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    Esophageal Varices, A Simple Guide To The Condition, Diagnosis, Treatment And Related Conditions
    Esophageal Varices, A Simple Guide To The Condition, Diagnosis, Treatment And Related Conditions
    Esophageal Varices, A Simple Guide To The Condition, Diagnosis, Treatment And Related Conditions
    Ebook153 pages1 hour

    Esophageal Varices, A Simple Guide To The Condition, Diagnosis, Treatment And Related Conditions

    By Kenneth Kee

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    About this ebook

    This book describes Esophageal Varices, Diagnosis and Treatment and Related Diseases
    Esophageal varices are excessively swollen sub-mucosal veins present in the lower third of the esophagus.
    They are most often an effect of portal hypertension, often due to cirrhosis
    Patients with esophageal varices have a strong tendency to bleed readily.
    Variceal hemorrhage happens from dilated veins (varices) at the junction between the portal and systemic venous systems.
    Varices are likely to occur in the distal esophagus and the proximal stomach but isolated varices may be present in the distal stomach, large and small intestine.
    Bleeding is typically severe and may be threatening to life.
    Bleeding from esophageal varices is responsible for 5-11% of all cases of upper gastrointestinal bleeding (UGIB).
    In Western countries, alcoholic and viral cirrhosis are the primary causes of esophageal varices and portal hypertension.
    30% of patients with compensated cirrhosis and 60-70% of patients with decompensated cirrhosis have gastro-esophageal varices at the time of presentation.
    Esophageal varices are diagnosed mainly with endoscopy
    Causes
    The causes of esophageal varices are anything that can produce portal hypertension.
    Pre-hepatic
    a. Portal vein thrombosis.
    b. Portal vein obstruction - congenital atresia or stenosis.
    c. Increased portal blood flow - fistula.
    d. Increased splenic flow
    Other Pre-hepatic causes are:
    1. Splenic vein thrombosis and
    2. Portal vein thrombosis.
    These disorders often are linked with:
    1. Hyper-coagulable states and
    2. Malignancy (e.g., pancreatic cancer).
    Intra-hepatic
    a. Cirrhosis due to different causes such as alcoholic, chronic hepatitis (e.g. viral or autoimmune).
    b. Idiopathic portal hypertension (hepatoportal sclerosis).
    c. Acute hepatitis (particularly alcoholic).
    d. Schistosomiasis.
    e. Congenital hepatic fibrosis.
    f. Myelosclerosis
    Post-hepatic
    a. Compression (e.g. from tumor).
    b. Budd-Chiari syndrome.
    c. Constrictive pericarditis (and rarely right-sided heart failure).
    Symptoms
    a. Hematemesis (most often),
    b. Melena.
    c. Abdominal pain
    d. Features of liver disease and specific underlying condition.
    e. Dysphagia or odynophagia (pain on swallowing; uncommon)
    f. Confusion secondary to encephalopathy (even coma).
    Diagnosis
    a. Endoscopy is needed at an early stage.
    b. FBC - hemoglobin may be low; MCV may be high, normal or low; platelets may also be low; WBC may be raised.
    c. Clotting factors including INR
    d. Renal function
    e. LFT
    Chest X-Ray - patients may have aspiration or chest infection.
    Treatment
    In emergency situations, the treatment is directed at:
    a. Stopping blood loss,
    b. Maintaining plasma volume,
    c. Correcting disorders in coagulation induced by cirrhosis,
    d. Proper use of antibiotics (normally a quinolone or ceftriaxone, as infection by gram-negative strains is either concomitant or a precipitant).
    The purpose of treatment should be hemodynamic stability and hemoglobin of over 8 g/dL.
    Two main treatment methods are present:
    a. Variceal ligation or banding
    b. Sclerotherapy
    Acute Variceal Bleeding Medical Treatment
    1. Upper Endoscopy urgently (within 12 hours)
    2. Vasoactive agents
    a. Octreotide or Sandostatin (preferred)
    b. Long-acting somatostatin analog
    This is the preferred vasoactive agent in Upper GI Bleed
    c. Intravenous Vasopressin
    This is used with Nitroglycerin
    d. Non-selective Beta Blocker
    Propanolol, Nadalol, Timolol
    Acute Variceal Bleeding Invasive Treatment
    1. Endoscopic ligation or banding
    2. Transjugular intrahepatic Portosystemic Shunt (TIPS)
    Liver transplant is the treatment of choice for patients with advanced liver disease

    TABLE OF CONTENT
    Introduction
    Chapter 1 Esophageal Varices

    LanguageEnglish
    PublisherKenneth Kee
    Release dateJan 29, 2018
    ISBN9781370534562
    Esophageal Varices, A Simple Guide To The Condition, Diagnosis, Treatment And Related Conditions
    Author

    Kenneth Kee

    Medical doctor since 1972.Started Kee Clinic in 1974 at 15 Holland Dr #03-102, relocated to 36 Holland Dr #01-10 in 2009.Did my M.Sc (Health Management ) in 1991 and Ph.D (Healthcare Administration) in 1993.Dr Kenneth Kee is still working as a family doctor at the age of 74However he has reduced his consultation hours to 3 hours in the morning and 2 hours inthe afternoon.He first started writing free blogs on medical disorders seen in the clinic in 2007 on http://kennethkee.blogspot.com.His purpose in writing these simple guides was for the health education of his patients which is also his dissertation for his Ph.D (Healthcare Administration). He then wrote an autobiography account of his journey as a medical student to family doctor on his other blog http://afamilydoctorstale.blogspot.comThis autobiography account “A Family Doctor’s Tale” was combined with his early “A Simple Guide to Medical Disorders” into a new Wordpress Blog “A Family Doctor’s Tale” on http://ken-med.com.From which many free articles from the blog was taken and put together into 1000 eBooks.He apologized for typos and spelling mistakes in his earlier books.He will endeavor to improve the writing in futures.Some people have complained that the simple guides are too simple.For their information they are made simple in order to educate the patients.The later books go into more details of medical disorders.He has published 1000 eBooks on various subjects on health, 1 autobiography of his medical journey, another on the autobiography of a Cancer survivor, 2 children stories and one how to study for his nephew and grand-daughter.The purpose of these simple guides is to educate patient on health disorders and not meant as textbooks.He does not do any night duty since 2000 ever since Dr Tan had his second stroke.His clinic is now relocated to the Buona Vista Community Centre.The 2 units of his original clinic are being demolished to make way for a new Shopping Mall.He is now doing some blogging and internet surfing (bulletin boards since the 1980's) startingwith the Apple computer and going to PC.The entire PC is upgraded by himself from XT to the present Pentium duo core.The present Intel i7 CPU is out of reach at the moment because the CPU is still expensive.He is also into DIY changing his own toilet cistern and other electric appliance.His hunger for knowledge has not abated and he is a lifelong learner.The children have all grown up and there are 2 grandchildren who are even more technically advanced than the grandfather where mobile phones are concerned.This book is taken from some of the many articles in his blog (now with 740 posts) A Family Doctor’s Tale.Dr Kee is the author of:"A Family Doctor's Tale""Life Lessons Learned From The Study And Practice Of Medicine""Case Notes From A Family Doctor"

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      Book preview

      Esophageal Varices, A Simple Guide To The Condition, Diagnosis, Treatment And Related Conditions - Kenneth Kee

      Esophageal Varices,

      A

      Simple

      Guide

      To

      The Condition,

      Diagnosis,

      Treatment

      And

      Related Conditions

      By

      Dr Kenneth Kee

      M.B.,B.S. (Singapore)

      Ph.D (Healthcare Administration)

      Copyright Kenneth Kee 2018 Smashwords Edition

      Published by Kenneth Kee at Smashwords.com

      Dedication

      This book is dedicated

      To my wife Dorothy

      And my children

      Carolyn, Grace

      And Kelvin

      This book describes Esophageal Varices, Diagnosis and Treatment and Related Diseases which is seen in some of my patients in my Family Clinic.

      (What The patient Need to Treat Esophageal Varices)

      This eBook is licensed for your personal enjoyment only. This eBook may not be re-sold or given away to other people. If the patient would like to share this book with another person, please purchase an additional copy for each reader.

      If you’re reading this book and did not purchase it, or it was not purchased for your use only, then please return to Smashwords.com and purchase your own copy.

      Thank you for respecting the hard work of this author.

      Introduction

      I have been writing medical articles for my blog http://kennethkee.blogspot.com (A Simple Guide to Medical Disorder) for the benefit of my patients since 2007.

      My purpose in writing these simple guides was for the health education of my patients.

      Health Education was also my dissertation for my Ph.D (Healthcare Administration).

      I then wrote an autobiolographical account of his journey as a medical student to family doctor on his other blog http://afamilydoctorstale.blogspot.com.

      This autobiolographical account A Family Doctor’s Tale was combined with my early A Simple Guide to Medical Disorders into a new Wordpress Blog A Family Doctor’s Tale on http://kenkee481.wordpress.com.

      From which many free articles from the blog was taken and put together into 1000 eBooks.

      Some people have complained that the simple guides are too simple.

      For their information they are made simple in order to educate the patients.

      The later books go into more details of medical disorders.

      The first chapter is always from my earlier blogs which unfortunately tends to have typos and spelling mistakes.

      Since 2013, I have tried to improve my spelling and writing.

      As I tried to bring the patient the latest information about a disorder or illness by reading the latest journals both online and offline, I find that I am learning more and improving on my own medical knowledge in diagnosis and treatment for my patients.

      Just by writing all these simple guides I find that I have learned a lot from your reviews (good or bad), criticism and advice.

      I am sorry for the repetitions in these simple guides as the second chapters onwards have new information as compared to my first chapter taken from my blog.

      I also find repetition definitely help me and maybe some readers to remember the facts in the books more easily.

      I apologize if these repetitions are irritating to some readers.

      Chapter 1

      Esophageal Varices

      What are esophageal Varices?

      Esophageal varices are excessively swollen sub-mucosal veins present in the lower third of the esophagus.

      They are most often an effect of portal hypertension, often due to cirrhosis.

      Patients with esophageal varices have a strong tendency to bleed readily.

      Variceal hemorrhage happens from dilated veins (varices) at the junction between the portal and systemic venous systems.

      Varices are likely to occur in the distal esophagus and the proximal stomach but isolated varices may be present in the distal stomach, large and small intestine.

      The majority of patients with variceal bleeding have chronic liver disease.

      Bleeding is typically severe and may be threatening to life.

      The size of the varices and their likelihood to bleed are directly connected to the portal pressure which is normally directly linked to the severity of underlying liver disease.

      Large varices with red spots are at greatest danger of rupture.

      Incidence

      Bleeding from esophageal varices is responsible for 5-11% of all cases of upper gastrointestinal bleeding (UGIB).

      In Western countries, alcoholic and viral cirrhosis are the primary causes of esophageal varices and portal hypertension.

      30% of patients with compensated cirrhosis and 60-70% of patients with decompensated cirrhosis have gastro-esophageal varices at the time of presentation.

      Esophageal varices occur in about 8% of patients with chronic liver diseases yearly for the first two years and in 30% of patients by the sixth year.

      The danger of bleeding from esophageal varices in the first year after discovery is 30%.

      Esophageal varices are diagnosed mainly with endoscopy

      Most of the blood from the esophagus is drained through the esophageal veins which supply deoxygenated blood from the esophagus to the azygos vein which in turn drains directly into the superior vena cava.

      These veins do have any part in the formation of esophageal varices.

      The remaining blood from the esophagus is passed into the superficial veins lining the esophageal mucosa, which drain into the left gastric vein (coronary vein), which in turn drains directly into the portal vein.

      These superficial veins (normally only about 1mm in diameter) become swollen up to 1–2cm in diameter in comparison with portal hypertension.

      Normal portal pressure is about 9mmHg compared to an inferior vena cava pressure of 2-6mmHg.

      This produces a normal pressure gradient of 3-7mmHg.

      If the portal pressure rises above 12mmHg, this gradient will go to 7-10mmHg.

      A gradient greater than 5mmHg is identified as portal hypertension

      At gradients greater than 10 mmHg, the blood flow through the hepatic portal system is displaced from the liver into areas with lower venous pressures.

      This will indicate that collateral circulation develops in the lower esophagus, abdominal wall, stomach, and rectum.

      The small blood vessels in these areas become swollen, becoming more thin-walled and occur as varicosities.

      In situations where portal pressures rise, such as with cirrhosis, there is widening of the veins in the anastomosis, leading to esophageal varices.

      Splenic vein thrombosis is an infrequent disorder that causes esophageal varices without a raised portal pressure.

      Splenectomy can prevent the variceal bleeding due to splenic vein thrombosis.

      Varices can also form in other areas of the body, such as the stomach (gastric varices), duodenum (duodenal varices), and rectum (rectal varices).

      The treatment of these forms of varices may be different.

      In some cases, schistosomiasis also results in esophageal varices.

      What are the causes of esophageal Varices?

      Causes

      The causes of esophageal varices are anything that can produce portal hypertension.

      Pre-hepatic

      a. Portal vein thrombosis.

      b. Portal vein obstruction - congenital atresia or stenosis.

      c. Increased portal blood flow - fistula.

      d. Increased splenic flow

      Other Pre-hepatic causes are:

      1. Splenic vein thrombosis and

      2. Portal vein thrombosis.

      These disorders often are linked with:

      1. Hyper-coagulable states and

      2. Malignancy (e.g., pancreatic cancer).

      Intra-hepatic

      a. Cirrhosis due to different causes such as alcoholic, chronic hepatitis (e.g. viral or autoimmune).

      b. Idiopathic portal hypertension (hepatoportal sclerosis).

      c. Acute hepatitis (particularly alcoholic).

      d. Schistosomiasis.

      e. Congenital hepatic fibrosis.

      f. Myelosclerosis

      Post-hepatic

      a. Compression (e.g. from tumor).

      b. Budd-Chiari syndrome.

      c. Constrictive pericarditis (and

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