Varices

Esophageal varices are dilated veins of the subepithelial connective tissue that are usually caused by portal hypertension in patients with cirrhosis or other liver pathology. Esophageal varices can be differentiated into three types: 1) uphill, 2) downhill, and 3) idiopathic.

Uphill varices occur when increased portal venous pressure leads to "upward" venous flow via dilated esophageal collaterals towards the superior vena cava. Esophageal varices have potentially fatal consequences if they rupture and hemorrhage. Variceal bleeding may present with hematemesis, melena, guaiac-positive stool, or iron-deficiency anemia. Dysphagia is not commonly seen in patients with esophageal varices.

Barium studies should be performed with the patient in a recumbent position (often prone, right anterior oblique). High-density barium suspensions or paste are used to increase adherence of the barium to the esophageal mucosa. Mucosal relief views of the esophagus can reveal serpiginous filling defects seen after the passage of barium via the peristaltic wave. Varices may also be visualized on double contrast esophograms when they are etched in white as areas of the barium being trapped between the edge of the varix and the esophageal wall. Uphill varices tend to be most prominent in the distal third or half of the thoracic esophagus.

Image "A" depicts multiple varices on esophagram. Image "B" is an angiographic demonstration of cavernous transformation of the portal vein (PV) with reversal of blood flow through the coronary veins (CV) and splenic vein (SV) producing esophageal varices (Var.)

Downhill varices occur less frequently and are due to obstruction of the superior vena cava which may lead to "downward" venous flow via esophageal collaterals towards the portal vein and inferior vena cava. Downhill varices are often asymptomatic, but may cause occasional hematemesis or low-grade gastrointestinal bleeding. However, patients often exhibit symptoms of superior vena cava syndrome.

If the SVC obstruction occurs above the level of the azygos vein, the downhill varices are confined to the upper or midthoracic esophagus because the varices can return blood from the head and upper extremities to the SVC via the azygos vein. If the obstruction is below the azygos, the varices cannot use the azygous vein to bypass the obstruction. Therefore they may involve the entire midthoracic esophagus. Just like uphill varices, downhill varices appear on barium studies as serpiginous longitudinal filling defects. They are differentiated between uphill varices based on their location in the esophagus. Downhill varices occur predominately in the distal third of the thoracic esophagus.

Idiopathic varices are found in patients who show no evidence of either portal hypertension or superior vena cava obstruction. It is postulated that these varices develop secondary to congenital weakness in the venous system of the esophagus.

Varices are often treated via scleroptherapy or endoscopic esophageal banding.