The Incidence of Esophageal Varices in Patients with Cirrhosis

Denata Prabhasiwi 03009062

Denata Prabhasiwi 03009062

Anatomy of hepar and portal vein

cirrhosis

Esophageal varices

discussion

Anatomy of hepar and portal vein

PORTAL SYSTEM
Superior mesenteric + Splenic vein+ gastric + part from inferior mesentric = Portal vein Portal Vein carries outflow from: 1.) Spleen 2.) Oesophagus 3.) Stomach 4.) Pancreas 5.) Small and large intestine

HEPATIC BLOOD FLOW

Very low pressure in the hepatic portal vein approx. 5-8 mmHg with only a small gradient across the liver to the hepatic vein which returns the blood to the inferior vena cava

Cirrhosis Hepatis

Definition
o Cirrhosis is a complication of many liver disease that is characterized by abnormal structure and function of the liver o It is characterized by widespread fibrosis with nodular regeneration. Its presence implies previous or continuing hepatic cell damage

A normal liver (left) shows no signs of scarring. In cirrhosis (right), scar tissue replaces normal liver tissue.

etiology
1. Alcohol (>70%) 2. Chronic infections hepatitis C, B, B+D brucellosis, syphilis 3. Chr. biliary obstruction PBC, PSC, stricture, stones, cystic fibrosis, billiary atresia 4. Autoimmune 5. Drugs and chemical

pathogenesis

Clinical manifestation
Many people with cirrhosis have no symptoms during the early phases of the disease. Symptoms are caused by either of 2 problems: Gradual failure of the liver to carry out its natural functions Distortion of the liver's usual shape and size because of scarring

Clinical manifestation
Early cirrhosis : Tiredness ( fatigue) or even exhaustion Weakness Nausea Loss of appetite leading to weight loss Loss of sex drive

Clinical manifestation
Advance cirrhosis: Jaundice Spider naevi, caput Medusae Bloody, black stools or unusually light-colored stools Vomiting of blood In women, abnormal menstrual periods In men, enlargement of the breasts (gynecomastia) scrotal swelling

Visible sign of advance cirrhosis :

gynecomastia

ascites
Caput medusae

Esophageal Varices

definition
Esophageal varices are abnormal, enlarged veins in the lower part of the esophagus. varices occur most often in people with serious liver diseases. Esophageal varices can rupture, causing lifethreatening bleeding.

etiology
Severe liver scarring (cirrhosis). Blood clot (thrombosis). A parasitic infection

Sign and symtoms

Esophageal varices usually don't cause signs and symptoms unless they bleed. Signs and symptoms of bleeding esophageal varices include: Vomiting blood Black, tarry or bloody stools

Discussion

CIRRHOSIS

PORTAL HYPERTENSION

ESOPHAGEAL VARICES

Portal hypertension results from both: 1.Increased resistance to portal flow (R) 2.Increased portal venous inflow (Q)

Portal Hypertension
Portal vein - Hepatic vein pressure gradient greater than 5 mm Hg

Cirrhosis
Increased splanchnic + peripheral NO

Decreased intrahepatic NO

Decreased systemic + splanchnic vascular resistance

Increased intrahepatic resistance

Collaterals
Increase portal blood flow
Maintains portal hypertension
Sodium retention

Fig 3. The pathogenesis of oesophageal varices

Collateral
The portal venous system has several anastomosis with the systemic venous system. Four collateral pathways Esophageal and gastric venous plexus umbilical vein from the left portal vein to the epigastric venous system retroperitoneal collateral vessels the hemorrhoidal venous plexus In cases of portal hypertension these anastamoses may become engorged, dilated, or varicosed and subsequently rupture

No varices

Small varices

Large varices

treatments
prevent bleeding
Non selective beta blocker endoscopic variceal band ligation
ocreotide Somatostatin endoscopic sclerotherapy and banding

Stop bleeding

Prevent bleeding occurance

betablockers, endoscopic variceal ligation or the combination of beta-blockers and endoscopic variceal ligation TIPS (surgical)

conclusion
Cirrhosis is a condition that is defined histopathologically and has a variety of clinical manifestations and complications, some of which can be life-threatening, portal hypertension is directly responsible for the major complications of cirrhosis, variceal hemorrhage. Variceal hemorrhage is an immediate life-threatening problem with a 2030% mortality associated with each episode of bleeding. There are treatments to stop bleeding in such as vasoactivedrugs, vasopressin, somatostatin, octreotide, endoscopic sclerotherapy and banding, and endoscopic variceal ligation. -Blockers and endoscopic variceal band ligation are the treatments to prevent bleeding.

Thank You