Esophageal Varices – Pathophysiology, Podcast, and Nursing Care Plan

esophageal varices

Esophageal Varices

The esophagus is what connects your throat to your stomach. Esophageal varices are enlarged and abnormal veins located in the lower part of the esophagus. This condition is usually seen in patients with liver disease. When normal blood flow to the liver is blocked by scar tissue or even a clot, varices begin to develop.

Blood will start bypass the larger vessels due to the blockage and start to flow in large amounts to the smaller vessels in the esophagus that are not made to carry such a large volume. As a result, these smaller blood vessels may begin to bleed or rupture, this can be a medical emergency.

 

esophageal varices

Causes of esophageal varices:

  • Chronic alcohol abuse: leads to Cirrhosis
  • Cirrhosis: Severe liver scarring . Esophageal varices happen in about 40 percent of people who have cirrhosis.
  • Blood clot (thrombosis): A blood clot in the vein that feeds into the portal vein called the splenic vein can cause esophageal varices.
  • Budd-Chiari syndrome: It is a rare condition that causes blood clots and can block the veins that carry blood out of your liver.
  • A parasitic infection: Schistosomiasis is an uncommon parasitic infection that is found in the Caribbean Africa, South America, the Middle East and Southeast Asia. This parasite can damage the liver, as well as the lungs, intestine and bladder.

Cirrhosis

Risk factors of esophageal varices:

 

Patients with chronic liver disease usually develop esophageal varices, however, most will not experience bleeding. Bleeding is more likely to occur if:

  • Portal hypertension, risk of bleeding will increase with high portal vein pressure.
  • Large varices, the larger the varices, the higher chance there is of bleeding
  • Liver failure or advanced cirrhosis
  • Chronic alcohol use

Signs and symptoms of esophageal varices:

It is important to note that there may not be any signs or symptoms of esophageal varices until that actually start to bleed. Once this occurs the following may be seen:

  • Vomiting blood
  • Bloody, black or tarry stools
  • Shock and trauma (In severe cases).

The healthcare provider may suspect a possibly of esophageal varices if the patient has liver disease.


  Tests and Diagnosis: Patients who have a history of liver disease and alcohol abuse should be screened for esophageal varices by their healthcare provider.  Some of these diagnostic tests are as follows:

    • Endoscopy

 

  • CT scan

 

 

  • MRI

 

 

  • Lab draws (CBC to monitor for bleeding)

 

 

Treatments The goal is to prevent bleeding. Once bleeding occurs the patient can develop hypovolemic shock and death can ensue. Therefore, the following treatment may be ordered by the healthcare provider:

    • Alcohol cessation teaching

 

  • Monitor hematocrit and hemoglobin levels

 

 

  • NPO

 

 

  • Be prepared to take patient to endoscopy  or surgery.

 

 

 

 

    • Monitor v/s

 

  • HOB elevated

 

 

  • Monitor for orthostatic hypotension

 

 

  • Assess lung sounds for presence of respiratory distress

 

 

  • O2 as prescribed to prevent hypoxemia

 

 

  • IV fluids as ordered  to restore fluid volume and electrolyte imbalance

 

 

  • Administer blood products and/or clotting factors as prescribed

 

 

  • Administer medications as ordered to reduce bleeding and induce vasocontriction

 

 

  • Avoid activities that may cause vasovagal responses

 

 

Nursing Care Plan

Nursing Diagnosis

1. Imbalanced Nutrition: Less than body requirements related to malabsorption.

Desired outcomes:

Within 24 hours of hospital discharge, the client is able to demonstrate progress towards adequate nutritional status as evidenced by progressive weight gain.

InterventionsRationals
InterventionsRationals
Weigh patient daily. Assess and record (I&O) intake and output.To assess adequacy of diet and measure the use of diuretic therapy if utilized.
Allow client to eat that are permitted within dietary meal plan. Explain dietary meal plan and restrictions.Sodium and fluids are restricted due to fluid retention and ascites.
Offer small and frequent meals.If ascites is present, the patient may not be able to tolerate larger meals.

2. Excess Fluid Volume: Risk for electrolyte imbalance related to compromised regulatory mechanisms with accumulation of fluid retention occurring with hepatocellular failure and portal hypertension.

Desired outcomes:

Within 1 day of discharge, client will exhibit normovolemic status as evidenced by respiratory rate between 12 -20 breaths per minute without any respiratory distress, edema at 1 or less,  and a reduction of abdominal girth.

InterventionsRationals
InterventionsRationals
Weigh patient daily. Assess and record (I&O) intake and output.To assess adequacy of diet and measure the use of diuretic therapy if utilized.
Measure abdominal girth for baseline point if reference.This will allow a comparison to observe if there is an increase or decrease in ascites. This will measure the effectiveness of medical treatments.
Assess level of edema from 1 - 4 and document findings.Edema allows health care provider assess if there is an excess on sodium intake or low serum albumin. Ascites is usually associated with low albumin levels.
Monitor vital signs q shiftThis will assess if there is any pulmonary congestion if there is a drop in resp rate. An increase in blood pressure can be associated with fluid retention.

3. Risk for bleeding related to altered stressed smaller vessels in the esophagus.

Desired outcomes: 

Patient will be free of occult or frank bleeding and will exhibit hemodynamic stability by maintaining a pulse of less than 100 beats per minute. A systolic blood pressure of at least 90 mmhg and a respiratory rate if 12-20 breaths per minute.

InterventionsRationals
InterventionsRationals
Monitor vital signs for indicators of bleeding or hemorrhage.Tachypnea, hypotension, and tachycardia may be associated with bleeding or hemorrhage. This can occur with anticoagulant therapy and will need prompt intervention.
At the minimum of every eight hours, inspect for any wounds that may have resulted from invasive procedures. Also check the oral mucosa and nares.This assessment will determine if there is any bleeding from anticoagulant therapy. Notify the physician immediately.
If patient is on heparin, monitor the PTT (partial thromboplastin time)Need to ensure that the PTT stays within the therapeutic range of 1.5-2.50 X control.
If patient is on Coumadin, monitor the PT (prothrombin time).Need to ensure that the PT stays within the therapeutic range of 1.5-2.50 X control, or INR value of 2.0-3.0.

 

Disclaimer:

Please follow your facilities infection control guidelines. The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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Anna C. RN-BC, BSN, PHN, CMSRN Anna began writing extra materials to help her BSN and LVN students with their studies. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process. She is a clinical instructor for LVN and BSN students along with a critical care transport nurse.

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