Esophageal Varices

Background

Varices are dilated veins that usually arise from chronic liver disease and cirrhosis. A cirrhotic or scarred liver is a very poor conduit of blood flow resulting in backflow through the venous system. Thus, there is increased venous pressure in vessels as varied as the portal vein, esophagus, and anal-rectal veins, often leading to hemorrhoids. If these varices rupture or hemorrhage, the result can be life threatening with a higher death rate than other causes of gastrointestinal bleeding.

OUTLINE

Epidemiology

Disease Associations

Pathogenesis

Laboratory/Radiologic/Other Diagnostic Testing

Gross Appearance and Clinical Variants

Histopathological Features and Variants

Special Stains/Immunohistochemistry/Electron Microscopy

Differential Diagnosis

Prognosis and Treatment

Commonly Used Terms

Internet Links

EPIDEMIOLOGY CHARACTERIZATION

SYNONYMS

INCIDENCE

AGE RANGE-MEDIAN

SEX (M:F)

GEOGRAPHY

DISEASE ASSOCIATIONS CHARACTERIZATION

HEPATOCELLULAR CARCINOMA

Risk factors for esophageal variceal bleeding in patients with hepatocellular carcinoma.

Akanuma M, Yoshida H, Okamoto M, Ogura K, Maeda S, Hata Y, Sato S, Shiina S, Kawabe T, Shiratori Y, Omata M.

Division of Gastroenterology, Department of Internal Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
Hepatogastroenterology 2002 Jul-Aug;49(46):1039-44 Abstract quote
BACKGROUND/AIMS: To evaluate the risk factors for esophageal variceal bleeding in patients with hepatocellular carcinoma.

METHODOLOGY: 103 patients with esophageal varices and hepatocellular carcinoma without previous history of varices bleeding or treatment of varices were followed up and the risk factors for variceal bleeding were evaluated by Cox proportional hazards regression.

RESULTS: During an average of 650 days' follow-up, 17 patients (17%) suffered from variceal bleeding, showing an annual incidence rate of 9.3%. Another 8 patients (8%) underwent endoscopic variceal ligation for the aggravation of esophageal varices. Multivariate analysis showed that the red color sign of varices and the size of tumor (> or = 33 mm) were independently associated with an increased risk of variceal bleeding (Risk Ratio = 20.33, P < 0.0001 and Risk Ratio = 2.64, P = 0.0231, respectively).

CONCLUSIONS: The large size of tumor, as well as the red color sign of varices, was a significant risk factor for variceal bleeding in patients with hepatocellular carcinoma.

PATHOGENESIS CHARACTERIZATION

LABORATORY/RADIOLOGIC/
OTHER TESTS
CHARACTERIZATION

RADIOLOGIC

LABORATORY MARKERS

GROSS APPEARANCE/
CLINICAL VARIANTS CHARACTERIZATION

GENERAL

VARIANTS

HISTOLOGICAL TYPES CHARACTERIZATION

GENERAL

VARIANTS

SPECIAL STAINS/IMMUNOPEROXIDASE/
OTHER CHARACTERIZATION

SPECIAL STAINS

IMMUNOPEROXIDASE

DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES

PROGNOSIS AND TREATMENT CHARACTERIZATION

PROGNOSTIC FACTORS

SUDDEN DEATH

Esophageal variceal hemorrhage presenting as sudden death in outpatients.

Tsokos M, Turk EE.

Institute of Legal Medicine, University of Hamburg, Hamburg, Germany.
Arch Pathol Lab Med 2002 Oct;126(10):1197-200 Abstract quote
Context.-Some autopsy studies have dealt with histologic features of esophageal varices after different therapeutic procedures. However, to the best of our knowledge, no reports have been published describing outpatient characteristics that are associated with fatal esophageal variceal hemorrhage in a medicolegal autopsy population.

Objectives.-To (1) assess the incidence of sudden deaths from esophageal variceal hemorrhage in an unselected medicolegal autopsy population and (2) determine demographics of outpatients dying from esophageal variceal hemorrhage with special reference to blood alcohol concentrations at the time of death.

Design.-We performed a retrospective study of all autopsy cases of sudden death from esophageal variceal hemorrhage from a total of 6038 medicolegal autopsies performed over a 5-year period (1997-2001). We analyzed individual cases to determine gender, age, location and histology of bleeding esophageal varices, pathogenic mechanism for esophageal varices, concomitant underlying diseases contributing to fatal outcome, body mass index, circumstances at the death scene, and blood alcohol levels at the time of death. We reviewed the results of toxicologic analyses of alcohol concentrations in samples of femoral venous blood and urine obtained at autopsy; concentrations had been determined by gas chromatography with mass spectroscopy and enzymatic assays.

Results.-We identified 45 cases of fatal esophageal variceal hemorrhage that occurred out of hospital and presented as sudden death; the corresponding 5-year incidence in this autopsy population was 0.75%. All of the deceased were white; the male-female ratio was 1.6:1, and the mean age was 50.6 years. Ruptured esophageal varices were located in the lower third of the esophagus in 44 cases. Cirrhosis of the liver was present in all cases (alcoholic cirrhosis of the liver in 42 cases), and a hepatocellular carcinoma was present in 3 cases. Alcohol-induced pancreatic tissue alterations were frequently found. The results of toxicologic analysis were positive for alcohol in femoral venous blood and urine in 30 cases. Blood alcohol levels at the time of death were less than 100 mg/dL (21.7 mmol/L) in 15 cases, between 100 and 200 mg/dL (21.7 and 43.4 mmol/L) in 8 cases, and greater than 200 mg/dL (43.4 mmol/L) in the remaining 7 cases.

Conclusions.-Apart from abnormalities in coagulation due to poor liver function in long-term alcohol users, acute alcohol intake may represent an important factor influencing mortality in individuals with esophageal variceal hemorrhage. Acute alcohol intake has transient effects on blood clotting time caused by ethanol and its main metabolites. In the present study, bloodstains at the death scene and unusual body positions of the deceased that aroused suspicion of a violent death were leading reasons for conducting a medicolegal autopsy. Apart from aspects of forensic pathology, the demographics of our study population are also noteworthy from the viewpoint of social medicine. The data we present stress the importance of fatal esophageal variceal hemorrhage as a relevant cause of sudden death occurring outside the hospital in socially isolated, alcohol-addicted individuals.

TREATMENT

ENDOSCOPIC SURGERY

Combined endoscopic and radiologic intervention to treat esophageal varices.

Taniai N, Onda M, Tajiri T, Yoshida H, Mamada Y.

First Department of Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyou-ku, Tokyo 113-8603, Japan.
Hepatogastroenterology 2002 Jul-Aug;49(46):984-8 Abstract quote
BACKGROUND/AIMS: In patients with esophageal varices, we investigated the impact on long-term outcome of combining interventional radiologic procedures with endoscopic therapy.

METHODOLOGY: Of 133 patients with esophageal varices, 86 were treated with endoscopic therapy alone and 47 underwent endoscopic therapy in addition to interventional radiologic procedures. End-points considered during 5-years of follow-up included recurrent bleeding and retreatment.

RESULTS: Bleeding rates were 24.4% in the endoscopy group and 25.4% in the combined therapy group. Retreatment rates at 1, 3, and 5 years for the endoscopy group versus the combined therapy group were 40.7% versus 30.3%, 72.0% versus 67.5%, and 88.2% versus 80.5%, respectively, representing no significant difference between two groups. However, cumulative retreatment rates in Child's class C cases were significantly lower in the combined therapy group than in the endoscopy group (P = 0.025). Patients who had combined therapy which included all embolizing techniques showed significantly lower retreatment rates than patients treated with endoscopy alone (P = 0.05).

CONCLUSIONS: In combination, interventional radiologic and endoscopic therapies are highly effective and can improve long-term outcome in patients with esophageal varices, especially those with poor liver function and those who undergo embolization by all techniques.

A comparison of combination endoscopic therapy and interventional radiology with esophageal transection for the treatment of esophageal varices.

Tajiri T, Onda M, Taniai N, Yoshida H, Mamada Y.

First Department of Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyou-ku, Tokyo 113-8603, Japan.
Hepatogastroenterology 2002 Nov-Dec;49(48):1552-4 Abstract quote
BACKGROUND/AIMS: The impact of long-term results of combination interventional radiology and endoscopic therapy were compared with esophageal transsection for the treatment of esophageal varices.

METHODOLOGY: This study was a retrospective chart review. The outcome of 16 patients with esophageal varices who underwent endoscopic therapy plus all interventional radiologic procedures (transportal vein obliteration, partial splenic embolization, and left gastric arterial embolization) were compared with those of 23 who underwent esophageal transection. Primary endpoints during a 5-year follow-up included retreatment and death.

RESULTS: The retreatment rates at 1 year, 3 years, and 5 years in the combined therapy group and transection group were 16.7% and 8.7%, 58.3% and 25.2% and 75.0% and 31.2%, respectively. The retreatment rates were lower in the transection group than in the combined therapy group (p = 0.015). Cumulative retreatment rates in Child's class C patients were significantly different between the two groups. The survival rates at 3 years and 5 years in the combined therapy group and transection group were similar 91.7% versus 91.7% and 82.5% versus 89.5%. The cumulative retreatment rates also were similar.

CONCLUSIONS: The combination of interventional radiologic and endoscopic therapy is highly effective and provides an alternative to surgery in patients with esophageal varices who have poor liver function.

SHUNT SURGERY

Comparison of the long-term results of distal splenorenal shunt and esophageal transection for the treatment of esophageal varices.

Tajiri T, Onda M, Yoshida H, Mamada Y, Taniai N, Yamashita K.

First Department of Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
Hepatogastroenterology 2000 Nov-Dec;47(36):1619-21 Abstract quote
BACKGROUND/AIMS: This study was undertaken to evaluate the comparison of long-term results of distal splenorenal shunt and esophageal transection for the treatment of esophageal varices.

METHODOLOGY: Twenty-four cirrhotic patients underwent distal splenorenal shunt, and 19 cirrhotic patients underwent esophageal transection with complete variceal eradication and follow-up for at least 3 years.

RESULTS: No recurrent varix was observed in the distal splenorenal shunt group. The cumulative recurrence rates of varices in the esophageal transection group were 31.6%, and 52.5% at 5 and 10 years, respectively. The cumulative rates of hyperammonemia at 5 and 10 years were significantly higher in the distal splenorenal shunt group (30.4%, 30.4%) than in the esophageal transection group (0%, 5.6%) (P = 0.009). The cumulative survival rates in the distal splenorenal shunt group versus the esophageal transection group were 90.9% versus 94.7%, and 85.2% versus 81.7% at 5 and 10 years (NS).

CONCLUSIONS: These results suggest that distal splenorenal shunt is more effective than esophageal transection in preventing recurrence of esophageal varices, but is associated with a higher incidence of hyperammonemia.

Rosai J. Ackerman's Surgical Pathology. Eight Edition. Mosby 1996.
Sternberg S. Diagnostic Surgical Pathology. Third Edition. Lipincott Williams and Wilkins 1999.
Robbins Pathologic Basis of Disease. Sixth Edition. WB Saunders 1999.

Commonly Used Terms

Esophagus

Internet Links

Last Updated 10/29/2002

PROGNOSIS AND TREATMENT	CHARACTERIZATION
PROGNOSTIC FACTORS
SUDDEN DEATH
Esophageal variceal hemorrhage presenting as sudden death in outpatients. Tsokos M, Turk EE. Institute of Legal Medicine, University of Hamburg, Hamburg, Germany.	Arch Pathol Lab Med 2002 Oct;126(10):1197-200 Abstract quote Context.-Some autopsy studies have dealt with histologic features of esophageal varices after different therapeutic procedures. However, to the best of our knowledge, no reports have been published describing outpatient characteristics that are associated with fatal esophageal variceal hemorrhage in a medicolegal autopsy population. Objectives.-To (1) assess the incidence of sudden deaths from esophageal variceal hemorrhage in an unselected medicolegal autopsy population and (2) determine demographics of outpatients dying from esophageal variceal hemorrhage with special reference to blood alcohol concentrations at the time of death. Design.-We performed a retrospective study of all autopsy cases of sudden death from esophageal variceal hemorrhage from a total of 6038 medicolegal autopsies performed over a 5-year period (1997-2001). We analyzed individual cases to determine gender, age, location and histology of bleeding esophageal varices, pathogenic mechanism for esophageal varices, concomitant underlying diseases contributing to fatal outcome, body mass index, circumstances at the death scene, and blood alcohol levels at the time of death. We reviewed the results of toxicologic analyses of alcohol concentrations in samples of femoral venous blood and urine obtained at autopsy; concentrations had been determined by gas chromatography with mass spectroscopy and enzymatic assays. Results.-We identified 45 cases of fatal esophageal variceal hemorrhage that occurred out of hospital and presented as sudden death; the corresponding 5-year incidence in this autopsy population was 0.75%. All of the deceased were white; the male-female ratio was 1.6:1, and the mean age was 50.6 years. Ruptured esophageal varices were located in the lower third of the esophagus in 44 cases. Cirrhosis of the liver was present in all cases (alcoholic cirrhosis of the liver in 42 cases), and a hepatocellular carcinoma was present in 3 cases. Alcohol-induced pancreatic tissue alterations were frequently found. The results of toxicologic analysis were positive for alcohol in femoral venous blood and urine in 30 cases. Blood alcohol levels at the time of death were less than 100 mg/dL (21.7 mmol/L) in 15 cases, between 100 and 200 mg/dL (21.7 and 43.4 mmol/L) in 8 cases, and greater than 200 mg/dL (43.4 mmol/L) in the remaining 7 cases. Conclusions.-Apart from abnormalities in coagulation due to poor liver function in long-term alcohol users, acute alcohol intake may represent an important factor influencing mortality in individuals with esophageal variceal hemorrhage. Acute alcohol intake has transient effects on blood clotting time caused by ethanol and its main metabolites. In the present study, bloodstains at the death scene and unusual body positions of the deceased that aroused suspicion of a violent death were leading reasons for conducting a medicolegal autopsy. Apart from aspects of forensic pathology, the demographics of our study population are also noteworthy from the viewpoint of social medicine. The data we present stress the importance of fatal esophageal variceal hemorrhage as a relevant cause of sudden death occurring outside the hospital in socially isolated, alcohol-addicted individuals.
TREATMENT
ENDOSCOPIC SURGERY
Combined endoscopic and radiologic intervention to treat esophageal varices. Taniai N, Onda M, Tajiri T, Yoshida H, Mamada Y. First Department of Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyou-ku, Tokyo 113-8603, Japan.	Hepatogastroenterology 2002 Jul-Aug;49(46):984-8 Abstract quote BACKGROUND/AIMS: In patients with esophageal varices, we investigated the impact on long-term outcome of combining interventional radiologic procedures with endoscopic therapy. METHODOLOGY: Of 133 patients with esophageal varices, 86 were treated with endoscopic therapy alone and 47 underwent endoscopic therapy in addition to interventional radiologic procedures. End-points considered during 5-years of follow-up included recurrent bleeding and retreatment. RESULTS: Bleeding rates were 24.4% in the endoscopy group and 25.4% in the combined therapy group. Retreatment rates at 1, 3, and 5 years for the endoscopy group versus the combined therapy group were 40.7% versus 30.3%, 72.0% versus 67.5%, and 88.2% versus 80.5%, respectively, representing no significant difference between two groups. However, cumulative retreatment rates in Child's class C cases were significantly lower in the combined therapy group than in the endoscopy group (P = 0.025). Patients who had combined therapy which included all embolizing techniques showed significantly lower retreatment rates than patients treated with endoscopy alone (P = 0.05). CONCLUSIONS: In combination, interventional radiologic and endoscopic therapies are highly effective and can improve long-term outcome in patients with esophageal varices, especially those with poor liver function and those who undergo embolization by all techniques.
A comparison of combination endoscopic therapy and interventional radiology with esophageal transection for the treatment of esophageal varices. Tajiri T, Onda M, Taniai N, Yoshida H, Mamada Y. First Department of Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyou-ku, Tokyo 113-8603, Japan.	Hepatogastroenterology 2002 Nov-Dec;49(48):1552-4 Abstract quote BACKGROUND/AIMS: The impact of long-term results of combination interventional radiology and endoscopic therapy were compared with esophageal transsection for the treatment of esophageal varices. METHODOLOGY: This study was a retrospective chart review. The outcome of 16 patients with esophageal varices who underwent endoscopic therapy plus all interventional radiologic procedures (transportal vein obliteration, partial splenic embolization, and left gastric arterial embolization) were compared with those of 23 who underwent esophageal transection. Primary endpoints during a 5-year follow-up included retreatment and death. RESULTS: The retreatment rates at 1 year, 3 years, and 5 years in the combined therapy group and transection group were 16.7% and 8.7%, 58.3% and 25.2% and 75.0% and 31.2%, respectively. The retreatment rates were lower in the transection group than in the combined therapy group (p = 0.015). Cumulative retreatment rates in Child's class C patients were significantly different between the two groups. The survival rates at 3 years and 5 years in the combined therapy group and transection group were similar 91.7% versus 91.7% and 82.5% versus 89.5%. The cumulative retreatment rates also were similar. CONCLUSIONS: The combination of interventional radiologic and endoscopic therapy is highly effective and provides an alternative to surgery in patients with esophageal varices who have poor liver function.
SHUNT SURGERY
Comparison of the long-term results of distal splenorenal shunt and esophageal transection for the treatment of esophageal varices. Tajiri T, Onda M, Yoshida H, Mamada Y, Taniai N, Yamashita K. First Department of Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.	Hepatogastroenterology 2000 Nov-Dec;47(36):1619-21 Abstract quote BACKGROUND/AIMS: This study was undertaken to evaluate the comparison of long-term results of distal splenorenal shunt and esophageal transection for the treatment of esophageal varices. METHODOLOGY: Twenty-four cirrhotic patients underwent distal splenorenal shunt, and 19 cirrhotic patients underwent esophageal transection with complete variceal eradication and follow-up for at least 3 years. RESULTS: No recurrent varix was observed in the distal splenorenal shunt group. The cumulative recurrence rates of varices in the esophageal transection group were 31.6%, and 52.5% at 5 and 10 years, respectively. The cumulative rates of hyperammonemia at 5 and 10 years were significantly higher in the distal splenorenal shunt group (30.4%, 30.4%) than in the esophageal transection group (0%, 5.6%) (P = 0.009). The cumulative survival rates in the distal splenorenal shunt group versus the esophageal transection group were 90.9% versus 94.7%, and 85.2% versus 81.7% at 5 and 10 years (NS). CONCLUSIONS: These results suggest that distal splenorenal shunt is more effective than esophageal transection in preventing recurrence of esophageal varices, but is associated with a higher incidence of hyperammonemia.

Epidemiology
Disease Associations
Pathogenesis
Laboratory/Radiologic/Other Diagnostic Testing
Gross Appearance and Clinical Variants
Histopathological Features and Variants
Special Stains/Immunohistochemistry/Electron Microscopy
Differential Diagnosis
Prognosis and Treatment
Commonly Used Terms
Internet Links

EPIDEMIOLOGY	CHARACTERIZATION
SYNONYMS
INCIDENCE
AGE RANGE-MEDIAN
SEX (M:F)
GEOGRAPHY

LABORATORY/RADIOLOGIC/ OTHER TESTS	CHARACTERIZATION
RADIOLOGIC
LABORATORY MARKERS

GROSS APPEARANCE/ CLINICAL VARIANTS	CHARACTERIZATION
GENERAL
VARIANTS

HISTOLOGICAL TYPES	CHARACTERIZATION
GENERAL
VARIANTS

SPECIAL STAINS/IMMUNOPEROXIDASE/ OTHER	CHARACTERIZATION
SPECIAL STAINS
IMMUNOPEROXIDASE