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CONTENTS 1

PREFACE 2

ABSTRACT 3

INTRODUCTION 4

LITERATURE REVIEW 5

REFERENCES 8

PREFACE

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I want to give my thanks to god; finally I could finish this paper. My goal for making

this paper, which is the task that had been given from dr Sulaiman to me, is to provide additional

information for anyone who read it. This paper is mainly about the incidences of esophageal

varices in patiens with hepatic cirrhosis. Also in this paper I will mention about the

patophysiology, complications, and the treatment for the disease that I mentioned above.

ABSTRACT

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Esophageal varices are abnormal, enlarged veins in the lower part of the esophagus,

which is the tube that connects the throat and stomach. Esophageal varices occur most often in

people with serious liver diseases, usually hepatic cirrhosis.

Esophageal varices develop when normal blood flow to the liver is slowed down. The

blood then backs up into nearby smaller blood vessels, such as those in esophagus, causing the

vessels to swell. Sometimes, esophageal varices can rupture, causing life-threatening bleeding.

A number of drugs and medical procedures are available to stop bleeding from

esophageal varices. These same treatments can help prevent bleeding in patients diagnosed with

esophageal varices.

Cirrhosis is scarring of the liver. Cirrhosis occurs in response to chronic damage to the

liver. With mild cirrhosis, the liver can repair itself and continue to do its job, such as

detoxifying harmful substances in the body, purifying blood and manufacturing vital nutrients.

But with more advanced cirrhosis, more and more scar tissue forms in the liver, making it

impossible to function adequately.

A number of diseases and conditions can cause the chronic liver damage that leads to

cirrhosis.

Keywords: esophageal varices, hepatic cirrhosis, complications

INTRODUCTION

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Cirrhosis often has no signs or symptoms until liver damage is extensive. When signs and

symptoms do occur, they may include: fatigue, bleeding easily, easy bruising, fluid accumulation

in abdomen, loss of appetite, nausea, swelling in legs, and weight loss.

Cirrhosis is caused by scar tissue that forms in the liver in response to damage that occur

repeatedly over many years.

Each time the liver is injured, it tries to repair itself. In the process, scar tissue forms in

the liver. As the scar tissue builds up, it becomes increasingly difficult for the liver to function

adequately. In advanced cirrhosis, the liver no longer works. Because the liver is a vital organ

that anyone can't live without, if it fails it must be replaced with a liver transplant.

A wide variety of diseases and conditions can damage the liver and lead to cirrhosis,

such as: chronic alcohol abuse, hepatitis, cystic fibrosis, and Wilson’s disease.

There are many complications of hepatic cirrhosis, such as hepatic encephalopathy,

esophageal varices, leg and abdominal swelling, even hepatic cancer.

This paper will mainly discuss the esophageal varices as the complication of hepatic

cirrhosis.

Esophageal varices usually don't cause signs and symptoms unless they bleed. Signs and

symptoms of bleeding esophageal varices include, vomiting blood, black, tarry or bloody stools,

and even shock, in severe cases.

LITERATURE REVIEW

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Although many patients with advanced liver disease such as cirrhosis develop

esophageal varices, most won't experience bleeding(3). Varices are more likely to bleed if

they have:

• High portal vein pressure. The risk of bleeding increases with the amount of pressure in

the portal vein.

• Large varices. The larger the varices, the more likely they are to bleed.

• Red marks on the varices. When viewed through an endoscope 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 the liver disease, the more

likely varices are to bleed.(3)

• Continued alcohol use. If the liver disease is alcohol related, the risk of variceal

bleeding is far greater if you continue to drink than if you stop.

The most serious complication of esophageal varices is bleeding. Once patients have

had a bleeding episode, their risk of another bleeding is greatly increased. In some cases,

bleeding can cause the loss of so much blood volume that will go into shock. This can lead to

death. (1)

The esophageal varices may be diagnosed with screening tests. How often the

patients will undergo screening tests depends on their condition. Tests used to diagnose

esophageal varices include: (2)

• Using a scope to examine the esophagus. During an endoscopy exam, the doctor inserts

an endoscope through the patient’s mouth and into their esophagus. If any dilated veins

are found, they're graded according to their size and checked for red streaks, which

usually indicate a significant risk of bleeding. (5)

• Imaging tests. Both CT scans and MRI may be used to diagnose esophageal varices.

These tests also allow the doctor to examine the patient’s liver and circulation in the

portal vein. (5)

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The primary aim in treating esophageal varices is to prevent bleeding. Bleeding

esophageal varices are life-threatening. If bleeding occurs, treatments are available to try to

stop the bleeding. (2)

Treatments to prevent bleeding

Treatments to lower blood pressure in the portal vein may reduce the risk of bleeding

esophageal varices. Treatments may include:

• Medications to slow flow of blood in the portal vein. Beta blocker may help reduce

blood pressure in portal vein, reducing the likelihood of bleeding. These medications

include propranolol and nadolol. (6)

• Using a scope to access esophagus and treat varices. If the esophageal varices appear

to have a very high risk of bleeding, using an endoscope to see inside the esophagus and

inject a medication or tie off veins with an elastic band can be done. (6)

Treatments to stop bleeding

Bleeding varices are life-threatening, and immediate treatment is essential. Treatments used

to stop bleeding include:

• Using elastic bands with endoscope to tie off bleeding veins (4)

• Medications to slow blood flow into the portal vein, reducing the pressure in the vein.

Octreotide is often used in combination with endoscopic therapy to treat bleeding from

esophageal varices. (4)

• Diverting blood flow away from the portal vein. A transjugular intrahepatic

portosystemic shunt (TIPS) is a small tube that is placed between the portal vein and the

hepatic vein, which carries blood from your liver back to your heart. By providing an

additional path for blood, the shunt often can control bleeding from esophageal varices.

But TIPS can cause a number of serious complications, such as liver failure which may

develop when toxins that would normally be filtered by the liver are passed through the

shunt directly into the bloodstream. TIPS is mainly used when all other treatments have

failed or as a temporary measure in people awaiting a liver transplant. (5)

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• Liver transplant, which is an option for people with severe liver disease or those who

experience recurrent bleeding of esophageal varices. Although liver transplantation is

often successful, the number of people awaiting transplants far outnumbers the available

organs. (5)

REFERENCES

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1. Shah VH, et al. Portal hypertension and gastrointestinal bleeding. In: Feldman M, et al.

Sleisinger and Fordtran's Gastrointestinal and Liver Disease. 9th ed. Philadelphia, Pa.:

Saunders; 2010. http://www.mdconsult.com/book/player/linkTo?type=bookHome&isbn=978-1-4160-6189-2&eid=4-u1.0-B978-1-4160-6189-2..X0001-

7--TOP&uniq=200844987-3. Accessed July 5, 2011.

2. Prevention and management of gastroesophageal varices and variceal hemorrhage in

cirrhosis. Alexandria, Va.: American Association for the Study of Liver Diseases.

http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/Prevention%20and%20Management%20of%20Gastro%20Varices

%20and%20Hemorrhage.pdf. Accessed July 5, 2011.

3. Cirrhosis. National Institute for Diabetes and Digestive and Kidney Diseases.http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis/index.htm. Accessed Sept. 12,

2010.

4. Nurman A. Ligasi varises esofagus dengan gelang karet per endoskopi pada penderita

sirosis hepatis dewasa. Jakarta : Trisakti University Press. 2003. Page 12-6.

5. Nurdjanah S. Buku Ajar Ilmu Penyakit Dalam. Jakarta : Interna Publishing. 2010. Page

668-79.

6. Mansjoer A. Kapita Selekta Kedokteran. Jakarta : Media Aesculapius.2008. Page 508-9.

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