Esophageal varices

Esophageal Varices

Barium swallow is generally used to demonstrate esophageal varices, which appear as serpiginous filling defects in the distal esophagus and cardia of the stomach. Angiography is used for pre-and postoperative shunt evaluation.

Esophageal varices develop most commonly in the setting of portal hypertension. Hemorrhage is a frequent and feared complication. Typical presentations include intermittent hematemesis, melena and massive hemorrhage. The immediate mortality associated with variceal bleeding is 10 to 15 percent.1

Management of esophageal varices is directed at relieving portal hypertension, through correction of the underlying disease process, surgical creation of a portal systemic shunt or, in some cases, liver transplantation. Bleeding esophageal varices are commonly treated with intravenous vasopressin (Pitressin), endoscopic sclerotherapy or balloon tamponade.2

Pathophysiology

The major tributaries of the portal venous system are the splenic vein, the superior mesenteric vein and the inferior mesenteric vein. Portal venous hypertension is propagated through these tributaries and is decompressed by the formation of portal-systemic anastomosis. Esophageal and gastric varices result from transmission of portal venous pressure through the coronary (left gastric) vein into the periesophageal pergastric venous plexus. Blood can then travel retrograde through the azygos system to the superior vena cava and, finally, into the right atrium, decompressing the portal system. Splenic venous hypertension causes perisplenic varices. Recanalization of the umbilical vein may result in dilatation of periumbilical veins in the abdominal wall. Inferior mesenteric venous hypertension produces hemorrhoids.

Radiographic Findings

Chest radiographs are frequently normal. Occasionally, varices are seen as a paraesophageal or periesophageal mass (Figure 1). Ascites may cause elevation of the diaphragm. Abdominal radiographs may show centrally placed bowel loops and bulging flanks, indicative of ascites.

Barium swallow is the imaging modality of choice for demonstrating esophageal varices. The dilated submucosal veins appear as serpiginous filling defects in the distal esophagus and cardia of the stomach (Figure 2). They are best demonstrated when the patient is in a horizontal position, with minimal barium distention of the esophagus.

Ultrasound may show abdominal varices, ascites, abnormal liver morphology and portal vein patency.(3)

Computed tomographic (CT) scanning demonstrates varices as enhancing serpiginous tubular or mass-like structures adjacent to the esophagus, stomach and splenic hilus (Figures 3 and 4). Ascites and hepatic morphology are also demonstrated.

Angiography is used to establish the etiology of portal hypertension and to assist in pre-and postoperative shunt evaluation. 1. Eisenberg RL. Gastrointestinal radiology: a pattern approach. Philadelphia: Lippincott, 1982: 111-7. 2. Wyngaarden JB, Smith LH, eds. Cecil Textbook of medicine. 16th ed. Philadelphia: Saunders, 1982: 804-6. 3. Freeny PC. Portal hypertension and hepatic veno-occlusive disease. In: Taveras JM, Ferrucci JT, eds. Radiology: diagnosis, imaging, intervention. Vol 4. Philadelphia: Lippincott, 1988: 1-13.

PHOTO : FIGURE 1. Posteroanterior radiograph of the chest, showing elongated vertically oriented retrocardiac opacity (arrows). Lateral view was normal.

PHOTO : FIGURE 2. Barium swallow, demonstrating serpiginous filling defects in the esophagus (arrow), typical of esophageal varices.

PHOTO : FIGURE 3. CT scan of the chest, showing a circumscribed mass (arrow) abutting the esophagus. Enhancement with intravenous contrast material indicates the vascular nature of the mass.

PHOTO : FIGURE 4. CT scan of the abdomen, showing tubular varices (arrow) medial to the spleen. (SP = spleen; S = stomach)

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