Case Write Up - Esophageal Varices Secondary to Liver Disease

1. Case Presentation
ESOPHAGEAL VARICES
SECONDARY TO LIVER DISEASE

2. PATIENT’S IDENTIFICATION
Name: Phuah Eng Tea
Age: 59 years old
Gender: Male
Race: Chinese
Religion: Christian
Address: Klang Utama
Occupation: Retired lorry driver
Marital status: Married
Registration No: 1564813
Ward: 4A
Bed: 24
Informant: Wife

3. CHIEF COMPLAINT
Vomiting blood, on same day of
admission.

4. HISTORY OF PRESENTING ILLNESS
Mr Phuah , 59 years old Chinese gentleman
came to the Emergency Department
complaining of vomiting blood
(hematemesis) which is red in colour and 1
small cup full(approximately 100ml), on
same day of admission. It was sudden and
this was the second episode of hematemesis.
This is associated with loose black
stool(melena), abdominal pain, dizziness,
fatigue and loss of appetite. The review of
other systems were unremarkable.

5. PERSONALAND SOCIAL HISTORY
Mr Phuah is a retired lorry driver. He is married
with no children and lives in a single-storey house
with his wife with basic amenities. He smokes 5-6
pieces of cigarette per day since 20 years old, he
also consumes 2-3 cans of beer everyday for more
than 30 years and he is a heroin drug user. He
takes a normal chinese diet and undergoes
sedentary lifestyle.
FAMILY HISTORY
There is no chronic illness or malignancies
running in his family.

6. PAST MEDICAL HISTORY and
DRUG HISTORY
He has hypertension.
He was admitted 2 twice before due to
drug abuse and altered mental status.
He was diagnosed with Hepatitis C in
2013.
Currently, he is taking Covapril for his
HTN.
He is also a heroin drug user since young.

7. ANATOMICAL & PATHOLOGICAL
CORRELATION
Anatomical correlation Pathological correlation
Esophagus Neoplasm
Inflammation
Stomach Inflammation
Neoplasm

8. PHYSICAL EXAMINATION
General Examination
Patient was lying comfortably on bed in supine
position supported with one pillow. The patient
was alert, conscious and well-oriented to time,
place and person. The patient was not in pain and
respiratory distress. There was an ID tag on his
right hand and branula attached on his dorsum of
right hand which is attached to IV Metronidazole.
He is moderately build, with adequate nutritional
status.

9.  Hands
 Hands were warm and dry
 No clubbing, koilonychia or leukonychia
 No peripheral cyanosis
 No palmar erythema
 Eyes
 Has conjunctival pallor
 No jaundice
 Oral cavity
 Tongue is coated
 No central cyanosis
 No mouth ulcers
 Moderate oral hygiene
 Neck
 No swelling observed
 Legs
 No pitting edema

10. Vital signs
Blood pressure : 144/77 mmHg
Pulse rate : 77 beats per minute
Respiratory rate : 18 breaths per minute
Temperature : 37.0 ᵒC

11. Local Examination Of The Abdomen
On Inspection
The abdomen was distended. The umbilicus was
centrally located and inverted. There were no
surgical scars or discoloration of the skin. All
quadrants of the abdomen moved symmetrically
during respiration.
On palpation
On superficial and deep palpation, there were no
rigidity, guarding and tenderness of abdomen. The
liver and spleen were not palpable.

12. On percussion
 The liver span is normal at 10cm.
 There was positive fluid thrill and shifting
dullness
On auscultation
Normal bowel sound was heard(3 times per
minute).

13. SUMMARY
A 59 years old Chinese man was admitted
to hospital due to hematemesis associated
with loose black stool(melena), dizziness,
fatigue, abdominal pain and loss of
appetite.
On physical examination the abdomen was
distended. There was positive fluid thrill
and shifting dullness.

14. Provisional Diagnosis
Diagnosis Points to support
Esophageal Varices 2⁰
to Liver Disease
- Age (> 60 years old)
- Past history of hematemesis and melena
- History of Hepatitis C (known history of
liver disease)
- Intravenous drug user
- Alcohol consumer and smoker
- Abdominal pain
- Loss of appetite
- Unknown loss of weight
- Loose stool (diarrhea)
- Weakness & Fatigue

15. Differential Diagnosis
DIAGNOSIS POINTS TO SUPPORT POINTS AGAINST
Peptic Ulcer Disease - Nausea & vomiting
- Unknown weight loss
- Loss of appetite
- Melena & hematemesis
(severe case)
- Smoking
- No abdominal bloating
- No burning pain before
or after meal
- No heartburn
- No indigestion
Esophageal Carcinoma - Gender - male
- Unknown weight loss
- Melena
- Hematemesis
- Vomiting
- Smoking
- Age (usually >65yrs)
- No persistent cough
- No hoarseness
- No indigestion
- No dyspepsia
- No heartburn
- No dysphagia
- No chest or back pain

16. Gastric Carcinoma - Age (common in elderly)
- Nausea or vomiting
- Loss of appetite
- Melena
- Hematemesis
- Weight loss
- Diarrhea
- Weakness and fatigue
- No indigestion
- No dysphagia
- No postprandial
fullness
- No palpable mass on
abdomen
- No heartburn
- No bloated feeling
after eating
DIAGNOSIS POINTS TO SUPPORT POINTS AGAINST

17. Investigations
Self revised Done by hospital
Full Blood Count Haemotological Test
Liver Function Test Renal Function Test
Renal Function Test Liver Function Test
Endoscopy (OGDS) Arterial Blood Gases
Coagulation Profile Chest X-Ray
Chest X-Ray Abdominal X-Ray
Abdominal X-Ray HIV Test
Hepatitis C Screening Hepatitis C Screening
Hepatitis B Screening
Rapid Plasma Reagin

18. 1) Haemotological Test
Test Patient’s Result Unit Normal Range Interpretation
RBC 2.68 10^6/uL 4.5 – 6.5 Low
WBC 19.6 10^3/uL 4 - 11 High
HGB 8.1 g/dL 13 - 18 Low
HCT 23.9 % 40 – 54 Low
MCV 89.2 fL 76 – 96 Normal
MCH 30.2 pg 27 – 32 Normal
PLT 207 10^3/uL 150 - 400 Normal
.

19. 2) Renal Function Test
Test Result Unit Range Interpretation
Urea 15.4 mmol/L 2.8 – 7.2 High
Sodium 140 mmol/L 136 – 145 Normal
Potassium 4.6 mmol/L 3.5 – 5.1 Normal
Chloride 104 mmol/L 98 – 107 Normal
Creatinine 95 umol/L 45 - 84 Normal

20. 3) Liver Function Test
Test
Patient’s
Result
Unit
Normal
Range
Interpretation
Total Protein 59 g/L 66 – 83 Low
Albumin 28 g/L 35 – 52 Low
Globulin 31 g/L 25 – 39 Normal
A/G Ratio 0.9 0:9 – 1:8 Normal
ALP 53 IU/L 30 – 120 Normal
ALT 79 IU/L 0 – 50 High
Total
Bilirubin
20.1 umol/L 5 - 21 Normal

21. 4) Arterial Blood Gas
Test Result Unit Range
pH 7.382 - 7.350 – 7.450
pCO2 37.1 mmHg 35.0 – 48.0
pO2 21.3 mmHg 83.0 - 108
5) HIV Test & Rapid Plasma Reagin
Test Result
HIV Ag/Ab Non-Reactive
Syphilis Reagin Ab Non-Reactive

22. 6) Hepatitis B Screening
Test Result
Hepatitis B e Ab Reactive
Hepatitis B e Ag Non-Reactive
Hepatitis B s Ag Non-Reactive
7) Hepatitis C Screening
Test Result
Anti HCV Reactive
HCV particle Agglutination Detected

23. 8) Chest X-Ray
Impression :
Shows no abnormalities
(normal)

24. 9) Abdominal X-Ray
Impression :
Shows no abnormalities
(normal)

25. CHILD-PUGH-SCORE (SEVERITY OF CIRRHOSIS)
CATEGORY 1 2 3
ENCEPHALOPATHY 0 I/II III/IV
ASCITES ABSENT MILD-MODERATE SEVERE
BILIRUBIN
(umol/L)
<34 34 – 51 >51
ALBUMIN(g/L) >35 28 – 35 <28
INR <1.3 1.3 – 1.5 >1.5
Score A : 6 or less
Score B : 7-9
Score C : 10 and greater
Encephalopathy
Grade I : confusion, altered mood and behaviour
Grade II : drowsy, inappropriate behaviour
Grade III : stuporous but obeys simple commands, slurred speech, marked confusion
Grade IV : unarousable coma

26. CATEGORY RESULT SCORE
ENCEPHALOPATHY No 1
ASCITES Mild 2
BILIRUBIN (umol/L) 20 1
ALBUMIN(g/L) 28 2
INR 1.7 3
Total score : 9
Grade : Child Pugh B

27. RESUSCITATION
• Vitals are monitored (pulse, BP, cardiac monitor, urine output)
• Assessment of haemodynamic stability – severity of blood loss
• IV Route - Fluid resuscitation such as normal saline
• Oxygen support to prevent hypoxia of tissues – nasal cannula
or facemask.
• Correction of coagulopathy and thrombocytopenia
• Urine output (through an indwelling catheter)
• Blood transfusion is administered to patients who are shocked
and are actively bleeding.
Management

28. • Pharmacological therapy : vasoconstrictors to arrest the
bleeding (terlipressin, octreotide, vasopressin, somatostatin)
• Banding
• Sclerotherapy
• Non-selective ß-adrenergic antagonists such as propranolol
and nadolol to prevent rebleeding.
• Transjugular Intrahepatic Portosystemic Shunt (TIPS)
• Distal Splenorenal Shunt (DSRS).
• Liver transplant
• Devascularization
• Esophageal transection
Management

30. TIPS DSRS

31. a) Currently, no treatment can prevent the development of esophageal
varices in people with liver disease.
b) While beta blocker drugs are effective in preventing bleeding in
many people who have esophageal varices, they do not keep
esophageal varices from forming.
c) If one have been diagnosed with liver disease, strategies to avoid
liver disease complications should be taken.
- Don't drink alcohol.
- Eat a healthy diet.
- Reduce your risk of hepatitis.
Prevention

32. Discussion
• Portal venous pressure = portal venous flow x portal venous
resistance
• Hepatic venous pressure gradient (HVPG) is the difference in
pressure between the portal vein (wedged hepatic venous
pressure) and free hepatic vein pressure.
• HVPG = surrogate for portal pressure
• Increased HVPG > 5mmHg = Portal Hypertension
• Clinical manifestation of portal hypertension are many
included Esophageal Varices.

33. Increased portal pressure
(HVPG > 10mmHg)
Formation of varices
Dilatation of varices
Rupture of varices
(HVPG > 12mmHg)
Natural History

35. Anatomy of esophagus
• The esophagus is a 25-cm long muscular tube that connects the
pharynx to the stomach.
• The esophagus extends from the lower border of the cricoid cartilage
(at the level of the 6th cervical vertebra) to the cardiac orifice of the
stomach at the side of the body of the 11th thoracic vertebra.
• The esophagus has 3 constrictions in its vertical course.
• These measurements are clinically important for endoscopy and
endoscopic surgeries of the esophagus.
• The esophagus has been subdivided into 3 portions:
a) Cervical
b) Thoracic
c) Abdominal
• Histologically, the esophagus has 4 concentric layers. (Mucosa,
Submucosa, Muscular, Adventitia)

37. Blood supply
• Cervical portion : inferior thyroid artery
• Thoracic portion : bronchial and esophageal branches of the
thoracic aorta
• Abdominal portion : ascending branches of the left phrenic and left
gastric arteries.
Venous drainage
• Venous blood from the esophagus drains into a submucosal plexus.
From this plexus, blood drains to the periesophageal venous plexus.
Esophageal veins arise from this plexus and drain in a segmental
way similar to the arterial supply, as follows:
• From the cervical esophagus, veins drain into the inferior thyroid
vein
• From the thoracic esophagus, veins drain into the azygos veins,
hemiazygos, intercostal, and bronchial veins
• From the abdominal portion, esophagus veins drain into the left
gastric vein; the left gastric vein is a tributary of the portal system.

38. Risk Factors
• High portal vein pressure. The risk of bleeding increases with the
amount of pressure in the portal vein (portal hypertension).
• Large varices. The larger the varices, the more likely they are to
bleed.
• Red marks on the varices. When viewed through an endoscope
passed down your throat, some varices show long, red streaks or
red spots. These marks indicate a high risk of bleeding.
• Severe cirrhosis or liver failure. Most often, the more severe your
liver disease, the more likely varices are to bleed.
• Continued alcohol use. Your risk of variceal bleeding is far greater if
you continue to drink than if you stop, especially if your disease is
alcohol related.
• Bacterial infection - schistosomiasis

39. Sign & Symptoms
1) Vomiting blood (in large amount) can cause
- Dizziness
- Loss consciousness
- Pallor
- Anaemia
2) Some patient bleed in smaller amount over a longer period, they
swallow the blood rather than vomit it, so they may have :
- Black, tarry or bloody stools
3) Shock and sepsis(in severe cases)
4) Low blood pressure (hypotension)
5) Rapid heart rate (tachycardia)
6) Abdominal pain
7) Confusion secondary to encephalopathy

40. Signs of liver disease :
1) Jaundice (yellow discoloration)
2) Spider nevi (cluster of tiny blood vessels shaped like spider)
3) Palmar erythema (Reddening on palm)
4) Splenomegaly
5) Hand deformity known as Dupuytren’s contracture
6) Testicular atrophy
7) Ascites (fluid build up)
8) Gynaecomastia
9) Hair Loss
10) Pruritus
11) Muscle loss

41. • Encephalopathy (sometimes called hepatic encephalopathy)
• Esophageal stricture after surgery or endoscopic therapy
• Hypovolemic shock
• Infection (pneumonia, bloodstream infection, peritonitis)
• Rebleeding after treatment
• Kidney failure
Possible Complications

42. References
• Bailey & Love's Short Practice of Surgery, 25th
edn
• http://www.hopkinsmedicine.org
• http://www.slideshare.net
• http://www.nlm.nih.gov
• http://emedicine.medscape.com

43. THANK YOU!