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What xray is it? What does it show? What is the diagnosis?
What is the cause and how does this condition present?
Outline the management?
This barium swallow shows gross oesophageal varices, the result of portal hypertension most commonly due to cirrhosis. (See below for details of presentation and management.)
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(See below for further details)
This is a barium swallow x-ray showing the whole length of the oesophagus. It shows multiple areas of filling defects involving the middle and more in the lower 1/3 of the oesophagus. They are long tortuous defects suggestive of dilated veins. The diagnosis is oesophageal varices.
The cause of oesophageal varices is portal hypertension. This can be due to pre-hepatic, hepatic and post-hepatic causes. The commonest cause is cirrhosis of liver presenting with portal hypertension. This condition presents either as an emergency or electively.
As an emergency the patient presents with massive haematemesis and is in shock. On examination there is evidence of shock with pallor, cold peripheries, sweating, weak thready pulse, tachycardia, hypotension and oliguria. The systemic examination may reveal features of liver failure.
In the elective situation the patient presents with repeated attacks of "herald bleed" (vomiting small amounts of blood). On examination of such a patient there is pallor due to blood loss, evidence of liver failure in the form of jaundice, palmar erythema, spider naevi, gynaecomastia, ascites, hepato-splenomegaly and testicular atrophy.
Emergency: The objectives of managing such a patient are to resuscitate, to confirm the diagnosis and institute definitive treatment. The patient is resuscitated by inserting two wide bore cannulae into the forearm veins and given crystalloids and colloids. A urinary catheter is inserted. Blood samples are taken for FBC, Us&Es and LFTs and for cross-matching.
Once the blood pressure is brought up to about 120 mmHg systolic, a central line is inserted to measure the CVP. Oxygen is started by mask and blood transfusion is given.
After resuscitation, a detailed history is taken with regard to drugs such as Aspirin, NSAIDs, Warfarin, H2 blockers, symptoms of peptic ulcer, history of jaundice and previous such episodes.
Usually most of the patients stop bleeding. An upper GI endoscopy is done to confirm the diagnosis of varices. At the same time the varices are injected with sclerosants or rubber band ligation is done. Once the bleeding has stopped the patient is discharged with the advice for repeat sclerotherapy after six weeks. The patient is then put on the sclerotherapy programme.
If the bleeding does not stop and it is continuous, a combination of mechanical and pharmacological control is started. A Sengstaken-Blakemore tube is inserted for balloon tamponade and at the same time parenteral infusion of vasopressin is given. Synthetic somatostatin analogue infusion also helps in reducing the portal pressure. With this combined treatment the bleeding usually stops. In the long term propanolol also helps. The patient is then put on the sclerotherapy programme.
If the bleeding re-starts after removal of the Sengstaken tube (which should not be left for more than 24 hours), the patient then undergoes emergency oesophageal transection and stapling. Alternatively, a shunt procedure can be done eg a TIPSS procedure (Transjugular Intrahepatic Porta-Systemic Shunt). Electively, if Child's criteria are met, a porta-caval anastomosis can be considered.