Esophageal varices

What is  Esophageal varices?

 Esophageal varices refer to the dilated subepithelial and submucosal venous plexuses of the

esophagus that drain into the left gastric (coronary) vein. The left gastric vein empties into the

portal vein from the distal esophagus and proximal stomach. Esophageal varices are caused by

portal hypertension due to cirrhosis of the liver.

What are Symptoms of   Esophageal varices?

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

bleeding esophageal varices include:

Vomiting large amounts of blood

Black, tarry or bloody stools

Lightheadedness

Loss of consciousness in severe cases

Your doctor might suspect esophageal varices if you have signs of liver disease, including:

Yellow coloration of your skin and eyes (jaundice)

Easy bleeding or bruising

Fluid buildup in your abdomen (ascites)

What are Causes of   Esophageal varices?

Esophageal varices sometimes form when blood flow to your liver is blocked, most often by scar tissue

in the liver caused by liver disease. The blood flow begins to back up, increasing pressure within the

large vein (portal vein) that carries blood to your liver.

This increased pressure (portal hypertension) forces the blood to seek other pathways through smaller

veins, such as those in the lowest part of the esophagus. These thin-walled veins balloon with the added

blood. Sometimes the veins rupture and bleed.

Causes of esophageal varices include:

Severe liver scarring (cirrhosis). A number of liver diseases — including hepatitis infection, alcoholic

liver disease, fatty liver disease and a bile duct disorder called primary biliary cirrhosis — can result in

cirrhosis.

Blood clot (thrombosis). A blood clot in the portal vein or in a vein that feeds into the portal vein

(splenic vein) can cause esophageal varices.

Parasitic infection. Schistosomiasis is a parasitic infection found in parts of Africa, South America, the

Caribbean, the Middle East and East Asia. The parasite can damage the liver, as well as the lungs,

intestine, bladder and other organs.

What are preventive measures of  Esophageal varices?

Prevention

Currently, no treatment can prevent the development of esophageal varices in people with cirrhosis. While beta blocker drugs are effective in preventing bleeding in many people who have esophageal varices, they don't prevent esophageal varices from forming.

If you've been diagnosed with liver disease, ask your doctor about strategies to avoid liver disease complications. To keep your liver healthy:

Don't drink alcohol. People with liver disease are often advised to stop drinking alcohol, since the liver processes alcohol. Drinking alcohol may stress an already vulnerable liver.

Eat a healthy diet. Choose a plant-based diet that's full of fruits and vegetables. Select whole grains and lean sources of protein. Reduce the amount of fatty and fried foods you eat.

Maintain a healthy weight. An excess amount of body fat can damage your liver. Obesity is associated with a greater risk of complications of cirrhosis. Lose weight if you are obese or overweight.

Use chemicals sparingly and carefully. Follow the directions on household chemicals, such as cleaning supplies and insect sprays. If you work around chemicals, follow all safety precautions. Your liver removes toxins from your body, so give it a break by limiting the amount of toxins it must process.

Reduce your risk of hepatitis. Sharing needles and having unprotected sex can increase your risk of hepatitis B and C. Protect yourself by abstaining from sex or using a condom if you choose to have sex. Get tested for exposure to hepatitis A, B and C, since infection can make your liver disease worse. Also ask your doctor whether you should be vaccinated for hepatitis A and hepatitis B.

What is esophagus?

A. General Features of Esophagus 

● The esophagus begins at the cricoid cartilage (at vertebral level C6) and ends at the gastroesopha-

geal (GE) junction. The esophagus pierces the diaphragm through the esophageal hiatus (at vertebral

level T10).

● The upper 5% of the esophagus consists of skeletal muscle only. The middle 45% of the esopha-

gus consists of both skeletal muscle and smooth muscle interwoven together. The distal 50% of

the esophagus consists of smooth muscle only.

● In clinical practice, endoscopic distances are measured from the incisor teeth and in the average male

the GE junction is 38 to 43 cm away from the incisor teeth.

● For purposes of classification, staging, and reporting of esophageal malignancies, the esophagus is

divided into four segments based on the distance from the incisor teeth: Cervical segment, upper

thoracic segment, midthoracic segment, and lower thoracic segment.

B. Constrictions. There are five main sites where the esophagus is constricted: (1) at the junction of

the pharynx and esophagus (cricoid origin), (2) at the aortic arch, (3) at the tracheal bifurcation (verte-

bral level T4) where the left main bronchus crosses the esophagus, (4) at the left atrium, and (5) at the

esophageal hiatus.

C. Sphincters

1. Upper Esophageal Sphincter (UES). The UES is a skeletal muscle that separates the pharynx

from the esophagus. The UES is composed of opening muscles (i.e., thyrohyoid and geniohyoid

muscles) and closing muscles (i.e., inferior pharyngeal constrictor and cricopharyngeus which is

the main player).

2. Lower Esophageal Sphincter (LES). The LES is a smooth muscle that separates the esopha-

gus from the stomach. The LES prevents GE reflux.

D. Arterial Supply

● The arterial supply of the cervical esophagus is from the inferior thyroid arteries (subclavian

artery → thyrocervical trunk → inferior thyroid artery) which give off ascending and descending

branches that anastomose with each other across the midline.

● The arterial supply of the thoracic esophagus is from four to five branches from the descend-

ing thoracic aorta.

● The arterial supply of the abdominal esophagus is from the left gastric artery (abdominal

aorta → celiac trunk → left gastric artery).

E. Venous Drainage

● The venous drainage of the cervical esophagus is to the inferior thyroid veins (inferior thyroid

veins → brachiocephalic veins → superior vena cava).

● The venous drainage of the thoracic esophagus is to an esophageal plexus of veins (esophageal

plexus of veins → azygous veins → superior vena cava).

● The venous drainage of the abdominal esophagus is to the left gastric vein (left gastric vein →

portal vein → hepatic sinusoids → central veins → hepatic veins → inferior vena cava).

F. Innervation. The innervation of the esophagus is by the somatic nervous system (upper portion

only) and by the enteric nervous system which in the esophagus consists of the myenteric plexus of

Auerbach only. The enteric nervous system is modulated by the parasympathetic and sympathetic ner-

vous systems.

1. Somatic Innervation

● Somatic neuronal cell bodies are located in the ventral horn of the spinal cord at cervical level

1 (C1) and travel with the hypoglossal nerve (cranial nerve [CN] XII) to innervate the open-

ing muscles of the UES (thyrohyoid and geniohyoid muscles).

2. Parasympathetic

● Preganglionic neuronal cell bodies are located in the dorsal nucleus of the vagus. Pregangli-

onic axons run in CN X and enter the esophageal plexus.

● Postganglionic neuronal cell bodies are located in the enteric nervous system, some of which

are the “traditional” postganglionic parasympathetic neurons that release acetylcholine (ACh)

as a neurotransmitter.

● The postganglionic axons terminate on mucosal glands, submucosal glands, and smooth muscle.

● Neuronal cell bodies located in the nucleus ambiguus send axons that run in CN X (recurrent

laryngeal nerves) and enter the esophageal plexus. These axons terminate on the closing

muscles of the UES (inferior pharyngeal constrictor and the cricopharyngeus muscle)

and the esophageal skeletal muscle.

3. Sympathetic

● Preganglionic neuronal cell bodies are located in the intermediolateral cell column of the

spinal cord (T5 to T9). Preganglionic axons form the greater splanchnic nerve.

● Postganglionic neuronal cell bodies are located in diffuse ganglia along the esophagus and the

celiac ganglion.

● Postganglionic axons synapse in the complex circuitry of the enteric nervous system.

ABDOMINAL PART OF OESOPHAGUS

1. The abdominal part of the oesophagus is only

about 1.25 cm long.

2. It enters the abdomen through the oesophageal

opening of the diaphragm situated at the level of

vertebra T10, slightly to the left of the median plane.

3. The oesophageal opening also transmits the

anterior and posterior gastric nerves, the oesophageal

branches of the left gastric artery and the accom-

panying veins.

4. These veins drain partly into portal and partly Into

systemic circulation. Veins accompanying left gastric

vein drain into portal vein. Others drain into

hemiazygos, in thoracic cavity, and continue into vena

azygos and superior vena cava. So it is a site of

portosystemic anastomosis.

5. The oesophagus runs downwards and to the left in

front of the left crus of the diaphragm and of the

inferior surface of the left lobe of the liver, and ends by

opening into the cardiac end of the stomach at the level

of vertebra Tl 1, about 2.5 cm to the left of the median

plane. Its right border is continuous with the lesser

curvature of the stomach, but the left border is

separated from the fundus of the stomach by the cardiac

notch. Peritoneum covers the oesophagus only

anteriorly and on the left side.

6. Anterior gastric nerve contains mainly the left

vagal fibres, and the posterior gastric nerve mainly the

right vagal fibres. Each gastric nerve is represented

by one or two trunks and combines a few sympathetic

fibres from the greater splanchnic nerve.