Esophageal Varicosities

Esophageal varices are diagnosed in almost one-third of compensated cases and almost two-thirds of decompensated cases of cirrhosis. Bleeding may occur in one-third of cases and is related to the size of the varix and the severity of the liver disease. There is a 1 in 8 chance of bleeding annually if varices are present. Each bleed has up to a 20% risk of resulting in death.

Varicosities occur secondary to portal hypertension and are defined as dilatations of various alternative pathways when cirrhosis obstructs the portal return of blood ( Fig. 9.1 ). Varicosities occur most often in the distal third but may occur throughout the esophagus. Acute variceal hemorrhage is the most lethal complication of portal hypertension. The median age of these patients is 52 years, and 73% are men.

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Esophageal Varicosities.

The most common cause of portal hypertension, affecting 94% of patients, is cirrhosis. The most common causes of cirrhosis are alcoholism (57%), hepatitis C virus (30%), and hepatitis B virus (10%).

Mortality rates from the initial episode of variceal hemorrhage range from 17% to 57%. Larger vessels bleed more frequently. Hospitalizations for acute bleeding from esophageal varices have been declining in recent years; this is believed to be a result of more active primary and secondary prophylaxis. Bleeding occurs when the tension in the venous wall leads to rupture, and shock may follow. Occasionally the bleeding may stop spontaneously, but more often it will recur. Thrombocytopenia and impaired hepatic synthesis of coagulation factors both interfere with hemostasis.