Pathomorphology of Esophageal and Gastric Varices

ABSTRACT

In this article, the gross pathology of varices and supplying veins are described comparing esophageal varices and varices of the cardia and fundus of the stomach. The angioarchitecture of the lower esophagus is such that normally very thin parallel veins in the lamina propria mucosae in the palisade zone become enlarged in portal hypertension and join the few larger submucosal veins to form esophageal varices. Enlarged parallel veins come to pile up and join the submucosal veins at an acute angle, rendering this area vulnerable to rupture. Most ruptures occur in this critical area. The basic differences between esophageal and gastric varices are the layers in which the varicose veins form: the lamina propria mucosae and submucosa in the esophageal varices and the submucosa in gastric varices. While cardiac veins and varices are continuous with esophageal varices, fundic varices develop independently as part of a splenogastrorenal shunt that runs through the stomach wall, having rare communications with other veins. The fundic varix is so large in caliber that when it ruptures, the muscularis mucosae and lamina propria are penetrated with massive bleeding. The treatment of varices calls for complete thrombosis of all varicose veins, and merits and demerits of available treatment modalities are discussed based on autopsies from the pathologic point of view. Because of the large size, the management of fundic varices is difficult, and the new technique called balloon-occluded retrograde transvenous obliteration for occluding fundic varices is discussed.

KEYWORD

Esophageal varices - cardiac varices - fundic varices - variceal rupture - palisade zone - parallel veins

REFERENCES

• 1 Arakawa M, Noda T, Fukuda K. Clinicopathological studies of esophageal varices. The structure of blood vessels in esophageal wall.  Jpn J Gastroenterol . 1983;  80 2339-2346
• 2 Noda T. Angioarchitectural study of esophageal varices: with special reference to variceal rupture.  Virchows Arch [A] . 1984;  404 381-389
• 3 Kegaries D L. The venous plexus of the oesophagus. Its clinical significance.  Surg Gynecol Obst . 1934;  58 46-51
• 4 Butler H. The veins of the oesophagus.  Thorax . 1951;  6 276-296
• 5 DeCarvalho C AF. Sur l'angio-architecture veineuse de la zone de transition oesophagogastrique et son interpretation fonctionelle.  Acta Anat . 1966;  64 125-162
• 6 Vianna A, Hayes P C, Moscoso G. Normal venous circulation of the gastroesophageal junction. A route to understanding varices.  Gastroenterology . 1987;  93 876-889
• 7 Spence R AJ. The venous anatomy of the lower oesophagus in normal subjects and in patients with varices: an image analysis study.  Br J Surg . 1984;  71 739-744
• 8 Arakawa M, Kage M, Ookubo K. Angioarchitecture of lower esophagus in portal hypertensive cases.  Jpn Gastroenterology . 1991;  8 1336-1340
• 9 Hashizume M, Kitano S, Sugimachi K. Three dimensional view of the vascular structure of the lower esophagus in clinical portal hypertension.  Hepatology . 1988;  8 1482-1487
• 10 Toyonaga A, Iwao T, Sumino M. Distinct portal venographic pattern in patients with sclerotherapy-resistant esophageal varices.  J Gastroenterol Hepatol . 1996;  11 1110-1114
• 11 Dagradi A E, Stempien S J, Owens L K. Bleeding esophagogastric varices. An endoscopic study of 50 cases.  Arch Surg . 1966;  92 944-947
• 12 Japanese Research Society for Portal Hypertension. The general rules for recording endoscopic findings on esophageal varices.  Jpn J Surg . 1980;  10 84-87
• 13 Kimura K, Ohto M, Matsutani S. Relative frequencies of portosystemic pathways and renal shunt formation through the ``posterior'' gastric vein: portographic study in 460 patients.  Hepatology . 1990;  12 725-728
• 14 Hashiguchi M, Tsujii H, Shimono J. Ruptured duodenal varices: an autopsy case report.  Hepatogastroenterology . 1999;  46 1751-1754
• 15 Okuda K, Takayasu K. Aberrant varices. In: Okuda K, Benhamou J-P, eds. Portal Hypertension Clinical and Physiological Aspects. Tokyo: Springer 1991: 429-440
• 16 Orloff M J, Thomas H S. Pathogenesis of esophageal varix rupture. A study based on gross and microscopic examination of the esophagus at the time of bleeding.  Arch Surg . 1963;  87 301-307
• 17 Dagradi A E, Mehler R, Ran D TD. Sources of upper gastrointestinal bleeding in patients with liver cirrhosis and early esophagogastric varices.  Am J Gastroenterol . 1970;  54 458-463
• 18 Waldram R, Davis M, Nunnerley H. Emergency endoscopy after gastrointestinal hemorrhage in 50 patients with portal hypertension.  BMJ . 1974;  4 94-96
• 19 Beppu K, Inokuchi K, Koyanagi N. Prediction of variceal hemorrhage by esophageal endoscopy.  Gastrointest Endosc . 1981;  27 213-218
• 20 Nevens F, Bustami R, Scheys I. Variceal pressure is a factor predicting the risk of a first variceal bleeding: a prospective cohort study in cirrhotic patients.  Hepatology . 1998;  27 15-19
• 21 Evans D MD, Jones D B, Cleary B K. Oesophageal varices treated by sclerotherapy. A histopathological study.  Gut . 1982;  23 615-620
• 22 Arakawa M, Kage M. Pathological finding after endoscopical injection sclerotherapy for esophageal varices. Treatment of esophageal varices. In: Idezuki Y, ed. Treatment of Esophageal Varices. Amsterdam: Excerpta Medica 1988: 111-121
• 23 Arakawa M, Kage M, Sumino M. The extension of thrombosis following sclerotherapy of esophageal varices with special reference to the mechanism of its recurrence.  Gastroenterol Endosc Jpn . 1991;  33 2375-2378
• 24 Kitano S, Koyanagi N, Higashi H. Prevention of recurrence of esophageal varices after endoscopic injection sclerotherapy with ethanolamine oleate.  Hepatology . 1987;  7 810-815
• 25 Choudhuri G, Dhiman R K, Agarwal D K. Endosonographic evaluation of the venous anatomy around the gastro-esophageal junction in patients with portal hypertension.  Hepatogastroenterol . 1996;  43 1250-1255
• 26 Bhargava D K, Porkharna R. Endoscopic variceal ligation versus endoscopic variceal ligation and endoscopic sclerotherapy: a prospective randomized study.  Am J Gastroenterol . 1997;  92 950-953
• 27 Sohendra N, Grimm H, Nam V C. N-butyl-2-cyanoacrylate: a supplement to endoscopic sclerotherapy.  Endoscopy . 1987;  19 221-224
• 28 Oho K, Iwao T, Sumino M. Ethanolamine oleate versus butyl cyanoacrylate for bleeding gastric varices: a nonrandomized study.  Endoscopy . 1995;  27 349-354
• 29 Takeuchi M, Nakai K, Nakamura K. Complication associated with endoscopic variceal ligation: gastric perforation [in Japanese].  Gastroenterol Endosc . 1996;  38 876-878
• 30 Goldschmiedt M, Haber G, Kandel G. A safety maneuver for placing overtubes during endoscopic variceal ligation.  Gastrointest Endosc . 1992;  38 399-400
• 31 Kanagawa H, Mima S, Kouyama H. A successfully treated case of fundic varices by retrograde transverses obliteration with balloon.  Jpn J Gastroenterology . 1991;  88 1459-1462
• 32 Kanagawa H, Miwa S, Kouyama H. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration.  J Gastroenterol Hepatol . 1996;  11 51-58