Variceal Bleeding

(Gastrointest Endosc 2005;62:651-5. NEJM 2001;345:669-81)

DEFINITION:

Bleeding from varices
For Portal Hypertensive Gastropathy (PHG) and Gastric antral vascular ectasia (GAVE), See also GI Bleed- UGIB & LGIB (Chapter 6.04)

EPIDEMIOLOGY:

Varices:
- Prevalence: 50% of all cirrhotics have varices (80% in Childs C, 20% in Childs A)
- Incidence: 10% per year in cirrhotics
Variceal Bleeding:
- Incidence: 24% per 2 years with moderate to large varices
- Mortality: >20% with first bleed; 70% 5-year mortality; 40-50% will re-bleed

ETIOLOGIES:

In acute bleeds (causes): Varices 50%.
- Nonvariceal source: Gastric erosions 50%, MWT 15%, Any PUD 14%, Erosive esophagitis 11%

PATHOPHYSIOLOGY:

Hepatic Venous Wedge Pressure Gradient [HVWPG] = ˜6 mmHg normally
- >10 mmHg is required for variceal development; >12 mmHg is at high risk for bleeding
- HVWPG represents the pressure difference between the wedged hepatic vein (which reflects the portal vein pressure) and the direct measurement of the abdominal IVC (or the free hepatic vein pressure)
- Similar concept to a right heart catheterization (Swan-Ganz), in other words:
  
  HVWPG = Wedge Pressure (balloon up)-Free Hepatic Vein (balloon down)
Types of Gastric Varices (Sarin classification):
- GV-1: lesser curve (74%); GV-2: greater curve (16%)
- Currently no data support use of prophylactic treatment of gastric varices
Isolated Gastric Varices (IGV): usually complication of splenic vein thrombosis (especially IGV-1) or portal vein thrombosis
- Cause: trauma, pancreatitis/pancreatic cancer, hypercoagulability/essential thrombocytosis, cirrhosis (schistosomiasis), idiopathic
- Types: IGV-1: fundus (8%), IGV-2: antrum/pylorus (2%)
- Therapy: splenectomy for isolated splenic vein thrombosis