BOX 1 Bleeding Esophageal Varices

Esophageal varices (fragile, distended, and thin-walled veins in the esophagus) occur in patients with liver failure because of portal hypertension. Obstructed blood circulates to low-resistance alternate vessels around the portal circulation in the liver, which is a high-pressure system. One of these routes is through the esophageal veins, which become distended with blood, irritated from pressure, and susceptible to rupture. Treatment of esophageal varices includes:

Surgery: Procedures include placing a portal caval shunt or distal splenorenal shunt, esophageal repair, or devascularization.

Endoscopic sclerotherapy: To cause fibrosis of the varices, patients are injected with solutions during an endoscopy procedure.

Esophageal balloon tamponade: A multilumen gastrointestinal tube with an esophageal and gastric balloon is passed into the upper gastrointestinal tract through the patient's mouth. The gastric balloon, which is filled with 250-300 mL of air, acts as an anchor; the esophageal balloon, which is filled with enough air to cause 20-75 mm Hg pressure, compresses the esophageal varices to decrease bleeding. Traction may be inserted by taping the outer portions of the multilumen tube to the face mask of a football helmet.

Parenteral therapy: Maintain a large-bore intravenous line and keep several units of packed cells on call from the blood bank at all times.

Vasopressin (Pitressin) therapy: A continuous infusion of this vasoconstrictor causes constriction of the mesenteric circulation and decreased blood flow to the portal circulation.

develop massive hepatic cystic disease that results in liver failure. Wilson disease is a genetic disorder (autosomal recessive pattern) leading to a large liver accumulation of copper. About 5% of patients suffer from acute liver failure or fulminant hepatitis.

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