Oesophageal varices ppt slideshare

OESOPHAGEAL VARICES AND
ITS MANAGEMENT
PRESENTED BY:
SONAM YADAV

EPIDEMIOLOGY
• The prevalence may range from 60-80% and the reported
mortality from variceal bleeding ranges from 17 to 57%.
• The acute mortality rate with each bleed is
approximately 30% and the survival rate is less than 40%
after 1 year with medical management alone.
• The 1-year incidence of variceal haemorrhage in patients
with oesophageal varices is about 5-15%.
• Highest risk of recurrence for bleeding (approx. 70%)
and death (approx. 30-50%).

 Portal hypertension
 Increased obstruction of the portal vein, venous blood
from the intestinal tract and spleen seeks an outlet through
collateral circulation
 Abnormalities of the circulation

RISK FACTORS
 High portal vein pressure
 Large varices
 Red marks on the varices

.
Portal hypertension (caused by resistance to portal flow and increased portal
venous inflow)
Development of pressure gradient of 12 mmHg or greater between portal vein
and inferior vena cava (portal pressure gradient)
Venous collaterals develop from high portal system pressure in systemic veins in
oesophageal plexus, hemorrhoidal plexus, and retroperitoneal veins
Abnormal varicoid vessels forms
Vessels may rupture causing life threatening haemorrhage

CLINICAL MANIFESTATION
 Deterioration in mental or physical status
 Splenomegaly
 Sign and symptoms of shock

FACTORS THAT CONTRIBUTE TO
HEMORRHAGE
 Esophagitis
 Straining
 Irritation of vessels by poorly
chewed food or irritating fluids
 Reflux of stomach contents
 Salicylates and any medication
that erodes the oesophageal
mucosa or interferes with cell
replication

 Portal hypertension measurements
o Indirect measurement- insertion of the catheter with a balloon into the
antecubital or femoral vein.
• The catheter is advanced under fluoroscopy to a hepatic vein.
• Fluid is infused once the catheter is in position to inflate the balloon.
• Although the values obtained may underestimate portal pressure, this
measurement may be taken several times to evaluate the result of the
therapy.
o Direct measurement- during laparotomy, a needle may be introduced into
the spleen
• a manometer reading of more than 20 ml saline is abnormal.

.
Evaluate the extent of bleeding, monitor vital signs continuously.
Intravenous fluids to restore fluid volume.
Parenteral nutrition.
Electrolytes to treat electrolyte imbalance.
Volume expanders.
Blood transfusion.
Urinary catheterization to monitor urine output.
Gastric suction to keep the stomach as empty as possible and to
prevent straining and vomiting.

PHARMACOLOGICAL THERAPY
1.Octreotide (Sandostatin)
• Synthetic analogue of somatostatin.
• Effective in decreasing bleeding from esophageal varices.
• Lacks the vasoconstrictive effects of vasopressin.
• Cause selective splanchnic vasoconstriction by inhibiting
glucagon release and are used mainly in the management of
active hemorrhage

.
2. Vasopressin (Pitressin)
• It produces constriction of the splanchnic arterial bed and
decreases portal pressure.
• Contraindication- coronary artery disease
3. Beta blocking agents
• Propranolol or nadolol that decrease portal pressure.
4. Nitrates such as isosorbide (Isodil)
• Lower portal pressure by venodilation and decreased cardiac
output and may be used in combination with beta blockers.

BALLOON TAMPONADE
Sengstaken-Blakemore Tube

ENDOSCOPIC SCLEROTHERAPY
• Injection sclerotherapy.
• A sclerosing agent (i.e. Sodium morrhuate, ethanolamine
oleate, sodium tetradecyl sulfate, or ethanol) is injected through
a fibreoptic endoscope into or adjacent to the bleeding
esophageal varices to promote process of sclerotherapy causes
inflammation of the involved vein with eventual thrombosis and
loss of the lumen of the vessel.

ENDOSCOPIC VARICEAL LIGATION
(ESOPHAGEAL BANDING THERAPY)
 A modified endoscope loaded with an elastic rubber band is passed
through an over tube directly onto the varices to be banded.
• After the bleeding varix is suctioned into the tip of the endoscope, the
rubber band is slipped over the tissue, causing necrosis, ulceration and
eventual sloughing of the varix.
• Complication:
 Superficial ulceration and dysphagia,Transient chest discomfort, and
rarely, esophageal strictures

TRANSJUGULAR INTRAHEPATIC
PORTOSYSTEMIC SHUNT (TIPS)
 In 10% to 20% of patients for whom urgent band ligation or
sclerotherapy and medication are not successful in
eradicating bleeding, a TIPS procedure can effectively
control acute variceal hemorrhage by rapidly lowering portal
pressure.

ADDITIONAL THERAPIES
 Tissue adhesives and fibrin glue
 Coated expandable stents

 These procedures are considered as second line management
(rescue therapy).
Direct surgical ligation of varices
Surgical bypass procedure:
Splenorenal,
mesocaval, and
portacaval venous shunts.
Esophageal transaction with devascularization.

SURGICAL BYPASS PROCEDURE
Shunting procedure:
 Distal splenorenal shunt: between the splenic vein and the left renal
vein after splenectomy.
 Mesocaval shunt: anastomosing the superior mesenteric vein to the
proximal end of the vena cava or to the side of the vena cava using
grafting material.
 The goal is to decrease portal pressure by draining only a portion of
venous blood from the portal bed, therefore, they are considered
selective shunts.

.
 The liver continues to receive some portal flow, and the incidence of
encephalopathy may be reduced.
 Portocaval shunts are considered non selective shunts because they
divert all portal flow to the vena cava via end to side or side to side
approaches.
 The mesoatrial shunt is required when the infrahepatic vena cava is
thrombosed and must be bypassed.

DEVASCULARIZATION AND
TRANSECTION
 Devascularization and staple gun transection procedures to separate the
bleeding site from the high-pressure portal system have been used in
the emergency management of variceal bleeding.
 The lower end of the esophagus is reached through a small gastrostomy
incision, a staple gun permits anastomosis of the transected ends of the
esophagus.

COMPLICATION
• Hypovolemic or hemorrhagic shock
• Hepatic encephalopathy
• Electrolyte imbalance
• Esophageal stricture
• Bloodstream infection
• Kidney failure
• Rebleeding after treatment

Risk for bleeding secondary to esophageal varices as evidenced by signs
of bleeding such as hematemesis, and melena.
Observe for any signs of bleeding such as hematemesis, melena, etc., Monitor
and record vital signs, Assess the patients nutritional and neurologic status
Assess for ascites, and abdominal examination should be performed
Gastric suction usually is initiated to keep the stomach as empty as possible to
prevent straining and vomiting
Administer drug to reduce portal hypertension as prescribed by the doctor
 Complete rest of esophagus if advised, parenteral nutrition is initiated.
 Vitamin K therapy and multiple blood transfusions often are indicated because
of blood loss

Fluid volume deficit related to active bleeding as evidenced by
decreased urine output (less than 30 ml/hr)
Monitor and document vital signs especially BP and HR, monitor intake output of
patient. Monitor for orthostatic hypotension.
Assess skin turgor and oral mucus membrane for signs of dehydration.
Assess for alteration in sensorium, mental status (confusion, slowed responses)
Assess color and amount of urine. Report urine output less than 30 ml/hr for 2
consecutive hours.
Note presence of nausea, vomiting and fever.
Advise patient to take plenty of fluids and to replenish himself or herself
The patient often complains of severe thirst, which may be relieved by frequent
oral hygiene and moist sponges to the lips

Ineffective tissue perfusion related to hypovolemia as evidenced by
abnormal arterial blood gases.
Assess for signs of decreased tissue perfusion. Check capillary refill time, spo2,
ABG, vital signs and hemoglobin levels.
Examine bowel sounds and assess for nausea, vomiting, abdominal distension and
constipation.
Check for pallor, cyanosis, mottling, cool or clammy skin, and note skin texture, and
skin turgor.
Provide oxygen therapy, if oxygen insufficiency, administer normal saline or ringer
lactate solution or assist in position change, semi fowler’s position may be given to
the patient.
Provide rest to the patient and advise to take plenty of fluids.
Close monitoring of the patient helps in detecting and managing complications

Imbalanced nutrition: less than body requirements related to digestive
tract bleeding secondary to esophageal varices, as evidenced by weight
loss, hematemesis, nausea and vomiting, loss of appetite, and dizziness
Explore the patient’s daily nutritional intake and food habits (e.g. Meal times,
duration of each meal session, snacks, etc.) Make a daily weight chart and food and
fluid chart
Help the patient to select dietary choices
If patient has been a heavy user of alcohol, delirium secondary to alcohol withdrawal
can complicate the situation.
Advise to limit alcohol intake.
Encourage soft foods such as banana and yogurts to reduce irritation of the esophagus
and ensure that the patient receives the right amount of nutrition.

Anxiety related to change in health status as evidenced by irritability
and nervousness due to bleeding
Assess the knowledge of the patient regarding the disease condition, sign and symptoms,
clinical manifestation, management, its complication and preventive measures.
Monitor the patient’s physical condition and evaluate emotional responses and cognitive
status
Encourage the patient to ask questions and listen actively. Clarify the patients doubts and
reassure the patient.
Teach the family members and advise them to support the patient during the time of crisis
A quiet environment and calm reassurance may help to relieve the patient’s anxiety and
reduce agitation.
Bleeding anywhere in the body is anxiety provoking, resulting in a crisis for the patient and
family

PROGNOSIS
• Bleeding oesophageal varices is life-threatening condition and can be
fatal in up to 50% of patients. People who have had an episode of
bleeding oesophageal varices are at risk for bleeding again. Treatment
with variceal ligation is effective in controlling first-time bleeding
episodes in about 90% of patients. However, about half of patients
treated with variceal ligation will have another episode of bleeding
within 1 to 2 years. Medication and lifestyle changes can help reduce
the risk of recurrence (return of bleeding)
• Liver transplant may be an option for patients who have severe
cirrhosis and/or repeated episodes of bleeding varices.

CONCLUSION
• As discussed throughout the presentation, learning about the
oesophageal varices and its management will help nurses to care for
patients of oesophageal varices. Nurses can do assessment of patients
with oesophageal varices observe the sign and symptoms provide the
necessary nursing care, prevent complications and support the patient
psychologically
• Nurses can also counsel the patients and their family for various
options available in treatment for oesophageal varices.

REFERENCES
 Brunner & suddarth’s. Textbook of medical surgical. 13th edition volume-2. New delhi:
wolters kluwer;2015; page no. 1349-1353
 Lewis’s. Textbook of medical-surgicalnursing.11theditionvolum 2. Chintamani mani;2010
 Joyce M. Black and jane hokanson; medical surgical nursing; volume 2, 8th edition, reed
elsevier, india pvt.
 Esophageal varices; causes, symptoms, diagnosis & treatment [internet]. Cleveland clinic.
2021 [cited 21 january 2021]. Available from:
https://my.Clevelandclinic.Org/health/diseases/15429-esophageal-varices
 Esophageal varices - diagnosis and treatment - mayo clinic [internet]. Mayoclinic.Org. 2021
[cited 21 january 2021]. Available from: https://www.Mayoclinic.Org/diseases-
conditions/esophageal-varices/diagnosis-treatment/drc-20351544

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