Esophageal Varices

Published on 29/07/2015 by admin

Filed under Radiology

Last modified 22/04/2025

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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

image Left renal > gonadal > other intra- and retroperitoneal veins
– Mesenteric varices

image Commonly form around ostomy sites in patients with portal hypertension (e.g., patient with cirrhosis due to primary sclerosing cholangitis whose ulcerative colitis was treated with colectomy)

MR Findings

• T1WI and T2WI

image Multiple areas of flow void
• T1WI C+

image Portal venous phase (PVP)

– Enhancement of varices seen

Ultrasonographic Findings

• Grayscale ultrasound

image Increased esophageal wall thickness at least 5 mm with irregular wall surface
• Color Doppler

image Hepatofugal venous flow within esophageal wall

Angiographic Findings

• Conventional

image Portal venogram

– Uphill varices: May show cavernous transformation of portal vein and reversal of blood flow via splenic vein → coronary vein → esophageal varices

Imaging Recommendations

• Helical NE + CECT
• Fluoroscopic-guided esophagography

image Position: Prone right anterior oblique (RAO)
image Mucosal relief views; avoid repetitive swallowing

DIFFERENTIAL DIAGNOSIS

Esophageal Carcinoma

• May simulate varices
• Varicoid carcinoma

image Produce thickened, tortuous folds in esophagus due to submucosal spread of tumor
image Rigid, fixed appearance; abrupt demarcation, well-defined borders
• Varices change in size and shape with peristalsis, respiration, and Valsalva maneuvers
• Diagnosis: Imaging and endoscopic biopsy

Reflux Esophagitis

• May mimic varices
• Submucosal edema may cause thickened folds
• Diagnosis: Endoscopy and history

Esophageal Metastases and Lymphoma

• Esophagus: Least common site within GI tract
• Usually non-Hodgkin and less commonly Hodgkin
• Patients almost always have generalized lymphoma or cancer
• Primary esophageal lymphoma seen in AIDS cases
• Diagnosis: Endoscopy with deep esophageal biopsy

PATHOLOGY

General Features

• Etiology

image Uphill varices

– Cirrhosis and portal HTN
– Pathogenesis: Collateral blood flow from portal vein → azygos vein → SVC
image Downhill varices

– Obstruction of SVC distal to entry of azygos vein
– Usually due to lung cancer, lymphoma, fibrosing mediastinitis
– Pathogenesis: Collateral blood flow from SVC → azygos vein → IVC or portal system
image Idiopathic varices: Exact mechanism is unknown

– Postulated to be result of congenital weakness in venous channels of esophagus
• Associated abnormalities

image Cirrhosis with portal HTN
image Normal esophageal venous drainage

– Upper 1/3 of esophagus: Via intercostal, bronchial, and inferior thyroid veins
– Middle 1/3: Via azygous and hemiazygos venous systems
– Distal 1/3: Via periesophageal plexus of veins → coronary vein → splenic vein

Gross Pathologic & Surgical Features

• Tortuous dilated veins in long axis of esophagus

Microscopic Features

• Tortuous, serpiginous, dilated veins protruding beneath mucosa
• ± superficial ulceration, inflammation, blood clot

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Asymptomatic until rupture

– Usually discovered on imaging (e.g., CECT for cirrhosis)
image Uphill varices: Hematemesis/mild bleeding (melena)
image Downhill varices: SVC syndrome

– Facial, periorbital, neck, bilateral arm swelling
– Dilated superficial veins over chest
image Lab data: Guaiac-positive stool or iron deficiency anemia
• Clinical profile

image Patient with history of cirrhosis, portal HTN, hematemesis/melena, facial/arm swelling

Demographics

• Age

image Middle-aged and elderly
• Gender

image M = F
• Epidemiology

image Incidence: 30-70% cases of cirrhosis and portal HTN

Natural History & Prognosis

• Complications

image Inflammation, ulceration, hemorrhage, hematemesis
image Esophageal variceal hemorrhage

– Common cause of acute upper GI bleeding
– Alcoholic cirrhosis: Most prevalent cause in USA
– Accounts for 20-50% of all deaths from cirrhosis

image May be less now due to transjugular intrahepatic portosystemic shunt (TIPS) and transplantation
• Prognosis

image Varices without bleeding

– Usually good after treatment
image Varices with massive bleeding

– Poor ± treatment

Treatment

• Nonbleeding varices

image β-blocker medication or esophageal variceal ligation
• Bleeding varices

image Vasopressin infusion
image Balloon tamponade (Sengstaken-Blakemore tube)
image Endoscopic sclerotherapy or variceal ligation
image TIPS: Has largely replaced surgical shunts

DIAGNOSTIC CHECKLIST

Consider

• Lack of change for thick folds should suggest esophagitis or cancer rather than varices

Image Interpretation Pearls

• Mucosal relief views: Tortuous, serpiginous, longitudinal radiolucent filling defects in collapsed esophagus

Reporting Tips

• Estimate size of varices on CT interpretation

image Correlates with likelihood of hemorrhage

image
(Left) Axial CECT in a middle-aged man with cirrhosis demonstrates cirrhosis but relatively small esophageal varices. The portal vein was thrombosed (not shown).
image
(Right) Axial CECT in the same patient shows large perisplenic varices image and calcification present image in the walls of some varices that might be mistaken for arterial aneurysms.
image
(Left) Axial CECT in the same patient shows a spontaneous splenorenal shunt with enlargement of the left renal vein image. Spontaneous or surgically created shunts help to decompress esophageal varices but increase the incidence of encephalopathy and portal vein thrombosis, making subsequent liver transplantation difficult or impossible.

image
(Right) Celiac arteriogram in the same patient shows opacification of the splenic vein and varices image but no portal vein flow.
image
(Left) Axial CECT in an elderly woman presenting with a puffy face shows obstruction of superior vena cava (SVC) with collateral flow through an enlarged azygous vein image and various mediastinal collateral veins.

image
(Right) Coronal CECT (same patient) shows enlarged azygous vein image and mediastinal collateral veins image. The collaterals are carrying flow from tributaries of the SVC into abdominal circulation to be returned to the heart via the inferior vena cava (IVC). These are sometimes referred to as “downhill varices.”
image
Axial CECT in a cirrhotic patient shows massive varices as tortuous enhanced vessels in the periesophageal region.

image
Axial CECT in the same patient shows massive varices image in the gastric fundus wall.
image
Esophagram shows serpiginous submucosal filling defects in the proximal 1/2 of the esophagus; downhill varices.
image
Catheter venacavogram shows obstruction of the superior vena cava. The SVC is occluded above the azygous arch. Downhill varices image in the periesophageal region are part of collateral venous drainage.

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