<B>Esophageal Varices </B>

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Esophageal Varices

Etiology:

• Portal hypertension

Pathogenesis:

• Varices represent portal-systemic venous shunts caused by an increase in portal venous pressure secondary to obstruction in portal blood flow
• Since cirrhosis is the etiology in most cases, the increase in portal venous pressure is due to compression of central veins and sinusoids by fibrosis and regerative parenchymal nodules, in addition to arterial-portal venous anastomoses with the scarred liver

Epidemiology:

• The major cause of portal hypertension is hepatic cirrhosis
• In the United States the most common cause of cirrhosis is alcohol abuse while in other parts of the world hepatic toxins and parasites play a role
• Other causes of portal hypertension are hepatic and portal vein obstruction, parasites and granulomatous disease

General Gross Description:

• Linear violaceous or red protrusions into the distal esophagus representing dilated submucosal veins
• Overlying mucosa is generally intact but may show evidence of inflammation primarily erythema
• The surface may show superficial erosions
• If variceal rupture occurs the esophagus is filled with blood and occasionaly a blood clot may be found over the site of rupture
• In the resected surgical and postmortem specimen the varices collapse and a flattened violaceous linear vascular outline is seen

General Microscopic Description:

• Markedly dilated submucosal veins are present
• The overlying esophageal mucosa is generally normal
• Partial thrombosis of varying age may be seen in the varices

Clinical Correlations:

• Esophageal varices are asymptomatic until they rupture
• Rupture usually results in severe bleeding with a mortality close to 50% for the first bleed
• In survivors, the incidence of rebleeding is 50% in each subsequent year with a mortality of 50% with each episode of massive bleeding
• Death is caused by acute blood loss and hepatic failure precipitated by the hemorrhagic episode
• Survival appears related to the severity of the underlying liver disease

References:
Cotran RS, Kumar V, Robbins SL. Robbins Pathologic Basis of Disease, 5th edition. W.B. Saunders. Philadelphia, 1994, pp.759-761, 835-836 Sleisenger MH and Fordtran JS Gastrointestinal Disease, 5th edition. W.B.Saunders Philadelphia, 1993 pp.172-1