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Role of Computed Tomography in Esophageal Varices

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Computed tomography is an excellent imaging tool to diagnose esophageal varices. Read this article for more information.

Medically reviewed by

Dr. Varun Chaudhry

Published At November 28, 2022
Reviewed AtNovember 28, 2022

Introduction:

The incidence of liver diseases is increasing worldwide. They account for significant morbidity and mortality rates among the general population. There are various kinds of liver diseases, such as those caused by viruses, drugs, or liver cancer. One such chronic liver disease is cirrhosis. Cirrhosis refers to scarring of the tissues resulting in extensive liver damage. Factors such as obesity, excessive alcohol consumption, and chronic hepatitis B and C infection are prime causes of liver cirrhosis. Advanced cirrhosis can be fatal. Esophageal varices and variceal bleeding are the signs of advanced and critical stages of cirrhosis.

What Are Esophageal Varices?

Esophageal varices are engorged and swollen veins of the esophagus (food pipe connecting the mouth to the stomach). Esophageal varices are the most common complication associated with liver cirrhosis. In cirrhosis, the blood flow through the liver is obstructed due to the scar tissues. This results in increased pressure inside one of the major blood vessels of the liver (portal vein). The portal vein takes the blood from the intestine to the liver. An increasing pressure would result in portal hypertension, which would subsequently lead to increased pressure in the veins of the stomach and lower part of the esophagus. The veins in this region are small and are not meant to carry high pressure; hence, they expand and become swollen resulting in esophageal varices. These varices can be stable in size or increase or decrease depending on the improvement of liver disease. However, if the liver disease worsens, these varices can rupture and be life-threatening.

What Are the Types of Esophageal Varices?

Types of Esophageal Varices

What Are the Causes and Risk Factors Associated With Esophageal Varices?

Various conditions associated with esophageal varices are mentioned below:

  • Liver Cirrhosis: Cirrhosis is one of the most common causes of esophageal varices.

  • Thrombosis: Any blood clot in the portal vein or its feeder’s veins could result in portal hypertension and lead to esophageal varices.

  • Schistosomiasis: It is a parasitic infection caused by blood flukes. Blood flukes are freshwater parasite worms that damage the liver and other organs.

All esophageal varices don’t bleed. Risk factors associated with rupture and bleeding of esophageal varices are as given below:

  • Portal Hypertension: As portal hypertension increases, the risk of bleeding also increases.

  • Larger Varices: Bigger varices are more susceptible to rupture and bleeding.

  • Pinpoint Red Marks: Endoscopic examination may reveal certain red marks or streaks along with the varices. These are indicative of high-risk bleeding.

  • Liver Failure: Advanced cirrhosis patients may suffer from liver failure. This could also result in bleeding of the varices.

  • Excessive Alcohol Consumption: Cirrhotic patients are more prone to variceal bleeding if they continue drinking alcohol.

What Are the Symptoms of Esophageal Varices?

Esophageal varices do not cause signs and symptoms until they rupture and bleed. The symptoms are mentioned below:

  • If the bleeding is minor, the patient will have dark or black streaks in their stools.

Severe bleeding will have the following symptoms:

  • Vomiting huge quantities of blood.

  • Bloody or tarry black stools.

  • In severe cases, the patient may faint or become unconscious.

Associated liver disease may have the following additional symptoms:

  • Yellowish discoloration of the skin.

  • The skin gets easily bruised.

  • Ascites (fluid accumulation in the abdomen).

What Are the Complications Associated With Esophageal Varices?

Esophageal varices are the most common complications of liver cirrhosis. Varices do not cause any symptoms until they bleed. However, severe bleeding could result in extensive hemorrhaging and the death of the patient. The risk of repeated bleeding episodes also increases. Early diagnosis and timely treatment can prevent the varices from progressing. Studies have reported that 25 to 40 % of patients experience esophageal bleeding, and the mortality rate from bleeding varices is 15 %. Hence cirrhotic patients must undergo routine screening for prompt diagnosis and management.

What Are the Various Imaging Modalities Used in the Diagnosis of Esophageal Varices?

Various diagnostics tests can detect the presence of esophageal varices; however, the gold standard test is endoscopy. In addition, non-invasive procedures such as CT, ultrasonography, and magnetic resonance imaging (MRI) can also be used to assess the severity of the varices. They are described in detail below:

1. Endoscopy:

Gastrointestinal endoscopy is an invasive procedure used to see the inside of the stomach and the esophagus. A thin, flexible tube with a camera attached to its end is inserted through the mouth into the esophagus and stomach. This camera helps visualize the mucosal lining and other associated gastrointestinal structures from the inside. If varices are noticed, they will be measured and assessed for other risk factors, such as red streaks or wheals, that indicate their risk for rupture and bleeding. The advantage of an endoscopic procedure is to perform a surgical intervention simultaneously if required. However, the major drawback of endoscopy is that it is an invasive procedure requiring intense patient cooperation; if not, the procedure will have to be performed under sedation. It is also an expensive procedure and cannot be used as a routine surveillance tool. In addition, this procedure is not viable for viewing the anatomical structures outside the gastrointestinal tract. Hence external factors contributing to esophageal varices cannot be determined.

2. Plain Radiography:

X-rays are not very specific in diagnosing esophageal varices. However, they can diagnose the varices outside the esophageal wall. They can be seen as abnormal opacities on the x-ray.

3. Barium Study:

Barium study is not very sensitive and should be used if other imaging modalities are contraindicated or cannot be performed. In this test, the patient is asked to swallow a certain amount of thick barium paste, and subsequently, x-ray images are taken. Esophageal varices appear as tortuous filling defects or as thickened folds. However, additional imaging tests need to support these findings as other anomalies may mimic similar findings.

4. MRI:

MRI is a superior choice in diagnosing esophageal varices. It provides high-resolution images and can quantitate (velocity and movement) the portal blood circulation. However, the limited accessibility and high cost restrict its widespread usage in esophageal varices.

5. Ultrasound:

Doppler ultrasound is an excellent tool to assess the movement of blood through the portal veins. It can be used to check for an obstruction in the venous blood flow or narrowing of the vessels. In addition, the endoscopic procedure can be conducted with ultrasound for more precision. However, a conventional ultrasound may not be beneficial in differentiating varices from other conditions causing submucosal masses.

What Is the Role of Computed Tomography in Esophageal Varices?

Prophylactic endoscopy was most commonly used in cirrhotic patients to screen the varices. However, considering the invasiveness, high cost, poor patient acceptance, and the need for sedation, endoscopy was replaced by computed tomography (CT). With the latest advancements, such as multidetector computed tomography (MDCT) and helical CT, patients with chronic liver disease can be routinely screened for disease progression. Contrast CTs have greater sensitivity and specificity in diagnosing esophageal varices. The benefits of CT are:

  • Non-invasive.

  • Less expensive than endoscopy.

  • 90 % sensitivity and 50 % specificity in diagnosing esophageal varices.

  • An excellent tool in risk stratification.

  • Excellent coverage till the distal part (farther away) of the esophagus.

  • The entire abdominal venous system and its associated structures can be seen in CT.

The disadvantages are:

  • Allergic reaction to contrast material.

  • CT cannot quantitate the blood flow through the portal circulation, which can be done with Doppler ultrasound and MRI.

Routine screening can help with early intervention, reducing the morbidity and mortality associated with variceal rupture.

Conclusion:

Esophageal varices can be a life-threatening condition if not promptly diagnosed and treated. To successfully manage esophageal varices, it is essential to determine the cause. Though endoscopy is the gold standard diagnostic tool, CT has shown far superior results in diagnosing and managing esophageal varices. Advantages such as minimal invasiveness, cost-effectiveness, and increasing compliance make CT a favorable screening tool in patients with chronic liver diseases.

Frequently Asked Questions

1.

Can CT Scan Be Used for Diagnosing Esophageal Varices?

CT scan can be used to diagnose esophageal varices. The sensitivity of a CT scan is about 87 % in detecting the esophageal varices. It is a minimally invasive procedure to detect esophageal varices. It helps in diagnosing moderate to large esophageal varices and evaluates the portal system.

2.

How Are Esophageal Varices Diagnosed?

Esophageal varices are usually diagnosed by performing an endoscopy procedure. Endoscopy is the preferred method for diagnosing esophageal varices. Abdominal CT scans and Doppler ultrasound scans of the splenic and portal veins are also performed to detect the presence of esophageal varices. 

3.

How Do Esophageal Varices Appear on a Radiograph?

Esophageal varices are visible on contrast-enhanced cross-sectional radiographic imaging. They appear as torturous, enlarged, smooth, tubular structures that enhance on a CT scan. It may protrude into the esophageal lumen, depending on its size and pressure. It is visible on a plain radiograph only if it is large in size.

4.

When Should the Screening for Esophageal Varices Be Performed?

Screening for esophageal varices is indicated for patients with liver cirrhosis. It is performed to identify varices with a high risk of bleeding, large varices, or varices with red signs. Screening is performed for all cirrhotic patients at the initial diagnosis of liver cirrhosis.

5.

What Are the Grades of Esophageal Varices?

Esophageal varices are classified under four grades.
Grade I - Microcapillaries that are located in the distal esophagus or esophagogastric junction.
Grade II - One or two small varices that are located in the distal esophagus.
Grade III - Medium-sized varices of varying numbers.
Grade IV - Large-sized varices that are present in any part of the esophagus.

6.

How Do Esophageal Varices Differ From Gastric Varices?

Gastric and esophageal varices are enlarged blood vessels, but they differ in the layers in which the varicose veins are formed. Varicose veins form in the lamina propria mucosa and submucosa in the esophageal varices. In gastric varices, varicose veins form in the submucosal layer.

7.

Can Esophageal Varices Occur Without Cirrhosis?

Esophageal varices occur as a complication in advanced cirrhosis. It can occur in the absence of liver cirrhosis or portal vein block. It is cuased by disruption of the normal blood flow to the liver. Esophageal varices are suspected in the presence of upper gastrointestinal hemorrhage. 

8.

What Does the Presence of Esophageal Varices Signify?

Esophageal varices are formed when the blood flow to the liver is disrupted by a clot or scar tissue in the liver. The blood flows into the small blood vessels to overcome the blockages. These vessels cannot carry large volumes of blood and result in life-threatening bleeding.

9.

How Many Times Can Esophageal Varices Banding Be Done?

Esophageal variceal banding can be performed several times to control enlarged varices and prevent bleeding. It is performed every two to four weeks in three to four sessions. The banded tissue falls off within a few days. Banded esophageal varices are frequently monitored.

10.

Is It Possible to Misdiagnose Esophageal Varices?

A giant hemangioma extends from the pharynx to the esophagus and appears similar to varices. An extended hemangioma can be misdiagnosed as esophageal varices on endoscopy. Careful examination during endoscopy is essential to avoid the misdiagnosis of esophageal varices.

11.

What Is the Main Cause of Esophageal Varices?

The common cause of esophageal varices is liver cirrhosis, which occurs as a complication of advanced liver cirrhosis. Liver cirrhosis can be caused by hepatitis, alcoholic liver disease, fatty liver disease, and bile duct disorder which is referred to as primary biliary cirrhosis. 

12.

What Are the Common Complications of Esophageal Varices?

The common complication of esophageal varices is bleeding. In severe cases, the dilated blood vessels burst and cause severe internal bleeding. One bleeding episode increases the risk of another bleeding episode. It can result in hypovolemic shock and death. 

13.

What Is the Other Name for Esophageal Varices?

Esophageal varices are enlarged and dilated veins in the esophagus. It is also referred to as esophageal varix. It occurs as a result of disrupted blood flow through the portal vein, which carries blood to the liver from the pancreas, intestine, and spleen.
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Dr. Varun Chaudhry

Radiodiagnosis

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