Esophageal Varices

Published on 29/07/2015 by admin

Filed under Radiology

Last modified 29/07/2015

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 Distal 1/3 or 1/2 of esophagus

image More common
• Downhill varices: Obstruction of SVC → downward venous flow via esophageal collaterals to portal vein and inferior vena cava (IVC)

image Upper or middle 1/3 of esophagus
image Less common
• Fluoroscopy: Tortuous, serpiginous, longitudinal radiolucent filling defects in collapsed or partially collapsed esophagus

image After sclerotherapy varices may appear as fixed, rigid filling defects
• CECT: Serpiginous periesophageal, gastric, etc.

image Enhance as other abdominal veins
image Esophageal, coronary ± paraumbilical: Most commonly visualized

TOP DIFFERENTIAL DIAGNOSES

• Esophageal (varicoid) carcinoma

image Thickened, tortuous folds due to submucosal spread of tumor
image Rigid, fixed appearance; abrupt demarcation; well-defined borders
• Reflux esophagitis

image Submucosal edema may cause thickened folds
• Esophageal metastases and lymphoma

CLINICAL ISSUES

• Esophageal variceal hemorrhage

image Accounts for 20-50% of all deaths from cirrhosis
• Transjugular intrahepatic portosystemic shunt (TIPS) provides more physiological means of treating varices and ascites than other surgical procedures
image
(Left) Graphic shows dilated, tortuous, submucosal collateral veins (varices) within the wall of the esophagus.

image
(Right) Double-contrast esophagram shows tortuous, nodular longitudinal folds, typical of varices. These are unusually well depicted, even with the esophageal lumen distended, suggesting that the varices may be thrombosed or sclerosed by endoscopic injection.
image
(Left) Axial CECT in a 55-year-old man with upper GI bleeding shows large esophageal varices image.

image
(Right) Esophagram in the same patient performed after endoscopic sclerosis of the varices shows fixed filling defects image in the esophageal wall and lumen. The fixed nature of these mimics the appearance of the “varicoid” morphology of some esophageal carcinomas.

TERMINOLOGY

Definitions

• Dilated tortuous submucosal venous plexus of esophagus

IMAGING

General Features

• Best diagnostic clue

image Tortuous or serpiginous longitudinal filling defects on esophagography
• Location

image Uphill varices: Distal 1/3 or 1/2 of esophagus (more common)
image Downhill varices: Upper or middle 1/3 of esophagus (less common)
• Morphology

image Tortuous dilated veins in long axis of esophagus, protruding directly beneath mucosa or in periesophageal tissue
• Other general features

image Usually due to portal hypertension (HTN) with cirrhosis or other liver diseases
image Idiopathic varices: In patients with no portal HTN or superior vena cava (SVC) block (very rare)
image Classification of esophageal varices based on pathophysiology

– Uphill varices: ↑ portal venous pressure → upward venous flow via dilated esophageal collaterals to SVC
– Downhill varices: Obstruction of SVC → downward venous flow via esophageal collaterals to portal vein and inferior vena cava (IVC)

Radiographic Findings

• Radiography

image Chest radiograph

– Retrocardiac posterior mediastinal lobulated mass
– ± mediastinal widening, abnormal azygoesophageal recess
• Fluoroscopic-guided esophagography

image Mucosal relief views

– Tortuous, serpiginous, longitudinal radiolucent filling defects in collapsed or partially collapsed esophagus
image Double-contrast study

– Multiple radiolucent filling defects etched in white
image Distended views of esophagus

– Varices may be obscured
image Varices may appear as fixed, rigid filling defects after sclerotherapy

CT Findings

• NECT

image Thickened esophageal wall, lobulated outer contour
image Scalloped esophageal mural masses
image Uni-/bilateral soft tissue masses (paraesophageal varices)
• CECT

image Well-defined round, tubular, or smooth serpentine structures
image Homogeneous; enhance to same degree as adjacent veins
image Location

– Esophageal, coronary ± paraumbilical: Most commonly visualized
– Abdominal wall, perisplenic, perigastric, paraesophageal, retroperitoneal, omental, mesenteric
– Commonly see spontaneous shunts develop between varices and systemic veins

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