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[Etiology and management of esophageal varices]
12nd Department of Surgery, Faculty of Medicine, Juntendo University.
Insights
Liver cirrhosis is the primary cause of portal hypertension, leading to esophageal varices and bleeding. Treatment varies by patient, including endoscopic sclerotherapy, surgery, and Transjuglar Intrahepatic Portasystemic Shunt (TIPS).
Area of Science:
- Gastroenterology and Hepatology
- Vascular Surgery
Context:
- Portal hypertension, predominantly caused by liver cirrhosis (84% of cases), leads to increased portal pressure and collateral circulation.
- Esophageal varices, a critical complication, pose a significant mortality risk and necessitate prompt management.
- Hepatoma frequently accompanies cirrhosis, requiring integrated treatment strategies.
Purpose:
- To outline the etiologies, complications, and diverse treatment modalities for portal hypertension, emphasizing esophageal varices.
- To discuss the efficacy and indications of various interventions, from endoscopic sclerotherapy to surgical options and TIPS.
- To highlight the role of liver transplantation for hepatic insufficiency and the consideration of hepatoma in treatment planning.
Summary:
- Liver cirrhosis is the main cause of portal hypertension, resulting in esophageal varices and bleeding, a high-mortality complication.
- Treatment strategies range from emergency endoscopic interventions (Sengstaken-Brakemor tube) to Endoscopic Injection Sclerotherapy (EIS), surgical procedures (e.g., Sugiura procedure), and Transjuglar Intrahepatic Portasystemic Shunt (TIPS).
- Treatment selection depends on patient factors like liver function (Child A, B, C), presence of gastric varices, splenomegaly, and hepatic insufficiency, with liver transplantation as a future option.
Impact:
- Provides a comprehensive overview of managing portal hypertension and its complications, guiding clinical decision-making.
- Highlights the evolving treatment landscape, incorporating both established and novel interventions like TIPS.
- Emphasizes a patient-centered approach, tailoring therapies based on disease severity and individual patient characteristics for improved outcomes.
Abstract:
The most common etiogenic disease of portal hypertension that we experience is liver cirrhosis, which accounts for 84% of all cases. In patients with portal hypertension, congestion by portal blood due to cirrhosis causes a rise in portal pressure and development of collateral circulation between the portal system and the postcaval system is observed. Esophageal varices are associated with higher mortality than any other symptom of portal hypertension and are an important consideration in treatment. When emergency endoscopic examination and diagnosis show esophageal variceal bleeding, the varices must be constricted directly using a Sengstaken-Brakemor tube. If hemostasis is maintained, medical and surgical procedures can be performed after the recovery of body strength. Endoscopic Injection Sclerotherapy (EIS) has recently been widely carried out to prevent variceal bleeding and its application is increasing. However, treatment with EIS alone is not sufficient in terms of long-term efficacy, and surgical treatment is effective, especially in patients with gastric varices or splenomegaly. For Child A and B groups, both with good liver function, non-shunting operation, especially, the SUGIURA procedure, shows a marked effectiveness on varices. For group Child C, EIS is selected. The newly-developed Transjuglar Intrahepatic Portasystemic Shunt (TIPS), is being used, recently. For hepatic insufficiency, liver transplantation is expected to be one of the method for future treatment. Cirrhosis is also commonly accompanied by hepatoma, and this must be taken into consideration in treatment.