Esophagus—Esophageal Varices
Concept
Life-threatening complication of portal hypertension. A major concern is often stabilizing these patients and know- ing appropriate timing of surgical intervention. Also, make sure to rule out other potential sources for UGIB.
Way Question May be Asked?
“A 51 y/o male presents to the emergency department with three episodes of massive hemoptysis. His social history is remarkable for extensive alcohol abuse and his past med- ical history is remarkable for multiple admissions for alco- holic pancreatitis.” May be referred to you with the diagnosis of bleeding varices from another hospital, or simply a patient with an UGIB.
How to Answer?
Brief, focused H +P while resuscitating the patient
History
Alcohol use
Episodes of encephalopathy, bleeding varices History of pancreatitis
History of PUD
(you must do this while resuscitating, or you will have great history on a dead pt!)
Physical Exam
Stigmata of liver disease Ascites
Resuscitation
IV access, CVP, labs (especially coags), T +C, transfu- sion pRBC/FFP
NGT, lavage stomach
Treatment
Can consider Sengstaken-Blakemore tube after intubat- ing pt (be prepared to describe technique)
Start Pitressin drip 0.4 U/min (add nitroglycerin gtt if h/o CAD and consider SGC)
Start Somatostatin gtt (25 micrograms/hr)
Beta blocker to lower HR if not lower than 100 (give slowly as may precipitously drop SBP)
(at the back of your mind, should be considering Child’s class as Child’s C pts need liver txp—Bilirubin > 3, albumin < 3, severe ascites)
Endoscopy (once hemodynamically stabilized) At EGD, can consider
Sclerotherapy Banding
(neither will be available or will work!) If EGD fails, can consider TIPS
(won’t be available!)
Surgical Treatment Indications—Uncontrolled Bleeding
Emergency portosystemic shunt (mesocaval 8 mm PTFE shunt b/w SMV and IVC) →identify middle colic vein, follow distally to SMV (to right of SMA), iden- tify IVC through right colonic mesentery adjacent to duodenum, anastomose to IVC first, then to side of SMV (can use left IJ if contaminated field). This
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shunt doesn’t dissect in porta hepatis so doesn’t com- promise potential for future liver txp
Other choices:
Gastric devascularization
EEA limited esophagectomy with ligation of the left gastric vein
Gastrostomy and suture ligation
Common Curveballs
UGIB secondary to PUD, esophagitis, gastric varices Bleeding will continue post-op
Pt will become encephalopathic post-op Pt will have had prior abdominal surgery Pt will be Child’s class C
Pt will aspirate or perforate after balloon tamponade Pt with thrombosed splenic vein and bleeding gastric
varices (needs only a splenectomy)
Pt will develop hepatic failure or hepatorenal syndrome post-op
Asked to describe other shunting procedures
Strikeouts
Performing distal splenorenal shunt
Not being able to describe your surgical procedure Describing the Suguira procedure (you don’t want to do
something you’ve never done before and this is rarely done in the U.S.)
Rushing to the operating room
Not performing EGD/trying sclerotherapy/banding Not knowing how to use Sengstaken-Blakemore tube Not resuscitating the pt properly
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