INTRODUCTION:

Esophageal varices are varicose, dilated sub mucosal veins in the distal esophagus that develop secondary to portal hypertension.

Portal Hypertension:

Portal pressure is the blood pressure existing throughout the portal system. It is normally 5-10mm of Hg. Portal hypertension is the elevation of hepatic venous pressure gradient (HVPG) to greater than 5mm of Hg resulting in portal pressure more than 12 mm of Hg.

Pathophysiology of portal hypertension:

Normally Portal venous system receives blood from the stomach, intestines, spleen, pancreas and gall bladder. The portal vein is formed by a confluence of the superior mesenteric vein and splenic vein. Deoxygenated blood from small bowel, head of the pancreas, ascending colon and part of transverse colon are collected by superior mesenteric vein, where as the splenic vein drains the spleen and pancreas. It is joined with inferior mesenteric vein which carries blood from transverse and descending colon as well as the superior two thirds of rectum. The portal vein divides and branches throughout the liver. Veins form venules at the lobular level. These connect to the central veins via hepatic sinusoids. The pressure in portal venules are same that in systemic venous circulation. There is approximate 3mm of Hg gradient normally across liver from portal (7mm Hg) to hepatic (4mm of Hg) venous systems. Any resistance or obstruction within the liver or outside the liver leads to increased pressure in the portal vein resulting in portal hypertension. Collateral vessels develop as compensatory mechanism for equalizing the venous pressures.

Causes of Portal Hypertension:

1. Presinusoidal: Divided into two; extra hepatic causes and intra hepatic causes

Table 1 (extra hepatic and intra hepatic causes)

Extra hepatic causes	Intra hepatic causes
Portal vein thrombosis	Schistosomiasis
Cavernous transformation of portal vein	Sarcoidosis
Extrinsic compression of portal vein	Idiopathic portal hypertension
Massive spleenomegaly	Primary biliary cirrhosis

2. Sinusoidal portal hypertension

These include cirrhosis, alcoholic hepatitis and vitamin A toxicity

3. Post sinusoidal hypertension

These include Veno-occlusive disease, Budd Chiari syndrome, Restrictive Heart Disease, Severe Congestive Heart Failure, Constrictive Pericarditis, etc.

How Gastroesophageal Varices Develop?

The portal vein communicates with systemic venous circulation through its tributaries. This porto systemic circulation exists at various parts which include

1. Cardia via intrinsic and extrinsic veins

2. Anal canal via anastomoses between superior and middle haemorrhoidal veins

3. Falciform ligament via paraumbilical veins draining abdominal wall

4. Splenic venous bed and left renal vein

5. Retro peritoneum

Among these communications the gastroesophageal collateral circulation allow portal blood flow to return to heart when flow through portal system is obstructed. This makes the gastroesophageal collaterals more significant than others.

Flow chart of esophagel varices Pathophysiology

Varices develop deep within the sub mucosa in the mid esophagus but became progressively more superficial in lower esophagus. Esophageal varices at the gastroesophageal junction have the thinnest coat of supporting tissue thus leading to rupture and bleed most likely.

Figure 1 – Esophageal varices

Diagnosis of esophagel varices:

Upper GI Endoscopy is the best method for diagnosis of varices. There is a strong correlation between variceal size assessed endoscopically and probability of bleeding. Various clinical as well as physiologic factors are used to predict the risk of variceal bleeding. The predictive factors used for variceal bleeding are

1. Hepatic venous pressure gradient (HVPG) more than 12 mm of Hg:

Intravariceal pressure is measured non invasively with a pressure sensitive endoscopic gauge or balloon technique.

2. Size of varix:

Varices are classified as small, medium and large. Small varices are defined as minimally elevated vein above the mucosal surface. Medium varices are defined as tortuous veins occupying less than one third of esophageal lumen. Large varices are defined as those occupying more than one third of esophageal lumen. Medium and large varices are having risk of rupture and bleeding.

Figure 2- Large esophageal varices

3. Endoscopic colour signs:

Through Upper GI endoscopy we can identify several signs which are predictable of variceal bleeding. These are called as ‘red signs’ due to colour. These include-

a. Red wale marks: these are longitudinal red streaks on varices like in the red cordurory wales.

Figure 3- Red wale marks

Cherry red spots:

These are discrete red cherry colored spots that appear overlying the varices and flat.

Figure 4- Cherry red spots

Hemotocystic spots:

Raised discrete red spots overlying varices and it appears like blood blisters

c. Diffuse erythema:-Diffuse red colour of the varix

4. Alcohol consumption in patients with alcoholic cirrhosis

5. Risk of bleeding increase significantly if there is increase in bilirubin and prothrombin time and decrease in albumin.

Previous history of variceal bleeding predicts a high chance of recurrent bleeding. There is 75% risk of bleeding within one year of previous bleeding. Risk of recurrent bleeding is extremely high in the period immediately after achieving haemostasis. The degree of recurrent bleeding is related to extend of liver failure, alcoholism, variceal size, renal failure and presence of Hepato cellular carcinoma. Approximately 70% untreated cases rebleed and die within one year of initial bleeding.

Management of Esophageal Varices:

The management of esophageal varices can be divided to two.

1. The primary prevention (prophylaxis) of esophageal variceal bleeding and

2. The secondary prevention (Prevention of recurrent variceal bleeding) of variceal bleeding.

Primary prevention of esophageal variceal bleeding:

Primary care is to prevent the first variceal bleeding which will provide less mortality and morbidity associated with bleeding. According to various recommendations the patients with large variceal size, red wale markings and severe liver failure are in high risk for bleeding and should be treated accordingly. The prophylactic measures include:

a. Periodical endoscopy to assess the size of varices and for any red wale markings. The American Association for the Study of Liver Diseases recommends repeated Upper GI endoscopy every 2-3 years for compensated cirrhosis patients and yearly for patients suffering from decompensated liver cirrhosis.

b. Non selective beta blockers are the first drug of choice as it causes reduction in portal pressure by beta blockage effect and leading to reduced portal blood flow and portal pressure thus the risk of initial bleeding. After either an oral or parenteral administration of the HVPG also decreases.

c. Endoscopic variceal ligation: prophylactic banding reduces the risk of bleeding. Most of the patients banding has to be repeated a few weeks later.

Treatment of an active bleeding:

Acute bleeding of varices is a medical emergency if not properly treated may cause death of the victim. Resuscitation is the important step if bleeding occurs. The air way should be protected to avoid aspiration of blood. Blood loss should be replaced with adequate blood. Antibiotics must be started to avoid infection of the patient. Vasopressin should be given as it reduces the portal pressure.

a. Medical Management of Acute Bleeding:

Management with drugs should be started immediately if bleeding suspects or occurs. Vasopressin is recommended.

· Vasopressin act by reducing portal venous inflow resulting from splanchnic vein constriction. This drug is contra indicated in patients with myocardial infarction due to its massive side effects. Terlipressin which is a synthetic analog of vasopressin is preferred drug due to its fewer side effects. Used in intravenous form.

· Somatostatin is another drug used to reduce the increased portal pressure. It also decreases the collateral blood flow. Used in intravenous form.

· Non selective beta blockers are used in active bleeding.

b. Balloon Tamponade:

It is used rarely used to control variceal bleeding nowadays. The esophageal and gastric balloons are inflated against the variceal bleeding and may stop bleeding. Pressure should be released in between so that tissue necrosis can be prevented. Minnesota tube or Sengstaken Blackmore tube is commonly used.

c. Endoscopic therapy:

Endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy are presently used treatment for variceal bleeding.

Endoscopic variceal ligation:

works on the method used in haemorrhoidal rubber band ligation. The band captures the enlarged varix resulting in necroses and sloughs off in few days or weeks. The site becomes ulcerated and heals rapidly. This procedure has less complication.

Figure 5- Endoscopic variceal ligation

Endoscopic injection sclerotherapy:

It is the injecting of a sclerosant into or adjacent to esophageal varices. It causes necrosis of esophageal tissues and mucosal ulcers. The most commonly used sclerosants are ethanolamine oleate, sodium tetradecylsulphate, sodium morrhuate and ethanol. Esophageal ulcers which can bleed or perforate, esophageal strictures, mediastinitis, pleural effusions, aspiration pneumonia, chest pain and bacteraemia are complications of injection sclerotherapy.

d. Transjugular intrahepatic portosystemic shunting (TIPS):

An artificial communication between the hepatic and portal vein is made angiographically. The veins are accessed by jugular approach. By dilation in the initial stage and by using metal stent in later stages the communication is maintained patent. The blood from high pressure portal veins flow to low pressure hepatic vein or inferior vena cava. TIPS can be used both in management of acute variceal bleeding and recurrent variceal bleeding.

e. Surgery:

Two types of surgeries are used as treatment modality in esophageal varices. The shunt operations (decompressive surgery) to divert flow from portal system and non shunt operations which includes esophagel transection or devascularisation of gastroesophageal junction.

· Secondary prevention of esophageal variceal bleeding:

There is 20% chance of rebleed within first 6 weeks after the initial bleed if it left untreated. The prevention of episodes of bleeding after initial bleeding is essential for prolongation of the life of patient. The methods used are endoscopic therapy (EVL and endoscopic sclerotherapy), drugs, TIPS and orthotopic liver transplantation (OLT). Beta blocker along with endoscopic variceal ligation is the effective method.

Orthotopic Liver Transplantation (OLT):

Liver transplantation is the remedy for end stage liver diseases complications including portal hypertension and variceal bleeding. But the procedure can be performed only in higher centres and only when the compatible donor is available.

Nursing Management of Esophageal Varices:

The nursing management of esophageal varices may be grouped as nursing care during active bleeding and nursing care for prevention of secondary bleeding.

Nursing care during active bleeding of esophageal varices

A patient with bleeding esophageal varices is to be considered in critical condition. Nursing management is aimed at assisting the physician in controlling bleeding and preventing shock and death. A thorough aggressive medical and nursing care is required for management of acute bleeding.

· The nurse must ensure patent airway

· Patient should be placed in semi fowler’s position or side lying position to avoid aspiration of blood.

· Provide oral suction/ endotracheal tube suction if necessary to clear secretions

· Monitor vital signs closely and assess level of consciousness frequently.

· Observe for signs of hypovolemic shock.

· Establish patent IV lines in both hands to manage emergency situations.

· Administer vasopressin as advised.

· Measures should be taken to arrange blood transfusion if required.

· Administer intravenous fluids and blood, as ordered.

· Measure and record intake and output.

· Offer reassurance and moral support to the patient and his family.

· Assess the patient’s mental status and coping mechanisms.

· Reinforce teaching and explanations to the patient and relatives.

Nursing care during emergency endoscopic procedures:

· Ensure patent airway before the procedure and level of consciousness of the patient.

· Monitor vital signs including saturation and blood pressure.

· Check and follow manufacturer’s instructions before using the endoscopic variceal band.

· Get an informed consent before the procedure.

· Educate the patient that after the procedure he may develop complications like post EVL bleeding, chest discomfort, dysphagia and odynophagia.

· Advise the patient to maintain NPO after the procedure as advised by the physician.

· If balloon tamponade is performed remove secretions and saliva that may accumulate above the balloon so that aspiration can be prevented.

Nursing care for prevention of secondary bleeding:

· Educate the patient about importance of regular follow up to the hospital.

· Advise the patient to avoid the risk factors that lead to bleeding from varices.

· Teach the patient to cope with the disease process.

CONCLUSION:

Nurses have a great role in managing patient with acute bleeding of ruptured varices and prevention of secondary bleeding. A thorough knowledge about esophageal varices will improve nursing care of such patients. Good nursing care will prolong the life of patient.

ACKNOWLEDGEMENTS:

There is no grant received from any organizations for this article.

CONTRIBUTIONS OF AUTHORS:

All authors have intellectually contributed for this article and they critically reviewed, evaluated and approved the article.

CONFLICT OF INTEREST:

There is no financial implication for this article and personal relationships with other people or organizations.

CONTRIBUTION OF THE PAPER

What is already known about the topic?

· Esophageal varices are secondary complication of the portal hypertension.

· There is a number of treatment modalities available for varices.

What this paper adds?

· Nursing care in patients with esophageal varices.

· Methods to adopt while managing acute variceal bleeding.

· Nurses role in prevention of secondary bleeding.

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Received on 06.12.2018 Modified on 10.02.2019

Asian J. Nursing Education and Research. 2019; 9(2):273-277.

DOI: 10.5958/2349-2996.2019.00059.4