Esophageal Varices

Esophageal Varices
Michael P. Federle, MD, FACR
Key Facts
Imaging
  • Uphill varices: ↑ portal venous pressure → upward venous flow via dilated esophageal collaterals to superior vena cava (SVC)
    • Distal 1/3 or 1/2 of esophagus
    • More common
  • Downhill varices: Obstruction of SVC → downward venous flow via esophageal collaterals to portal vein and inferior vena cava (IVC)
    • Upper or middle 1/3 of esophagus
    • Less common
  • Fluoroscopy: Tortuous, serpiginous, longitudinal radiolucent filling defects in collapsed or partially collapsed esophagus
    • After sclerotherapy varices may appear as fixed, rigid filling defects
  • CECT: Serpiginous periesophageal, gastric, etc.
    • Enhance as other abdominal veins
    • Esophageal, coronary ± paraumbilical: Most commonly visualized
Top Differential Diagnoses
  • Esophageal (varicoid) carcinoma
    • Thickened, tortuous folds due to submucosal spread of tumor
    • Rigid, fixed appearance; abrupt demarcation; welldefined borders
  • Reflux esophagitis,
    • Submucosal edema may cause thickened folds
  • Esophageal metastases and lymphoma
Clinical Issues
  • Esophageal variceal hemorrhage
    • Accounts for 20-50% of all deaths from cirrhosis
  • TIPS provides more physiological means of treating varices and ascites
(Left) Graphic shows dilated, tortuous, submucosal collateral veins (varices) within the wall of the esophagus. (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.
(Left) Axial CECT in a 55-year-old man with upper GI bleeding shows large esophageal varices 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
    • Tortuous or serpiginous longitudinal filling defects on esophagography
  • Location
    • Uphill varices: Distal 1/3 or 1/2 of esophagus (more common)
    • Downhill varices: Upper or middle 1/3 of esophagus (less common)
  • Morphology
    • Tortuous dilated veins in long axis of esophagus, protruding directly beneath mucosa or in periesophageal tissue
  • Other general features
    • Usually due to portal HTN with cirrhosis or other liver diseases
    • Idiopathic varices: In patients with no portal HTN or SVC block (very rare)
    • Classification of esophageal varices based on pathophysiology
      • Uphill varices: ↑ portal venous pressure → upward venous flow via dilated esophageal collaterals to superior vena cava (SVC)
      • Downhill varices: Obstruction of SVC → downward venous flow via esophageal collaterals to portal vein and inferior vena cava (IVC)
Radiographic Findings
  • Radiography
    • Chest radiograph
      • Retrocardiac posterior mediastinal lobulated mass
      • ± mediastinal widening, abnormal azygoesophageal recess
  • Fluoroscopic-guided esophagography
    • Mucosal relief views
      • Tortuous, serpiginous, longitudinal radiolucent filling defects in collapsed or partially collapsed esophagus
    • Double-contrast study
      • Multiple radiolucent filling defects etched in white
    • Distended views of esophagus
      • Varices may be obscured
    • After sclerotherapy varices may appear as fixed, rigid filling defects
CT Findings
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Jun 8, 2016 | Posted by in GENERAL RADIOLOGY | Comments Off on Esophageal Varices

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