Esophagus Varices Gastric
Severe Variceal Bleeding.

Video Endoscopic Sequence 1 of 5.

 Severe Variceal Bleeding.

This 49 year-old alcoholic male, has had a history of alcoholism for more than thirty years.

Two hours previously begun with severe upper GI bleeding, an emergency endoscopy was carry out without endotracheal intubation, this video clips shows a severe hemorrhage due to a rupture esophageal varix.

 See in YouTube Esophagus Gastric Varices Animation

For more endoscopic details, download the video clip by clicking on the endoscopic image. Wait to be downloaded complete then Press Alt and Enter for full screen.

All endoscopic images shown in this Atlas contain video clips.
We recommend seeing the video clips in full screen mode.

Endoscopy of Acute variceal bleeding

Video Endoscopic Sequence 2 of 5.

Endoscopy of Acute variceal bleeding

Acute variceal bleeding is a life-threatening complication in patients with portal hypertension.

Although overall survival may be improving, mortality is still closely related to failure to control hemorrhage or early re-bleeding.
Factors that influence this failure include severity of liver disease and active bleeding during endoscopy.

In addition increased portal pressure has been proposed as a prognostic factor of early re-bleeding.

Endoscopy of Acute variceal bleeding

Video Endoscopic Sequence 3 of 5.

Endoscopy of Acute variceal bleeding

First we try to perform rubber bands ligation but Although the exact site of bleeding was identified, with the ligating apparatus it was more difficult to identify the bleeding, because this one darkens the visibility so sclerotherapy was used.

Therapeutic aims in acute variceal bleeding The important point is to treat the patient and not just the source of bleeding. The specific aims are:

Correct hypovolaemia; Stop bleeding as soon as possible; Prevent early rebleeding; Prevent complication associated with bleeding; Prevent deterioration in liver function.


 Follow in YouTube Gastrointestinal Endoscopy Animation





Endoscopic sclerotherapy.

Video Endoscopic Sequence 4 of 5.

Endoscopic sclerotherapy.

Endoscopic sclerotherapy is successful in controlling acute esophageal variceal bleeding in up to 90% of patients. Hemorrhagic control should be obtained with 1-2 sessions. Patients continuing to bleed after 2 sessions should be considered for alternative methods to control their bleeding. · In the United States, sodium tetradecyl sulfate or sodium morrhuate has generally been used as a sclerosant, whereas polidocanol or ethanolamine has been more popular in Europe.

Variations in the technique or the sclerosant used have not been shown to influence the outcome. ·

Serious complications related to sclerotherapy have been reported in 15-20% of patients, with an associated mortality rate of 2%.

Complications of sclerotherapy may include mucosal ulceration, bleeding, esophageal perforation, mediastinitis, and pulmonary complications.
Long-term complications, such as esophageal stricture formation, may also occur.


Acute variceal bleed

Video Endoscopic Sequence 5 of 5.

Acute variceal bleed

After the bleeding was stopped the endoscope was advanced through the trachea and the bronchial tree in order to aspirate some blood that was aspirated during the hemorrhage.

To avoid this, always whenever is possible, before the endoscopy should be performed carefully endotracheal intubation.

Video Endoscopic Sequence 1 of 6.

This is the case of a 49 year-old male with gastro esophageal varices secondary to alcoholic cirrhosis.

Esophageal varices are dilated blood vessels within the wall of the esophagus. Patients with cirrhosis developPortal Hypertension. When Portal Hypertension occurs, blood flow through the liver is diminished.
Thus, blood flow increases through the microscopic blood vessels within the esophageal wall. As this blood flow increases, the blood vessels begin to dilate. This dilation can be profound. The original diameter the of blood vessels is measured in millimeters while the final, fully established, esophageal varix may be 0.5 to 1.0 cm or larger in diameter.


Video Endoscopic Sequence 2 of 6.

Endoscopic Image of Esophageal Varices.
This patient has lager esophageal varices as well as gastric varices.
These blood vessels then continue to dilate until they become large enough to rupture. When esophageal varices rupture, patients become acutely ill. In fact, 50 percent of patients with esophageal varices will eventually bleed from the varices. The mortality rate for esophageal variceal bleeding, on the first event, is between 40 and 70 percent. Mortality is due to multiple factors.

Esophageal varices are distended submucous veins that project into the esophageal lumen. They are part of the collateral circulation that develops between the portal vein and vena cava in response to portal hypertension. They develop from the plexus of esophageal veins that drain into the azygos and hemiazygos veins. They receive blood from the left gastric vein and its esophageal branches and also from the short gastric veins via the splenic vein.

Video Endoscopic Sequence 3 of 6.

Gastric Varices.

Multiple large gastric varices can be seen in the gastric cardia and fundus.

Concomitant fundic varices are associated with anincreased risk of esophageal variceal bleeding


Video Endoscopic Sequence 4 of 6.

Gastric varices can be a perplexing problem for
gastroenterologists to manage. These vascular channels
can be large and deep, and bleeding can be difficult to
control.



Video Endoscopic Sequence 5 of 6.

Larger Gastric Varices of the Gastric Cardias.

See the chapter Gastric Varices




Video Endoscopic Sequence 6 of 6.

This image as well as the video clip show the Red Wale Sign.
Variceal appearance on endoscopy ("red signs")

Red wale marks (longitudinal red streaks on varices)

Cherry-red spots (red, discrete, flat spots on varices)

Hematocystic spots (red, discrete, raised spots)

Diffuse erythema.

Esophageal varices are enlarged veins in the esophagus — usually the lower part of the esophagus. They're often due to obstructed blood flow through the portal vein, which carries blood from the intestine and spleen to the liver.

Red Wale” Sign: Endoscopy of a chain of varices in the distal esophagus showing erythematous raised areas indicating an increased risk of bleeding.

Video Endoscopic Sequence 1 of 2.

Endoscopy of Post Sclerotherapy Esophageal Ulcer.

Severe persistent chest pain and pyrexia after sclerotherapy are clinical pointers of ulcerogenesis


Video Endoscopic Sequence 2 of 2.

Endoscopy of Post Sclerotherapy Esophageal Ulcer.

Endoscopic ligation causes statistically fewer local complications than sclerotherapy and achieves variceal eradication more rapidly. Ligation is a viable alternative tosclerotherapy and may have some advantages as a treatment for bleeding esophageal varices.

Endoscopic sclerotherapy is associated with various local and systemic complications that may limit its effectiveness. Therefore, endoscopic ligation was developed in an attemptto provide a treatment at least as effective as sclerotherapy but with fewer adverse side effects



Video Endoscopic Sequence 1 of 12.

This 70 year-old female, presented an upper gastrointestinal bled due to esophageal varix, six months previously had two sessions of esophageal banding with six varices ligated each time.

 

Video Endoscopic Sequence 2 of 12.

This image shows a blood clot where identify the site of the bleeding.


 

 


  Medline.

Video Endoscopic Sequence 3 of 12.


This image shows a blood clot where identify the site of the bleeding.
When Portal Hypertension occurs, blood flow through the liver is diminished.

Video Endoscopic Sequence 4 of 12.

After careful examination, the bleeding has been reactivated.

Video Endoscopic Sequence 5 of 12.

Red brilliant blood is emerging from the site of the hemorrhage observed in the GI junction.




Video Endoscopic Sequence 6 of 12.

To localize the exact site some vigorous washing with water is performed, the next video clips were taken with the double channel therapeutical endoscope that perform a better suction of the blood.

Video Endoscopic Sequence 7 of 12.


This image and the video clip shows the exact site of this hemorrhage.



Video Endoscopic Sequence 8 of 12.

Efficacy of argon plasma coagulation in variceal upper gastrointestinal bleeding.
In order to stop the hemorrhage, the argon plasma coagulator is being used. The catheter of the argon plasma coagulator is observed that will initiate the therapeutical approach.

Endoscopic variceal ligation is an established procedure for eradication of esophageal varices. However, varices frequently recur after endoscopic variceal ligation. Argon plasma coagulation has been used as supplemental treatment for eradication of varices and for prevention of variceal recurrence in small uncontrolled series



 

Video Endoscopic Sequence 9 of 12.

Various methods of endoscopic hemostasis for esophageal varices have been described, sclerotherapy, rubber band ligation, hemoclips etc.




Video Endoscopic Sequence 10 of 12.

Efficacy of argon plasma coagulation in variceal bleeding.


Video Endoscopic Sequence 11 of 12.

The varix was successfully coagulated.




 

 

 


Video Endoscopic Sequence 12 of 12.

This image shows the status post coagulation of the varix.The hemorrhage has been stopped.





String of Pearls “ Varices of the Esophagus.

Portal hypertension must be present with pressures more of 12 mm Hg or greater in order for varices to develop.

However the level of pressure elevation does not correlate with the risk of rupture. Nonbleeding esophageal varices are asymptomatic. Rarely they are detected incidentally, but in most cases they are found during the work-up of liver diseases and occasionally in patients with acute upper gastrointestinal bleeding. Bleeding.

The most serious complication of esophageal varices is acute bleeding. Approximately 30% of all patients with varices have an episode of variceal bleeding. The mortality rate is 30− 40%.
The risk of rebleeding after an initial bleeding episode is 70%.

Video Endoscopic Sequence  1 of 4.

An 83 year-old, non-alcoholic female that had an upper gastrointestinal hemorrhages.

Esophageal varices are dilated blood vessels within the wall of the esophagus. Patients with cirrhosis develop Portal Hypertension. When Portal Hypertension occurs, blood flow through the liver is diminished. Thus, blood flow increases through the microscopic blood vessels within the esophageal wall. As this blood flow increases, the blood vessels begin to dilate. This dilation can be profound. The original diameter of the blood vessels is measured in millimeters while the final, fully established, esophageal varix may be 0.5 to 1.0 cm or larger in diameter. Bleeding varices are a life-threatening complication of portal hypertension (increased blood pressure in the portal vein caused by liver disease). Increased pressure causes the veins to balloon outward. The vessels may rupture, causing vomiting of blood and bloody stools or tarry black stools. If a large volume of blood is lost, signs of shock will develop. Any cause of chronic liver disease can cause bleeding varices.

Video Endoscopic Sequence 2 of 4.

Endoscopic Image of Esophageal Varices
Sequences of images and videos of a case on esophageal varices.
Esophageal varices the venous structures are tortuous in appearance. The best predictor of variceal hemorrhage is the size of the varices. Several studies have shown that large varices are more likely to bleed than small one.

Video Endoscopic Sequence 3 of 4.

Small Varices of the epiglottis. Same patient as described above.

Video Endoscopic Sequence 4 of 4.

Large tortuous varices with red color sign. Cherry red spots are signs of imminent hemorrhage.

Classification of gastroesophageal varices.

Esophageal.
Small, straight.
Enlarged, tortuous; occupy less than one third of the lumen. Large, coil-shaped; occupy more than one third of the lumen.

Gastric.
In continuity with esophageal varices. Along lesser curve (2 to 5 cm long). Along greater curve extending toward the fundus Isolated In the fundus. Elsewhere in the stomach.





Endoscopic Image of Esophageal Varices

Hematocystic spots are seen that are stigmata of recent
 hemorrhage.


A 61 year-old woman that was under hepatic transplant
 program in a United States Hospital. She returned to her
 country El Salvador, and the same day that she arrived, sh
 was hospitalized because of her first hemorrhage.


85 year-old man with esophageal varices

Due to Alcoholic Cirrhosis

A variety of factors affect the prognosis of a patient with variceal bleeding. Patients with alcoholic cirrhosis usually have a poor prognosis, with few 5-year survivors irrespective of treatment.

On the other hand, complete abstinence from alcohol can improve the prognosis and result in both lowering of portal pressure and reduction in the size of the varices. The main causes of portal hypertension can be classified.
anatomically: pre hepatic (portal vein thrombosis), hepatic (mainly cirrhosis, schistosomiasis and rarer causes) and post hepatic (Budd-Chiari and rarer causes).



Unique Varix of the Esophagus.

Finding a isolated varix of the mild esophagus is without
portal hypertension and no clinical importance.

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Variceal Bleeding.

One of the most ominous complications of portal hypertension is hemorrhage from esophageal or gastric varices. Patients who bleed from varices have a poorlong-term prognosis, irrespective of treatment and few survive more than 5 years.

In view of the prognosis of portal hypertensive bleeding, it is essential to have an urgent treatment of acute variceal bleeding and interval management, in order to prevent rebleeding


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Video Endoscopic Sequence 1 of 5.

Esophagel Varices and Status Post Total Gastrectomy.

This 63 year-old male underwent a total gastrectomy due to a gastric cancer



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Video Endoscopic Sequence 2 of 5.

Total gastrectomy may be indicated in treating extensive stomach malignancies. This radical procedure is not performed when carcinoma with distant metastasis to the liver or pouch of Douglas or seeding throughout the peritoneal cavity is present.

It may be performed in association with the extirpation of adjacent organs, such as the spleen, body and tail of the pancreas, a portion of the transverse colon, and so forth.

It is also the procedure of choice in controlling the intractable ulcer diathesis associated with non-beta islet cell tumors of the pancreas when pancreatic tumor or metastases remain that cannot be controlled medically".

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Video Endoscopic Sequence 3 of 5.

Jejuno-Jejuno Anastomosis

 

 

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Video Endoscopic Sequence 4 of 5.

 

Esophago Jejunostomy.

 

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Video Endoscopic Sequence 5 of 5.

The Esophagus with some varices.

 

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