The Role of Endoscopic Ultrasound for Esophageal Varices

Abstract

Esophageal varices are caused by the development of collateral circulation in the esophagus as a result of portal hypertension. It is important to administer appropriate preventive treatment because bleeding varices can be fatal. Esophageal varices have complex and diverse hemodynamics, and there are various variations for each case. Endoscopic ultrasound (EUS) can estimate the hemodynamics of each case. Therefore, observation by EUS in esophageal varices provides useful information, such as safe and effective treatment selection, prediction of recurrence, and appropriate follow-up after treatment. Although treatment for the esophagogastric varices can be performed without EUS imaging, understanding the local hemodynamics of the varices using EUS prior to treatment will lead to more safe and effective treatment. EUS observation is an indispensable tool for thorough variceal care.

Keywords: endoscopic injection sclerotherapy; endoscopic ultrasound; endoscopic variceal ligation; esophageal varices; hemodynamics.

Figure 1

Diagram of the hemodynamics of esophageal varices.

Figure 2

Observation of esophageal varices using a thin probe (20 MHz UMP, Olympus Co., Tokyo, Japan). Even narrow blood vessels can be observed.

Figure 3

Observation of esophageal varices using a radial-arrayed echoendoscope (FUJIFILM, EG-580UR). (a) Observation in B-mode. Perforating veins (short arrow) and esophageal varix (long arrow) are observed. (b) Color Doppler observation. The esophageal varix (long arrow) is seen as a flow of mixed red and blue signals. Furthermore, the perforating vein (short arrow) is primarily presented in blue, and this site acts as the outflow passage from esophageal varices.

Figure 4

Diagram of UMP observation of esophageal varices. UMP can reveal collateral vessels inside and outside the esophageal wall in detail. The esophageal collateral veins (ECVs) are divided into two types, peri- and para-ECVs. In addition, perforating veins between esophageal varices and ECVs are also seen.

Figure 5

Intramural and extramural observation items of the esophagus. (a) Peri-ECVs. Many blood vessels of small diameter are observed adjacent to the esophageal adventitia (arrow). The existence of these vessels makes the margin of the musculus longitudinalis externus appear unclear. (b) Para-ECVs. Blood vessels with a relatively large diameter located distant to the esophageal adventitia (arrow). (c) Veins perforating the esophageal wall. Perforating veins communicating between the esophageal varices and extramural ECVs (arrow).