ESOPHAGEAL VARICES – Etiology, Signs and Symptoms, Diagnostic Evaluation and Management
Esophageal varices are abnormal, enlarged veins in the lower part of the esophagus. It develops when normal blood flow to the liver is obstructed by scar tissue. Seeking a way around the blockages, blood flows into smaller blood vessels that are not designed to carry large volumes of blood. The vessels may leak blood or even rupture, causing life-threatening bleeding.
ETIOLOGY
- Prehepatic causes: portal vein thrombosis, portal vein obstruction – congenital atresia or stenosis, increased portal blood flow – fistula, increased splenic flow
- Intrahepatic causes: cirrhosis due to causes, including alcoholic, chronic hepatitis (e.g. viral or autoimmune), idiopathic portal hypertension, acute hepatitis, schistosomiasis, congenital hepatic fibrosis, myelosclerosis
- Post hepatic causes: compression (from tumor), Budd-Chiari syndrome
SIGNS AND SYMPTOMS
- Hemoptysis
- Black, tarry or bloody stools
- Shock
- Jaundice
- Spider veins
- Palmar erythema
- Dupuytren’s contracture
- Shrunken testicles
- Swollen spleen
- Ascites
DIAGNOSTIC EVALUATION
- Endoscopic examination: a procedure called esophagogastroduodenoscopy. It will insert in mouth and into esophagus and small intestine to evaluate the dilated veins, measure their size
- Imaging tests: both CT and MRI scans may be used to diagnose esophageal varices. These tests also allow to examine liver and circulation in the portal vein
- Capsule endoscopy: in this test, the patient swallows a vitamin-sized capsule containing a tiny camera, which takes pictures of the esophagus as it passes. This may be an option for people who are unable or unwilling to undergo an endoscope examination
- CBC
- Clotting including INR
- Renal function
- LFTs
- Ascitic tap may be needed if bacterial peritonitis is suspected
MANAGEMENT
- Beta blockers: it may help reduce blood pressure in portal vein, decreasing the likelihood of bleeding. These medications include propranolol, etc
- Band ligation: it is used if esophageal varices appear to have a very high risk of bleeding. Using an endoscope, the varices are wrap with each other with an elastic band, which essentially ‘strangles’ the veins so they cannot bleed. Esophageal band ligation carries a small risk of complications, such as scarring of the esophagus
- Transjugular intrahepatic portosystemic shunt (TIPS): the shunt is a small tube that is placed between the portal vein and the hepatic vein, which carries blood from liver back to heart. By providing an additional path for blood, the shunt reduces pressure in the portal vein and often stops bleeding from esophageal varices
- Balloon tube tamponade (Sengstaken-Blakemore Tube): the Sengstaken tube is inserted through the mouth and into the stomach. The gastric balloon is inflated with air and the gastric balloon in then pulled up against the esophagogastric junction, compressing submucosal varices. The Sengstaken tube also contains an esophageal balloon which is only rarely required when the gastric balloon does not work. If bleeding continues, it may be that the tube is wrongly positioned or bleeding is from another source
NURSING MANAGEMENT
Nursing Diagnosis
- Risk for bleeding related to obstruction in blood flow
- Imbalanced nutrition: less than body requirements related to vomiting and jaundice
Interventions
- Provide ongoing assessment
- Assess for ecchymosis, epistaxis, petechiae, and bleeding gums
- Monitor level of consciousness, vital signs, and urinary output to evaluate fluid balance
- Monitor the client during blood transfusion administration, if prescribed
- Use small-gauge needles, and apply pressure or cold for bleeding
- Explain the procedure to the client to reduce fear and enhance cooperation with insertion and maintenance of the esophageal tamponade tube
- Monitor the client closely to prevent accidental removal or displacement of the tube with resultant airway obstruction
Ensure nasogastric tube patency to prevent aspiration (observe gastric aspirate for evidence of bleeding, protect the client from chilling)
Administer prescribed vasopressin and vitamin K
Closely assess for signs and symptoms of GI bleeding: check all secretions for frank or occult blood. Observe color and consistency of stools, NG drainage, or vomitus
Observe for presence of petechiae, ecchymosis, bleeding from one or more sites
- Monitor pulse, BP (and CVP, if available)
- Avoid rectal temperature and be gentle with GI tube insertions
- Encourage use of soft toothbrush, electric razor, avoiding straining for stool, vigorous nose blowing, and so forth
- Use small needles for injections. Apply pressure to small bleeding and venipuncture sites for longer than usual
- Advise to avoid aspirin-containing products
- Monitor Hb/Hct and clotting factors
- Supplemental vitamins: vitamins K, D and C
- Administer stool softeners
- Assist with insertion and maintenance of GI tube
- Provide gastric lavage with room temperature and cool saline solution or water as indicated
