High-resolution endoluminal sonography assessment of the hematocystic spots of esophageal varices

Background: Many variables are associated with an increased potential for esophageal variceal rupture, especially the presence of hematocystic spots and other red signs on upper endoscopy. The etiology of hematocystic spots is unknown. High-resolution endoluminal sonography has been shown to be an accurate and sensitive imaging modality for detection, as well as the qualitative and quantitative assessment of esophageal varices. Because the high-resolution endoluminal sonography transducer permits detailed resolution of submucosal structures thereby allowing more precise examination of the actual wall of the varix, we sought to image variceal hematocystic spots in an effort to better define their anatomy. Methods: Simultaneous upper endoscopy and high-resolution endoluminal sonography were performed in 68 patients with cirrhosis. Endoscopy was performed as part of screening for varices during evaluation for liver transplantation or in patients with previous presumed variceal bleeding. On endoscopy and high-resolution endoluminal sonography, two independent reviewers identified the same 10 patients having esophageal varices with hematocystic spots. The patients who had bled from their varices had not received prior endoscopic treatment. Results: Hematocystic spots as seen with high-resolution endoluminal sonography imaging appeared as saccular aneurysm-like projections on the variceal surface in 6 of 10 patients. Four of six patients would later have recurrent bleeding; two of these patients were again noted to have hematocystic spots on endoscopy with a similar corresponding high-resolution endoluminal sonography appearance. Patients without hematocystic spots did not have similar high-resolution endoluminal sonography imaging. Conclusion: Aneurysm-like projections in the wall of varices may represent focal weaknesses of the variceal wall and thus play a role in the pathophysiology of esophageal variceal rupture. The present findings may help to explain why there is an increased risk of variceal hemorrhage associated with the presence of hematocystic spots on esophageal varices.