Esophageal Varices
 

• Dilated submucosal veins due to increased collateral blood flow from portal venous system to azygous system

• Uphill varices

  • Collateral blood flow from portal vein via azygous vein into SVC (usually lower esophagus drains via left gastric vein into portal vein)

  • Most common cause is portal hypertension secondary to cirrhosis

  • Varices in lower half of esophagus to the level of the carina (azygous vein)

  • More common than downhill varices

• Causes

  • Intrahepatic obstruction from cirrhosis

  • Splenic vein thrombosis (usually gastric varices only)

  • Obstruction of hepatic veins

  • Portal vein thrombosis

  • IVC obstruction below hepatic veins

  • Marked splenomegaly / splenic hemangiomatosis (rare)

• Downhill varices

  • Collateral blood flow from SVC via azygous vein into IVC / portal venous system (upper esophagus usually drains via azygous vein into SVC)

  • Varices in upper 1/3 of esophagus

    • Usually extend down to the level of the carina (azygous vein)

  • Less common than uphill varices

• Causes

  • Obstruction of superior vena cava distal to entry of azygous vein due to

    • Lung cancer (most common)

    • Lymphoma

    • Retrosternal goiter

    • Thymoma

    • Mediastinal fibrosis

• Examination Technique

  • Small amount of barium (not to obscure varices)

  • Relaxation of esophagus (not to compress varices)

    • Refrain from swallowing because each succeeding swallow initiates a primary peristaltic wave that lasts for 10-30 seconds

  • Sustained Valsalva maneuver precludes swallowing

  • In LAO projection with patient recumbent or in Trendelenburg position

• Plain film

  • Lobulated masses in posterior mediastinum (visible in a small percentage of patients with varices)

  • Silhouetting of descending aorta

  • Abnormal convex contour of azygoesophageal recess

• Upper GI

  • Thickened and interrupted mucosal folds (earliest sign)

  • Tortuous radiolucencies of variable size and location

  • "Worm-eaten" smooth lobulated filling defects

  • Findings may be accentuated after sclerotherapy

• CT

  • Thickened esophageal wall and lobulated outer contour

  • Scalloped esophageal luminal masses

  • Right and/or left-sided soft-tissue masses = paraesophageal varices

  • Marked enhancement following dynamic CT

Enhanced CT of the lower thorax shows multiple, large,
contrast-containing varices surrounding the region of the distal esophagus

• Complications

  • Bleeding in 28% within 3 years

  • Exsanguination in 10-15%

• DDx

  • Early

    • Other forms of chronic esophagitis

  • Late

    • Varicoid carcinoma of esophagus

      • Wall more rigid and less likely to change in varicoid carcinoma

      • Nodular filling defects in varicoid ca
        
        
        

• Practical Alimentary Tract Radiology, 1993

• Dahnert 4^th edition