageal varix, paraesophageal varices, portal hypertension, gastric varices, esophageal disease, dilated veins of the esophagus, SVC flow obstruction, portal venous flow obstruction, uphill varices, downhill varices, esophageal varix, esophageal hemorrhage, variceal hemorrhage, upper gastrointestinal hemorrhage, upper GI bleeding, cirrhosis

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Contributor Information and Disclosures

Author

Cenon Buencamino, MD, Department of Medical Imaging, St. Mary's Hospital and Medical Center
Cenon Buencamino, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Radiological Society of North America, Society of Thoracic Radiology, and State Medical Society of Wisconsin
Disclosure: Nothing to disclose.

Medical Editor

Zahir Amin, MD, MBBS, MRCP, FRCR, Consulting Staff, Department of Imaging, University College Hospital, UK
Zahir Amin, MD, MBBS, MRCP, FRCR is a member of the following medical societies: British Institute of Radiology, British Medical Association, and Royal College of Radiologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Abraham H Dachman, MD, FACR, Professor, Department of Radiology, The University of Chicago School of Medicine; Director of CT, Department of Radiology, The University of Chicago Hospitals
Abraham H Dachman, MD, FACR is a member of the following medical societies: Radiological Society of North America
Disclosure: iCAD, Inc. Consulting fee Consulting; iCAD, Inc. Grant/research funds Other; GE Healtcare, Inc. Honoraria Speaking and teaching

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Clinical Assistant Professor of Radiology, University of Washington Medical School
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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