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Abstract

STRATEGIC MANAGEMENT APPROACHES FOR ESOPHAGEAL VARICES: A COMPREHENSIVE ANALYSIS

Dr. Aanchal Mogri*, Drishti Chouhan, Neelam Dangi and Krishna Hingad

Abstract

Esophageal varices, enlarged submucosal veins connecting portal and systemic circulations, are a critical consequence of portal hypertension, often associated with cirrhosis. The risk of variceal rupture and bleeding becomes significant when hepatic venous pressure gradient (HVPG) exceeds 12 mmHg, highlighting the importance of early diagnosis and management. Superior endoscopy remains the gold standard for diagnosing esophageal varices, particularly in cirrhotic patients, with varices present in 60% of decompensated and 30% of compensated cases. The risk of bleeding from esophageal varices is closely correlated with variceal size and morphology. Treatment options encompass non-selective β blockers, endoscopic band ligation, and vasoactive agents like octreotide, terlipressin, somatostatin, and vasopressin, which aim to reduce portal pressure. Early administration of vasoactive agents is crucial for confirmed or suspected variceal bleeding and should continue for 2-5 days, with potential early cessation if the patient undergoes a transjugular intrahepatic portosystemic shunt (TIPS) procedure. The literature review delves into the pathophysiology of esophageal varices, emphasizing their role as portal-systemic collaterals and the complications arising from variceal bleeding. Laplace's law is discussed as a determinant of variceal rupture, with increased intravariceal pressure and reduced wall thickness contributing to this phenomenon. Various diagnostic modalities, including endoscopy, transient elastography, and imaging techniques like CT scan and Doppler sonography, are explored for their role in assessing variceal risk and evaluating portal hypertension. Management of esophageal varices involves a three-stage approach: prevention of initial bleeding, acute bleeding management, and prevention of rebleeding. Pharmacologic, endoscopic, and shunt therapies are considered, with a focus on the efficacy of long-acting somatostatin analogs and terlipressin in controlling variceal bleeding. Antibiotic prophylaxis is recommended to reduce the risk of rebleeding, and non-selective β blockers are explored as an essential component of treatment. Endoscopic treatments, including endoscopic sclerotherapy (EST) and band ligation (EBL), aim to reduce variceal wall strain and promote variceal obliteration. The significance of spontaneous hemodynamic responders to endoscopic treatments is highlighted, suggesting potential synergies with beta-blockers for enhanced efficacy. This comprehensive review provides valuable insights into the complex landscape of esophageal varices in portal hypertension, emphasizing the multifaceted approach required for their diagnosis and management.

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