eMedicine Specialties > Radiology > Gastrointestinal

Esophageal Varices: Multimedia

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

Updated: Nov 5, 2008

Multimedia

<STRONG>Normal venous flow through the portal and...
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Media file 1: Normal venous flow through the portal and systemic circulation. IMC = inferior mesenteric vein; IVC = inferior vena cava; SVC = superior vena cava.
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<STRONG>Normal venous flow through the portal and...

Normal venous flow through the portal and systemic circulation. IMC = inferior mesenteric vein; IVC = inferior vena cava; SVC = superior vena cava.

<STRONG>Redirection of flow through the left gast...
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Media file 2: Redirection of flow through the left gastric vein secondary to portal hypertension or portal venous occlusion. Uphill varices develop in the distal one third of the esophagus. IMC = inferior mesenteric vein; IVC = inferior vena cava; SVC = superior vena cava.
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<STRONG>Redirection of flow through the left gast...

Redirection of flow through the left gastric vein secondary to portal hypertension or portal venous occlusion. Uphill varices develop in the distal one third of the esophagus. IMC = inferior mesenteric vein; IVC = inferior vena cava; SVC = superior vena cava.

<STRONG>Direction of venous flow with superior ve...
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Media file 3: Direction of venous flow with superior vena cava (SVC) obstruction proximal to the azygous vein. Flow is redirected through the azygous vein into the systemic circulation. Downhill varices develop in the upper one third of the esophagus. IMC = inferior mesenteric vein; IVC = inferior vena cava.
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<STRONG>Direction of venous flow with superior ve...

Direction of venous flow with superior vena cava (SVC) obstruction proximal to the azygous vein. Flow is redirected through the azygous vein into the systemic circulation. Downhill varices develop in the upper one third of the esophagus. IMC = inferior mesenteric vein; IVC = inferior vena cava.

<STRONG>Direction of flow with superior vena cava...
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Media file 4: Direction of flow with superior vena cava (SVC) obstruction involving or distal to the azygous vein. Flow is redirected through the azygous vein, the esophageal veins, and into the portal circulation. Flow enters the systemic circulation through the inferior vena cava (IVC). Downhill varices develop the entire length of the esophagus. IMC = inferior mesenteric vein.
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<STRONG>Direction of flow with superior vena cava...

Direction of flow with superior vena cava (SVC) obstruction involving or distal to the azygous vein. Flow is redirected through the azygous vein, the esophageal veins, and into the portal circulation. Flow enters the systemic circulation through the inferior vena cava (IVC). Downhill varices develop the entire length of the esophagus. IMC = inferior mesenteric vein.

<STRONG>Uphill esophageal varices. Barium swallow...
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Media file 5: Uphill esophageal varices. Barium swallow demonstrates multiple serpiginous filling defects primarily involving the lower one third of the esophagus with striking prominence around the gastroesophageal junction. The patient had cirrhosis secondary to alcohol abuse.
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<STRONG>Uphill esophageal varices. Barium swallow...

Uphill esophageal varices. Barium swallow demonstrates multiple serpiginous filling defects primarily involving the lower one third of the esophagus with striking prominence around the gastroesophageal junction. The patient had cirrhosis secondary to alcohol abuse.

<STRONG>Uphill esophageal varices on mucosal reli...
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Media file 6: Uphill esophageal varices on mucosal relief barium swallow.
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<STRONG>Uphill esophageal varices on mucosal reli...

Uphill esophageal varices on mucosal relief barium swallow.

<STRONG>Uphill esophageal varices on barium swall...
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Media file 7: Uphill esophageal varices on barium swallow.
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<STRONG>Uphill esophageal varices on barium swall...

Uphill esophageal varices on barium swallow.

Downhill esophageal varices. Mucosal relief view...
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Media file 8: Downhill esophageal varices. Mucosal relief view shows the serpiginous varicoid filling defects in the proximal esophagus, with normal distal mucosa in this patient with superior vena cava obstruction.
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Downhill esophageal varices. Mucosal relief view...

Downhill esophageal varices. Mucosal relief view shows the serpiginous varicoid filling defects in the proximal esophagus, with normal distal mucosa in this patient with superior vena cava obstruction.

Downhill esophageal varices on barium swallow exa...
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Media file 9: Downhill esophageal varices on barium swallow examination. Notice the serpiginous filling defects proximally with normal-appearing esophagus distally.
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Downhill esophageal varices on barium swallow exa...

Downhill esophageal varices on barium swallow examination. Notice the serpiginous filling defects proximally with normal-appearing esophagus distally.

Barium swallow demonstrating esophageal varices i...
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Media file 10: Barium swallow demonstrating esophageal varices involving the entire length of the esophagus. This appearance may be seen in advanced uphill varices or downhill varices secondary to superior vena cava obstruction at or below the level of the azygous vein.
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Barium swallow demonstrating esophageal varices i...

Barium swallow demonstrating esophageal varices involving the entire length of the esophagus. This appearance may be seen in advanced uphill varices or downhill varices secondary to superior vena cava obstruction at or below the level of the azygous vein.

Varices involving the entire esophagus on barium ...
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Media file 11: Varices involving the entire esophagus on barium swallow examination. Note the thickened folds with rounded expansions at the level of the gastroesophageal junction that are characteristic of esophageal varices findings on barium studies.
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Varices involving the entire esophagus on barium ...

Varices involving the entire esophagus on barium swallow examination. Note the thickened folds with rounded expansions at the level of the gastroesophageal junction that are characteristic of esophageal varices findings on barium studies.

Full-column image of the esophagus with varices t...
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Media file 12: Full-column image of the esophagus with varices throughout its entire length. Note scalloping of the borders of the filled esophagus. This sign, in conjunction with thickened folds with rounded expansions and some degree of distensibility, is pathognomonic for esophageal varices. (See also Image 16.)
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Full-column image of the esophagus with varices t...

Full-column image of the esophagus with varices throughout its entire length. Note scalloping of the borders of the filled esophagus. This sign, in conjunction with thickened folds with rounded expansions and some degree of distensibility, is pathognomonic for esophageal varices. (See also Image 16.)

<STRONG>Computed tomographic appearance of esopha...
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Media file 13: Computed tomographic appearance of esophageal varices. Arrow points to enhancing vascular structures within the wall of the esophagus projecting into the lumen.
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<STRONG>Computed tomographic appearance of esopha...

Computed tomographic appearance of esophageal varices. Arrow points to enhancing vascular structures within the wall of the esophagus projecting into the lumen.

<STRONG>Computed tomography scan shows large, enh...
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Media file 14: Computed tomography scan shows large, enhancing paraesophageal varices just to the left of the esophagus. Note the ascites and cirrhosis.
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<STRONG>Computed tomography scan shows large, enh...

Computed tomography scan shows large, enhancing paraesophageal varices just to the left of the esophagus. Note the ascites and cirrhosis.

<STRONG>Computed tomography sections demonstrate ...
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Media file 15: Computed tomography sections demonstrate esophageal varices protruding into the lumen, as well as paraesophageal varices.
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<STRONG>Computed tomography sections demonstrate ...

Computed tomography sections demonstrate esophageal varices protruding into the lumen, as well as paraesophageal varices.

<STRONG>Computed tomography scan showing esophage...
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Media file 16: Computed tomography scan showing esophageal varices. Note the extensive collateralization within the abdomen adjacent to the spleen as a result of severe portal hypertension.
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<STRONG>Computed tomography scan showing esophage...

Computed tomography scan showing esophageal varices. Note the extensive collateralization within the abdomen adjacent to the spleen as a result of severe portal hypertension.

<STRONG>Maximum intensity projection magnetic res...
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Media file 17: Maximum intensity projection magnetic resonance image of the normal portal venous system. PV = portal vein; SMV = superior mesenteric vein; SV = splenic vein. Courtesy of Ali Shirkhoda, MD, William Beaumont Hospital, Royal Oak, Mich.
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<STRONG>Maximum intensity projection magnetic res...

Maximum intensity projection magnetic resonance image of the normal portal venous system. PV = portal vein; SMV = superior mesenteric vein; SV = splenic vein. Courtesy of Ali Shirkhoda, MD, William Beaumont Hospital, Royal Oak, Mich.

<STRONG>Maximum intensity projection magnetic res...
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Media file 18: Maximum intensity projection magnetic resonance image of the portal venous system. A = abdominal aorta; AS = spleen; IVC = inferior vena cava; L = liver. Courtesy of Ali Shirkhoda, MD, William Beaumont Hospital, Royal Oak, Mich.
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<STRONG>Maximum intensity projection magnetic res...

Maximum intensity projection magnetic resonance image of the portal venous system. A = abdominal aorta; AS = spleen; IVC = inferior vena cava; L = liver. Courtesy of Ali Shirkhoda, MD, William Beaumont Hospital, Royal Oak, Mich.

<STRONG>Maximum intensity projection magnetic res...
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Media file 19: Maximum intensity projection magnetic resonance image of the portal venous system demonstrates extensive esophageal varices (arrows) in conjunction with splenic and gastric varices. L = liver. Courtesy of Ali Shirkhoda, MD, William Beaumont Hospital, Royal Oak, Mich.
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<STRONG>Maximum intensity projection magnetic res...

Maximum intensity projection magnetic resonance image of the portal venous system demonstrates extensive esophageal varices (arrows) in conjunction with splenic and gastric varices. L = liver. Courtesy of Ali Shirkhoda, MD, William Beaumont Hospital, Royal Oak, Mich.

More on Esophageal Varices

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

  1. Cotran RS, Kumar V, Collins T, eds. Robbins Pathologic Basis of Disease. 6th ed. Philadelphia, Pa: WB Saunders Co; 1999:845-901.

  2. Sherlock S, Dooley J. Diseases of the Liver and Biliary System. 10th ed. Oxford, United Kingdom: Blackwell Science; 1997:135-80.

  3. Wolf G. Die Erkennug von osophagus varizen im rontgenbilde. Fortsch Roentgenstr Nuklearmed Ergenzungsband. 1928;37:890-3.

  4. Gazelle GS, Saini S, Mueller PR, eds. Hepatobiliary and Pancreatic Radiology: Imaging and Intervention. New York, NY: Thieme Medical Pub; 1998:294-317.

  5. Gore RM, Livine MS, eds. Textbook of Gastrointestinal Radiology. 2nd ed. Philadelphia, Pa: WB Saunders Co; 2000:454-63, 2082.

  6. Lee JKT, Sagel SS, Stanley RJ, Heiken JP, eds. Computed Body Tomography with MRI Correlation. Philadelphia, Pa: Lippincott Williams & Wilkins; 1998:645-6.

  7. Lefkovitz Z, Cappell MS, Kaplan M, Mitty H, Gerard P. Radiology in the diagnosis and therapy of gastrointestinal bleeding. Gastroenterol Clin North Am. Jun 2000;29(2):489-512. [Medline].

  8. Pieters PC, Miller WJ, DeMeo JH. Evaluation of the portal venous system: complementary roles of invasive and noninvasive imaging strategies. Radiographics. Jul-Aug 1997;17(4):879-95. [Medline]. [Full Text].

  9. Felson B, Lessure AP. "Downhill" varices of the esophagus. Dis Chest. Dec 1964;46:740-6. [Medline]. [Full Text].

  10. The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med. Oct 13 1988;319(15):983-9. [Medline].

  11. Nevens F, Bustami R, Scheys I, Lesaffre E, Fevery J. Variceal pressure is a factor predicting the risk of a first variceal bleeding: a prospective cohort study in cirrhotic patients. Hepatology. Jan 1998;27(1):15-9. [Medline]. [Full Text].

  12. Luketic VA, Sanyal AJ. Esophageal varices. I. Clinical presentation, medical therapy, and endoscopic therapy. Gastroenterol Clin North Am. Jun 2000;29(2):337-85. [Medline].

  13. Wojtowycz AR, Spirt BA, Kaplan DS, Roy AK. Endoscopic US of the gastrointestinal tract with endoscopic, radiographic, and pathologic correlation. Radiographics. Jul 1995;15(4):735-53. [Medline]. [Full Text].

  14. Ishikawa T, Saeki M, Tsukune Y, et al. Detection of paraesophageal varices by plain films. AJR Am J Roentgenol. Apr 1985;144(4):701-4. [Medline]. [Full Text].

  15. Perri RE, Chiorean MV, Fidler JL, Fletcher JG, Talwalkar JA, Stadheim L, et al. A prospective evaluation of computerized tomographic (CT) scanning as a screening modality for esophageal varices. Hepatology. May 2008;47(5):1587-94. [Medline].

  16. Mifune H, Akaki S, Ida K, Sei T, Kanazawa S, Okada H. Evaluation of esophageal varices by multidetector-row CT: correlation with endoscopic 'red color sign'. Acta Med Okayama. Oct 2007;61(5):247-54. [Medline].

  17. Kim SH, Kim YJ, Lee JM, Choi KD, Chung YJ, Han JK, et al. Esophageal varices in patients with cirrhosis: multidetector CT esophagography--comparison with endoscopy. Radiology. Mar 2007;242(3):759-68. [Medline].

  18. Stanford W, Jolles H, Ell S, Chiu LC. Superior vena cava obstruction: a venographic classification. AJR Am J Roentgenol. Feb 1987;148(2):259-62. [Medline]. [Full Text].

  19. Cihangiroglu M, Lin BH, Dachman AH. Collateral pathways in superior vena caval obstruction as seen on CT. J Comput Assist Tomogr. Jan-Feb 2001;25(1):1-8. [Medline].

  20. Zhao LQ, He W, Chen G. Characteristics of paraesophageal varices: A study with 64-row multidetector computed tomograghy portal venography. World J Gastroenterol. Sep 14 2008;14(34):5331-5. [Medline]. [Full Text].

  21. [Best Evidence] Liu CH, Hsu SJ, Liang CC, Tsai FC, Lin JW, Liu CJ, et al. Esophageal varices: noninvasive diagnosis with duplex Doppler US in patients with compensated cirrhosis. Radiology. Jul 2008;248(1):132-9. [Medline].

  22. Burtin P, Calès P, Oberti F, et al. Endoscopic ultrasonographic signs of portal hypertension in cirrhosis. Gastrointest Endosc. Sep 1996;44(3):257-61. [Medline].

  23. Baum S, Pentecost MJ, eds. Abrams Angiography: Interventional Radiology. 4th ed. Boston, Mass: Little, Brown & Co; 1997:397-404, 525-8, 1027-9.

  24. Lahoti S, Catalano MF, Alcocer E, Hogan WJ, Geenen JE. Obliteration of esophageal varices using EUS-guided sclerotherapy with color Doppler. Gastrointest Endosc. Mar 2000;51(3):331-3. [Medline].

  25. Azuma M, Kashiwagi T, Nagasawa M, et al. Evaluation of portosystemic collaterals by SPECT imaging after endoscopic variceal sclerotherapy: usefulness for predicting recurrence. J Nucl Med. Apr 2000;41(4):600-4. [Medline]. [Full Text].

  26. Burkart DJ, Johnson CD, Ehman RL. Correlation of arterial and venous blood flow in the mesenteric system based on MR findings. 1993 ARRS Executive Council Award. AJR Am J Roentgenol. Dec 1993;161(6):1279-82. [Medline]. [Full Text].

  27. Butler H. The veins of the oesophagus. Thorax. Sep 1951;6(3):276-96. [Medline]. [Full Text].

  28. Chedid A, Mendenhall CL, Gartside P, et al. Prognostic factors in alcoholic liver disease. VA Cooperative Study Group. Am J Gastroenterol. Feb 1991;86(2):210-6. [Medline].

  29. Cho KC, Patel YD, Wachsberg RH, Seeff J. Varices in portal hypertension: evaluation with CT. Radiographics. May 1995;15(3):609-22. [Medline]. [Full Text].

  30. de Franchis R, Primignani M. Natural history of portal hypertension in patients with cirrhosis. Clin Liver Dis. Aug 2001;5(3):645-63. [Medline].

  31. Escorsell A, Garcia-Pagán JC, Bosch J. Assessment of portal hypertension in humans. Clin Liver Dis. Aug 2001;5(3):575-89. [Medline].

  32. Fevery J, Nevens F. Oesophageal varices: assessment of the risk of bleeding and mortality. J Gastroenterol Hepatol. Aug 2000;15(8):842-8. [Medline].

  33. Grace ND. Prevention of initial variceal hemorrhage. Gastroenterol Clin North Am. Mar 1992;21(1):149-61. [Medline].

  34. Hegab AM, Luketic VA. Bleeding esophageal varices. How to treat this dreaded complication of portal hypertension. Postgrad Med. Feb 2001;109(2):75-6, 81-6, 89. [Medline].

  35. Hughes LA, Hartnell GG, Finn JP, et al. Time-of-flight MR angiography of the portal venous system: value compared with other imaging procedures. AJR Am J Roentgenol. Feb 1996;166(2):375-8. [Medline]. [Full Text].

  36. Irisawa A, Saito A, Obara K, et al. Endoscopic recurrence of esophageal varices is associated with the specific EUS abnormalities: severe periesophageal collateral veins and large perforating veins. Gastrointest Endosc. Jan 2001;53(1):77-84. [Medline].

  37. Kirsh IE, Blackwell CC, Bennett HD. Roentgen diagnosis of esophageal varices; comparison of roentgen and esophagoscopic findings in 502 cases. Am J Roentgenol Radium Ther Nucl Med. Sep 1955;74(3):477-85. [Medline].

  38. L'Herminé C, Chastanet P, Bonnière P, Gauthier P. [Embolization treatment of hemorrhages due to intestinal and umbilical varices in portal hypertension] [French]. Ann Radiol (Paris). 1987;30(2):161-4. [Medline].

  39. Lowe RC, Grace ND. Pharmacologic therapy for portal hypertension. Curr Gastroenterol Rep. Feb 2001;3(1):24-9. [Medline].

  40. Merkel C, Bolognesi M, Angeli P, et al. Prognostic indicators of survival in patients with cirrhosis and esophageal varices, without previous bleeding. Am J Gastroenterol. Jul 1989;84(7):717-22. [Medline].

  41. Mikkelsen WJ. Varices of the upper esophagus in superior vena caval obstruction. Radiology. Dec 1963;81:945-8. [Medline].

  42. Nelson SW. The roentgenologic diagnosis of esophageal varices. Am J Roentgenol Radium Ther Nucl Med. Apr 1957;77(4):599-611. [Medline].

  43. Otto DL, Kurtzman RS. Esophageal varices in superior vena caval obstruction. Am J Roentgenol Radium Ther Nucl Med. Nov 1964;92:1000-12. [Medline].

  44. Park A, Cwikiel W. Emergent treatment of variceal bleeding in two infants. Acta Radiol. Oct 2008;49(8):951-4. [Medline].

  45. Patel NH, Ryu RK, Sze D. TIPS. Presented at: 26th Annual Meeting of the Society of Cardiovascular & Interventional Radiology (SCVIR); March 3-8, 2001; San Antonio, Texas.

  46. Russo MW, Zacks SL, Sandler RS, Brown RS. Cost-effectiveness analysis of transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic therapy for the prevention of recurrent esophageal variceal bleeding. Hepatology. Feb 2000;31(2):358-63. [Medline]. [Full Text].

  47. Sanyal AJ, Purdum PP 3rd, Luketic VA, Shiffman ML. Bleeding gastroesophageal varices. Semin Liver Dis. Nov 1993;13(4):328-42. [Medline].

  48. Shirkhoda A, Konez O, Shetty AN, et al. Contrast-enhanced MR angiography of the mesenteric circulation: a pictorial essay. Radiographics. Jul-Aug 1998;18(4):851-61; discussion 862-5. [Medline]. [Full Text].

  49. Swain P. The future of wireless capsule endoscopy. World J Gastroenterol. Jul 14 2008;14(26):4142-5. [Medline]. [Full Text].

  50. Taylor CR. Computed tomography in the evaluation of the portal venous system. J Clin Gastroenterol. Mar 1992;14(2):167-72. [Medline].

  51. Trenkner SW, Levine MS, Laufer I, Glick SN. Idiopathic esophageal varix. AJR Am J Roentgenol. Jul 1983;141(1):43-4. [Medline]. [Full Text].

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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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