Esophageal bleeding disorders

Esophageal varices and Mallory Weiss syndrome are the two major esophageal bleeding disorders. Although there have been major breakthroughs in the treatment of peptic ulcer bleeding, the management of esophageal bleeding disorders remains a challenging problem. This review focuses on studies published in the previous 12 months that provide further understanding of the appropriate treatment of various esophageal bleeding disorders. Other uncommon causes of esophageal bleeding are also discussed.

With the advances in endoscopic and pharmacologic treatments, mortality resulting from variceal hemorrhage has been substantially reduced. Band ligation is the first-line endoscopic treatment of esophageal variceal hemorrhage. Vasoactive agents such as somatostatin analog and terlipressin are both safe and effective pharmacologic treatments of esophageal variceal hemorrhage. Use of a nonselective beta-blocker is still the most widely accepted treatment for both primary and secondary prophylaxis. However, the effectiveness of beta-blockers is limited by intolerance and nonresponders in a significant proportion of patients. Thus, endoscopic band ligation is used increasingly as an alternative strategy for primary prophylaxis. A transjugular intrahepatic portosystemic shunt should be reserved as rescue therapy for failure of medical and endoscopic treatments. In recent years, noninvasive surrogate markers have been reported to identify high-risk patients with large esophageal varices. Platelet count, spleen diameter, and their ratio are accurate predictors of esophageal varices in patients with cirrhosis. The endosonographic measurement of the cross-sectional surface area predicts the risk of variceal hemorrhage. For Mallory Weiss syndrome, endoscopic clipping is an emerging treatment modality, especially for deep laceration with risk of perforation.

A combination of various clinical, laboratory, and endosonographic parameters accurately predicts the risk of variceal hemorrhage. A streamlined screening strategy allows more cost-effective use of endoscopy and prompt prophylactic treatment for high-risk esophageal varices.