Esophageal Varices
 

• Dilated submucosal veins due to increased collateral blood flow from portal venous system to azygos system
• Uphill varices
  • Collateral blood flow from portal vein via azygos 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 azygos vein into IVC / portal venous system (upper esophagus usually drains via azygos 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 azygos 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
• UGI
  • 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- / left-sided soft-tissue masses = paraesophageal varices
  • Marked enhancement following dynamic CT
• 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
        
        
• Dahnert 4^th edition
• Practical Alimentary Tract Radiology 1993