Esophageal Varices

Clinical Pharmacy Week 4: Tingkat 2 & 3 By Liew Hui Lian (PRP) 2009/2010

Outline

Esophageal Varices

What is it? Classification Epidemiology Risk factors Clinical manifestation Management

Case Study

What is it?

Very dilated submucosal vein in the lower esophagus like internal varicose veins Due to portal hypertension, most commonly from liver cirrhosis Normally, veins are 1 mm in diameter and becomes distended to 1-2 cm in diameter Most likely 5-8% patients who are diagnosed liver cirrhosis develop EV. Varices size increase 10-15% annually.

ClassificationJapaneseJapanese Absent Grade Absent 1: small, straight varices not disappearing with insufflation Grade 2: medium varices occupying less than one third of the lumen Grade 3: large straight varices not disappearing with Grade 1: small, varices occupying more than one third of the lumen

US

US Absent Absent I smal Absent< 5 mm Absent II medium 5-9 mm III large mm smal > 9 < 5 mmIV

VA Paquet VA Trial Paquet Trial I II III IV

insufflation Grade 2: medium varices occupying less than one third of the lumen Grade 3: large varices occupying more than one third of the lumen mediu m large 5-9 mm > 9 mm

* The Japanese Classification is the preferred grading scale for the staging of oesophageal Varices.

30% will experience haemorrhage Risk is greatest during first year of diagnosis Mortality 30-50% within 6 weeks Those that survive first bleed are at significant risk of recurrent haemorrhage (70%) and a third are fatal Risk of re-bleeding: hepatic decompensation, age >60, severity of initial bleed, renal insufficiency, level of portal pressure, size of varices, presence of hematoma

Epidemiology Prevalence in patient with cirrhosis 24-81% Variceal bleeding accounts for 6.4% of upper gastrointestinal bleeding in Malaysia. 15% of emergency endoscopy for UGIB in Selayang Hospital are due to acute variceal bleeding. Aetiology in Malaysia mainly: hepatitis B or alcohol Majority of patients are Chinese, followed by Indians

Risk Factors

Severity of liver dysfunction Size of varices Presence of endoscopic red wale signs Hepatic venous pressure gradient (HVPG). Bleeding is likely if it's above 12 mmHg

For patients with cirrhosis American College of Gastroenterology and the American Association for the Study of Liver Disease No varices: Every other year Small varices: every 1-2 years

Screening Endoscopy

OGDS view

1. Normal 2. Variced esophageal 3. Bleeding varices

Clinical Manifestation

Anemia Coughing up or vomitting blood Black tarry stools due to bleeding in the gut Lightheadedness from the loss of blood Passing out from the lost of blood

Non selective B adrenergic antagonist (e.g. propanolol and nadolol) Prevents splanchnic vasoconstriction Reduce risk of bleeding by 45% Propanolol is the most cost effective

Nitrates Reduces portal pressure But ineffective in preventing bleeding in patients as monotherapy

Pharmacological Therapy

Variceal ligation

Endoscopic Therapy

Injection sclerotherapy

Endoscopic Therapy

ManagementHypovolumic shock: Blood transfusion of pack cells Bacterial infections : Antibiotic (3 generation cephalosporin or quinolones i.e. norfloxacin/ ciprofloxacin) 7 days prophylaxisrd

Effective to stop bleeding but have high re-bleeding rate and other complications (ulceration, perforation and aspiration pnewmonia). Only for when no endoscopy is not available.

Balloon Tamponade

Rescue therapy for uncontrolled variceal bleeding after combined pharmacological and endoscopic therapy.

Transjugular Intrahepatic Portosystemic Shunts (TIPS)

Case Study

Patient's profile

Name: NDNK MRN: 28116 Age: 46 Gender: M Race: Siamese Weight: 70 kg DOA: 9 November 2009 DOD: 12 November 2009 Ward/ Bed: T2/311

Chief Complaint:

Passing black stool and abdominal discomfort and pain

History of Present Illness

Passing of black stool 2/7 and hematemesis 1 time today No fresh blood or spitting black blood Mild headache Soft and tender at epigastric region

Past Medical History k/c/o Hepatitis C OGDS done in June 2009 at Sungai Petani hospital, and was diagnosed with having esophageal varices.

Review of System

BP: 110/60 PR: 86 /min RR: 21 /min T: 37 C

Social/ Family History

Smokes 1 pack of cigarette per day Married and lives with wife

Past Medication History

None

Compliance evaluation

Not applicable

Diagnosis/ Surgical Procedure

UGIB 2nd to esophageal varices 2nd to portal hypertension Grade 1 large bleeding

Laboratory ResultsNormal Range TWBC HB4-11 x 10 L 11.5-16.5 g/100ml 4.5-6.3 x 106 0.4/0.370.52/0.48 150-400x 10/L

Day 1 12.0 8.6

Day 2* 15.6 6.9

Day 3 14.4 8.6

Day 4 5.9 9.0

RBC HCT

2.8 6.3

2.3 21.7

2.9 26.3

3.0 27.7

Platelet

107

127

96

72

* 2 pints of PC were transfused that day

Laboratory ResultsNormal Range Urea Na K Ca Mg PO4Scr 1.7-8.3 mmol/L 135-145 mmol/L 3.5-5.0 mmol/L 2.1-2.6 mmol/L 0.7-1.3 mmol/L 0.8-1.45 mmol/L 64-122 umol/L Day 1 11.1 138 4.1 Day 2 10.8 140 4.8 Day 3 Day 4

83

Laboratory ResultsNormal Range Albumin 35-50 g/L Day 129 27.9

Day 2

Day 3

Day 4

T. < 20 umol/L Bilirubin T. Protein 66-87 g/L ALP ALT 53-141 u/L < 32 u/L

64

88 56

Laboratory ResultsNormal Range PT APTT INR 10-13.5 sec 26-42 sec < 1.5 Day 114.7 37.1 1.35Day 2 Day 3 Day 4

Laboratory Results

Normal Range CK LDH AST 24-195 u/l 0-248 u/L