Esophageal varices

Classification of varices

Depending on the direction of pathological blood shunting and etiology, two main types of varices are distinguished:

• "Ascending" varices (uphill varices). Blood flow is directed cranially. Blood enters from the left gastric veins, which belong to the portal venous system, and shunts into systemic venous tributaries. Drainage most commonly occurs into the azygos system (azygos system).
• "Descending" varices (downhill varices). Encountered significantly less frequently in clinical practice. They occur due to superior vena cava obstruction (superior vena cava obstruction). Unlike the ascending type, these dilated varices are usually localized in the upper and middle thirds of the organ.

Imaging findings

Computed tomography (CT) and conventional contrast fluoroscopy are used for diagnosis. Regardless of whether it is ascending or descending varices, the imaging appearance presents a characteristic and easily recognizable pattern. Both types are visualized as specific serpentine filling defects (serpentine filling defects).

Differential diagnosis: diverticula

During single-contrast barium fluoroscopy, in addition to varices, esophageal diverticula (oesophageal diverticula) are frequently detected. They are generally divided into two categories based on the mechanism of formation:

1. Traction diverticula (tractional diverticulum). As a rule, these are solitary lesions located in the lower third of the esophagus. The etiology is driven by external traction on the wall—for example, due to adhesions with an adjacent calcified lymph node.
2. Pulsion diverticula (pulsion diverticula). These are multiple outpouchings typically localized in the middle and lower thirds. Their appearance is frequently associated with impaired normal esophageal motility (oesophageal dysmotility).

Structural anomalies and dysphagia

During the differential diagnosis, it is important to also consider other causes of swallowing disorders (dysphagia):

• Schatzki ring (Schatzki Ring). This is a 2–3 mm thick circular mucosal ring located strictly at the level of the Z-line (Z-line). Clinical symptoms depend on the lumen diameter: at sizes greater than 20 mm, dysphagia is highly unlikely, whereas with narrowing of less than 13 mm, it is present almost always.
• Dysphagia lusoria (Dysphagia Lusoria). Occurs due to esophageal compression by a congenital aberrant right subclavian artery (aberrant right subclavian artery). Symptomatic presentation is a rarity. Barium fluoroscopy reveals an oblique tubular extrinsic impression in the upper part (oblique tubular extrinsic impression). Management is conservative (proton pump inhibitors / PPIs), surgery is reserved only for severe symptoms.
• Dysphagia aortica (Dysphagia Aortica). The acquired counterpart of dysphagia lusoria. Compression of the posterior wall of the lower third occurs due to a tortuous or dilated aorta. Short elderly women are in the risk group.

Traumatic injuries

Anatomically, the thoracic cage reliably protects the esophagus from blunt and penetrating injuries in most types of external trauma. However, there is a risk of iatrogenic injuries. The most common cause of organ trauma is endoscopy. The statistical incidence of perforation during this procedure is approximately 1 in 10,000 cases.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Pathophysiology of portosystemic anastomosis formation in portal hypertension.
• Radiological signs of a normal left main bronchus impression.
• Principles of conservative management of dysphagia lusoria using proton pump inhibitors.
• Imaging workup protocol for patients with suspected iatrogenic esophageal perforation.

Other topics in the section "Diagnostic Radiology of the Abdominal Organs"

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