updates in management of Oesophageal Varices

بســم الله الرحمــن الرحيـــم:

بســم الله الرحمــن الرحيـــم UPDATES IN MANAGEMENT OF OESOPHAGEAL VARICES BY Hosam M. Hamza, M S c Assistant Lecturer Of GI Surgery & Endoscopy MINIA FACULTY OF MEDICINE MINIA- EGYPT 2011

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INTRODUCTION :- * Bleeding from oesophageal varices is a catastrophic complication of chronic liver disease. * Many years ago, surgery was the only treatment option available. In the 1980s, endoscopic treatment contributed to improved survival of such patients.

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AN ATOMIC REVIEW :

I. Intra –hepatic : portal V. tributaries + Hepatic V. tributaries II. Extra- hepatic::

I. Intra –hepatic : portal V. tributaries + Hepatic V. tributaries II. Extra- hepatic: SITE PORTAL SYSTEMIC IMPORTANCE lower end of the oesophagus Lt gastric Azygos ?? HAEMATEMESIS around the umbilicus paraumbilical Superficail veins of ant. Abd. Wall ?? Caput medusa ?? UH lower end of the rectum & anal c. Superior rectal Middle & inferior rectal ?? Haemorrhoids around the kidneys Middle colic (Rt & Lt) Renal ( Rt & Lt) ---------------- lower surface of the diaphragm Hepatic phrenic ---------------- Vein of Retzius Connects the Superior mesenteric Vein with the IVC

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DIAGNOSING OESOPHAGEAL VARICES: HISTORY TAKING. - History of jaundice, blood transfusions, schistosomiasis in childhood, hereditary liver disease, alcohol abuse…. etc - History of dyspepsia, lt hypochondrial pain, abdominal enlargement, haematemesis, melaena, hematochaezia, altered mental status changes… etc PHYSICAL EXAMINATION. INVESTIGATIONS

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DIAGNOSING OESOPHAGEAL VARICES: HISTORY TAKING. PHYSICAL EXAMINATION. INVESTIGATIONS

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Diagnosis . Grading . Treatment . I- GI ENDOSCOPY GRADE (OV) ENDOSCOPIC APPEARANCE I Dilated veins (< 5mm) elevating the mucosa. II Dilated, straight veins (> 5 mm) protruding into the esophageal lumen but not obstructing it. III Large winding veins considerably obstructing the lumen. IV Tense veins with near complete obstruction of lumen with impending danger of hemorrhage (cherry red spots)

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GRADE II GRADE III GRADE IV GRADE I GRADE II GRADE III

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Risk factors for variceal hemorrhage: GENERAL: Active alcohol intake. Bacterial infection (by endotoxin release and worsening of haemostasis) Ascites (Child’s classification) increases the risk of hemorrhage. LOCAL (ENDOSCOPIC): Variceal size. Endoscopic red color signs (eg, red whale markings, cherry red spots). Local changes in distal esophagus ( eg, GER “ weak evidence” ).

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Virtual endoscopy (computed endoscopy) New promising method of diagnosis using conventional CT and MRI → cross section "slices" → high performance computing → direct 3-D representations of human anatomy similar or equivalent to those produced by standard endoscopic procedures .

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__________________________ Advantages __________________________ Noninvasive No sedation required Can image entire oesophagus and localize lesions precisely Fast Sensitivity equal to that of gastro-oesophagoscopy for lesions >10 mm in diameter and superior to that of barium studies Less technically demanding _________________________ Disadvantages ______________________ Cost Radiation exposure No biopsy, not therapeutic Cannot show texture and color details of mucosa Retained food can be misinterpreted as pathology (eg. Polyps)

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II- IMAGING “Non-specific” 1- PLAIN RADIOGRAPHS 2- BARIUM STUDIES 3- CT/ ( CT portal venography) 4- M.R.I.

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5- EUS (Endoscopic ultrasonography) 6- Nuclear imaging 7- Angiography 8- Multi-detector CT oesophagography II- IMAGING

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life-long nonselective beta-adrenergic blocker therapy, provided that their use is not contraindicated. ( ↓ risk of initial variceal bleeding by approximately 45% ) If contraindications exist, long-acting nitrates are alternatives. The role of endoscopic variceal ligation is as effective as beta-adrenergic blockers in decreasing incidence of first bleeding. Injection sclerotherapy (alone or combined with treatment by nonselective beta-blockers) offer no advantages over the use of beta-blockers alone and should be better avoided. TTT OF ASYMPTOMATIC (silent) OV (1ry Prophylaxis)

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1- EMERGENCY THERAPY: A- Hospitalization. B- Resuscitation: -assess A ,B ,C . -sedation (? morphine ) -cimitidine. -blood transfusion (? fresh ), vit K. , FFP. -antibiotics (? prophylactic ). -prevention of encephalopathy . C- Emergency diagnosis: history ,exam ,endoscopy ,….. . D- Specific measures needed as bleeding usually continues: 1-drugs: vasopressin , somatostatin,.. . 2-interventional radiology. 3-endoscopic therapy. 4-balloon tamponade . 5 - surgery TTT OF BLEEDING (SYMPTOMATIC) OV

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TTT OF BLEEDING (SYMPTOMATIC) OV, cont. 1- Interventional radiology : In the 1970s, interventional radiology techniques were developed for the treatment of OVs: * Percutaneus transhepatic transportal venous obliteration * Partial splenic artery embolization .

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TTT OF BLEEDING (SYMPTOMATIC) OV, cont. 2- Endoscopic therapy : * Endoscopic variceal injection sclerotherapy . * Endoscopic variceal band ligation . * Endoscopic variceal argon plasma coagulation . * Combined techniques: 1- endoscopic scleroligation Umehara M, Onda M, Tajiri T, Toba M, Yoshida H, Yamashita K. Sclerotherapy plus ligation versus ligation for the treatment of esophageal varices: a prospective randomized study. Gastrointest Endosc 1999; 50: 7-12 2- combined endoscopic & interventional radiology: Cumulative retreatment rates in patients with Child’s class C disease were lower after endoscopic treatment + interventional radiology than after endoscopic treatment alone ( P = 0.025) Taniai N, Onda M, Tajiri T, Yoshida H, Mamada Y. Combined endoscopic and radiologic intervention to treat esophageal varices. Hepatogastro 2002; 49: 984-988

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TTT OF BLEEDING (SYMPTOMATIC) OV, cont. 3- Balloon tamponade : indications 1- Severe upper GI bleeding that does not clear with gastric lavage and pharmacologic therapy. 2- Haemorrhage not controlled with endoscopic interventions. 3- Lack of endoscopy. contraindications 1-Lack of strict clear indications for balloon tamponade. 2-Lack of clinical experience with these tubes. 3-Definitive treatment is immediately available.

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TTT OF BLEEDING (SYMPTOMATIC) OV, cont. 4- SURGERY :

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TTT OF BLEEDING (SYMPTOMATIC) OV, cont. Indication of surgery: failure of initial nonsurgical TTT in patients still having good liver function. Goal of surgery:- 1).decompression of the high-pressure portal system into a low-pressure systemic venous system ( i.e. portosystemic shunts ) 2).devascularization of distal esophagus and prox. stomach. ( i.e. ps disconnection OR variceal ablation)

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TTT OF BLEEDING (SYMPTOMATIC) OV, cont. Surgical Options:- @ PORTOSYSTEMIC SHUNTS either: {1 - TOTAL}: * Portocaval shunt (end-to-side). *Portocaval shunt (side-to-side). *Mesocaval shunt. *Central splenorenal shunt (+ splenectomy). {2-PARTIAL}: *Distal splenorenal (Sallam-Warren’s) shunt. *Gastrocaval shunt. { 3-T.I.P.S.}:

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TTT OF BLEEDING (SYMPTOMATIC) OV, cont. Surgical Options; cont. @PORTOSYSTEMIC DISCONNECTION (VARICEAL ABLATION) *Oesophageal transection (TANNER’S RESECTION) now replaced by T.I.P.S. *Splenectomy-vasoligation (HASSAB-KHIARY OPERATION)

SUGIURA-FUTAGAWA OPERATION:

SUGIURA-FUTAGAWA OPERATION

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TTT OF BLEEDING (SYMPTOMATIC) OV, cont. Surgical Options; cont. how to CHOOSE the operation ??? 1-advantage-disadvantage score: Advantage Disadvantage Nonselective shunts End-to-end portoc less bleeding encephalopathy Side-to-side portoc less bleeding liver hypoperfusion Selective shunts Distal splenoren less encephalop . Technically difficult worsening of ascites Partial shunts mesocaval less bleeding graft stenosis or thrombosis less encephalop. good liver perfusion

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TTT OF BLEEDING (SYMPTOMATIC) OV, cont. Surgical Options; cont. how to CHOOSE the operation ??? 2-child’s classification : PARAMETER A [1 Point] B [2 points] C [3points] Ascites none slight moderate Encephalopathy None minimal Marked (coma) SerumBillirubin (mg%) <2 2-3 >3 Serum Albumen (gm%) >3.5 3-3.5 <3 Increase in PT (sec) 4 4-6 6

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TTT OF BLEEDING (SYMPTOMATIC) OV, cont. Surgical Options; cont. how to CHOOSE the operation ??? CHILD A (5-7 points):- CHILD B (8-11 points):- adult - -----splenectomy-vasoligation child - -----mesocaval shunt CHILD C (12-15 points):- adult -----T.I.P.S. child -----mesocaval shunt Operative Mortality: CHILD A----------  2% CHILD B---------- 10% CHILD C----------  50%

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THANK U