Definition
- Bleeding esophageal varices are hemorrhagic processes involving dialted, tortuous veins in the submucosa of the lower esophagus. .
Risk Factors
- Portal hypertension resulting from obstructed portal venous circulation
Pathophysiology
- In portal hypertension, collateral circulation develops in the lower esophagus as venous blood, which is diverted from the GI tract and spleen because of portal obstruction, seeks an outlet.
- Because of excessive intraluminal pressure, these collateral veins become tortuous, dilated, and fragile. They are particularly prone to ulceration and hemorrhage. Rupture of esophageal varices is the most common cause of death of clients with hepatic cirrhosis.
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Assessment/Clinical Manifestations/Signs And Symptoms
- Hematemesis and melena, if ulcerated massive hemorrhage occurs
- Signs of hepatic encephalopathy
- Dilated abdominal veins
- Ascites
Laboratory and diagnostic study findings
- Endoscopy identifies the cause and site of bleeding
- Ultrasound and computed tomography assist in identifying the site of bleeding
Medical Management
Non-surgical treatment is preferred because of the high mortality associated with emergency surgery to control bleeding from esophageal varices and because of the poor physical condition of most of these patients.
Nonsurgical measures include:
- Pharmacologic therapy: somatostatin, vasopressin, beta-blocker and nitrates
- Balloon tamponade, saline lavage, endoscopic sclerotherapy
- Transjugular intrahepatic portosystemic shunting (TIPS)
- Esophageal banding therapy, variceal band ligation
If necessary, surgery may involve:
- Bypass procedures (e.g. portacaval shunts, splenorenal shunt, mesocaval shunt)
- Devascularization and transaction
Aggressive medical care includes evaluation of extent of bleeding and continuous monitoring of vital signs when hematemesis and melena are present.
Signs of potential hypovolemia are noted; blood volume is monitored with a central venous pressure or arterial catheter.
Oxygen is administered to prevent hypoxia and maintain adequate blood oxygenation, and intravenous fluids and volume expanders are administered to restore fluid volume and replace electrolytes.
Need for blood transfusion is assessed, and intake and output (insert indwelling catheter) are monitored.
Nursing Diagnosis
- Risk for bleeding
- Imbalanced nutrition: less than body requirements
Nursing Management
Provide ongoing assessment
- Assess for ecchymosis, epistaxis, petechiae, and bleeding gums
- Monitor level of consciousness, vital signs, and urinary output to evaluate fluid balance.
- Monitor the client during blood transfusion administration if prescribed.
Institute measure to address bleeding.
- Use small-gauge needles, and apply pressure or cold for bleeding.
Provide nursing care for the client undergoing a prescribed balloon tamponade to control bleeding.
- Explain the procedure to the client to reduce fear and enhance cooperation with insertion and maintenance of the esophageal tamponade tube.
- Monitor the client closely to prevent accidental removal or displacement of the tube with resultant airway obstruction.
Provide nursing intervention for the client undergoing a prescribed iced saline lavage.
- Ensure nasogastric tube patency to prevent aspiration
- Observe gastric aspirate for evidence of bleeding.
- Protect the client from chilling.
After injection sclerotherapy, assess for:
- Aspiration
- Esophageal perforation
- Continued bleeding
After portal-systemic surgical intervention, monitor for complications.
- Development of systemic encephalopathy
- Liver failure
- Continued bleeding
