The role of endoscopy in the treatment of esophageal varices, 2002–2003

Abstract

Great strides have been made in the endoscopic and radiologic therapy of esophageal varices in the past few years. With the advent of variceal band ligation and transjugular intrahepatic portosystemic shunt, almost every acute variceal bleed can be controlled. In addition, over the past decade great strides have been made in the noninvasive imaging and pressure measurement of esophageal varices. Yet, the mortality rate from variceal bleeding has not changed significantly and the pharmacologic therapy of esophageal varices and the prophylaxis of the initial variceal bleed has lagged behind these other interventional advances. These authors believe that progress in these areas has been slow because the pathophysiology and hemodynamics of esophageal varices are not well understood. It is through progress in the areas of endoluminal ultrasound imaging of esophageal varices and noninvasive pressure measurement that progress has finally been made in the area of the pathophysiology of variceal bleeding. In this update, two novel ideas regarding the pathophysiology of variceal bleeding are described. The first regards increased variceal pressure during peristaltic contraction. The second describes increased variceal pressure with increasing intraabdominal pressure. These new observations suggest a new pathophysiology in the cause of variceal bleeding and imply new methods to prevent and treat variceal bleeding. This update and review of esophageal varices is given in five sections: new developments in the pathophysiology of esophageal variceal bleeding, screening for esophageal varices, prediction of variceal bleeding, treatment of esophageal varices and new modalities to evaluate esophageal varices.