Download - Esophageal Varices Week 4 T2T3
Esophageal Varices
Clinical Pharmacy Week 4: Tingkat 2 & 3 By Liew Hui Lian (PRP) 2009/2010
Outline
Esophageal Varices
What is it? Classification Epidemiology Risk factors Clinical manifestation Management
Case Study
What is it?
Very dilated submucosal vein in the lower esophagus like internal varicose veins Due to portal hypertension, most commonly from liver cirrhosis Normally, veins are 1 mm in diameter and becomes distended to 1-2 cm in diameter Most likely 5-8% patients who are diagnosed liver cirrhosis develop EV. Varices size increase 10-15% annually.
ClassificationJapaneseJapanese Absent Grade Absent 1: small, straight varices not disappearing with insufflation Grade 2: medium varices occupying less than one third of the lumen Grade 3: large straight varices not disappearing with Grade 1: small, varices occupying more than one third of the lumen
US
US Absent Absent I smal Absent< 5 mm Absent II medium 5-9 mm III large mm smal > 9 < 5 mmIV
VA Paquet VA Trial Paquet Trial I II III IV
insufflation Grade 2: medium varices occupying less than one third of the lumen Grade 3: large varices occupying more than one third of the lumen mediu m large 5-9 mm > 9 mm
* The Japanese Classification is the preferred grading scale for the staging of oesophageal Varices.
30% will experience haemorrhage Risk is greatest during first year of diagnosis Mortality 30-50% within 6 weeks Those that survive first bleed are at significant risk of recurrent haemorrhage (70%) and a third are fatal Risk of re-bleeding: hepatic decompensation, age >60, severity of initial bleed, renal insufficiency, level of portal pressure, size of varices, presence of hematoma
Epidemiology Prevalence in patient with cirrhosis 24-81% Variceal bleeding accounts for 6.4% of upper gastrointestinal bleeding in Malaysia. 15% of emergency endoscopy for UGIB in Selayang Hospital are due to acute variceal bleeding. Aetiology in Malaysia mainly: hepatitis B or alcohol Majority of patients are Chinese, followed by Indians
Risk Factors
Severity of liver dysfunction Size of varices Presence of endoscopic red wale signs Hepatic venous pressure gradient (HVPG). Bleeding is likely if it's above 12 mmHg
For patients with cirrhosis American College of Gastroenterology and the American Association for the Study of Liver Disease No varices: Every other year Small varices: every 1-2 years
Screening Endoscopy
OGDS view
1. Normal 2. Variced esophageal 3. Bleeding varices
Clinical Manifestation
Anemia Coughing up or vomitting blood Black tarry stools due to bleeding in the gut Lightheadedness from the loss of blood Passing out from the lost of blood
Non selective B adrenergic antagonist (e.g. propanolol and nadolol) Prevents splanchnic vasoconstriction Reduce risk of bleeding by 45% Propanolol is the most cost effective
Nitrates Reduces portal pressure But ineffective in preventing bleeding in patients as monotherapy
Pharmacological Therapy
Variceal ligation
Endoscopic Therapy
Injection sclerotherapy
Endoscopic Therapy
ManagementHypovolumic shock: Blood transfusion of pack cells Bacterial infections : Antibiotic (3 generation cephalosporin or quinolones i.e. norfloxacin/ ciprofloxacin) 7 days prophylaxisrd
Effective to stop bleeding but have high re-bleeding rate and other complications (ulceration, perforation and aspiration pnewmonia). Only for when no endoscopy is not available.
Balloon Tamponade
Rescue therapy for uncontrolled variceal bleeding after combined pharmacological and endoscopic therapy.
Transjugular Intrahepatic Portosystemic Shunts (TIPS)
Case Study
Patient's profile
Name: NDNK MRN: 28116 Age: 46 Gender: M Race: Siamese Weight: 70 kg DOA: 9 November 2009 DOD: 12 November 2009 Ward/ Bed: T2/311
Chief Complaint:
Passing black stool and abdominal discomfort and pain
History of Present Illness
Passing of black stool 2/7 and hematemesis 1 time today No fresh blood or spitting black blood Mild headache Soft and tender at epigastric region
Past Medical History k/c/o Hepatitis C OGDS done in June 2009 at Sungai Petani hospital, and was diagnosed with having esophageal varices.
Review of System
BP: 110/60 PR: 86 /min RR: 21 /min T: 37 C
Social/ Family History
Smokes 1 pack of cigarette per day Married and lives with wife
Past Medication History
None
Compliance evaluation
Not applicable
Diagnosis/ Surgical Procedure
UGIB 2nd to esophageal varices 2nd to portal hypertension Grade 1 large bleeding
Laboratory ResultsNormal Range TWBC HB4-11 x 10 L 11.5-16.5 g/100ml 4.5-6.3 x 106 0.4/0.370.52/0.48 150-400x 10/L
Day 1 12.0 8.6
Day 2* 15.6 6.9
Day 3 14.4 8.6
Day 4 5.9 9.0
RBC HCT
2.8 6.3
2.3 21.7
2.9 26.3
3.0 27.7
Platelet
107
127
96
72
* 2 pints of PC were transfused that day
Laboratory ResultsNormal Range Urea Na K Ca Mg PO4Scr 1.7-8.3 mmol/L 135-145 mmol/L 3.5-5.0 mmol/L 2.1-2.6 mmol/L 0.7-1.3 mmol/L 0.8-1.45 mmol/L 64-122 umol/L Day 1 11.1 138 4.1 Day 2 10.8 140 4.8 Day 3 Day 4
83
Laboratory ResultsNormal Range Albumin 35-50 g/L Day 129 27.9
Day 2
Day 3
Day 4
T. < 20 umol/L Bilirubin T. Protein 66-87 g/L ALP ALT 53-141 u/L < 32 u/L
64
88 56
Laboratory ResultsNormal Range PT APTT INR 10-13.5 sec 26-42 sec < 1.5 Day 114.7 37.1 1.35Day 2 Day 3 Day 4
Laboratory Results
Normal Range CK LDH AST 24-195 u/l 0-248 u/L