Q: My father’s age is 70. Ten days back, he got an attack of vomiting of blood. He was then hospitalised urgently. The blood tests showed HBV+. The ultrasound report showed: mild splenomegaly, ascitis and coarse echotexture with irregular outline. The endoscopy report has showed a grade II oesophageal varices with oesophagitis. Now the situation is that bleeding is stopped, but the patient is restless and there is jaundice. Ascitis is also present and there is oedema in feet. Now the doctor has suggested that we will have to repeat the endoscopy 3-4 more times. My father is very worried and is reluctant to get an endoscopy done. Please suggest us how should I compel my father to get ready for an endoscopy or should I resist the doctor for doing another endoscopy?

A:The most common causes of bleeding in the upper part of the gastro-intestinal tract are duodenal and gastric ulcers, oesophageal varices, acute gastric erosions/haemorrhagic gastritis, tear of the oesophageal lining and gastric carcinoma. Oesophageal varices are dilated blood vessels within the wall of the oesophagus. A large blood vessel called portal vein carries approximately 1500 mL/min of blood from the small and large intestines, the spleen, and the stomach to the liver. Any obstruction to this blood flow due to any cause results in an increase in pressure in the vein (portal hypertension) which leads to development of a collateral circulation diverting the obstructed blood flow to other veins. These collaterals form by the opening and dilatation of preexisting vascular channels that connect the portal venous system and the superior and inferior vena cava. The most important such collateral is at the junction of the food pipe and the stomach and this is responsible for the main complication of portal hypertension—massive upper gastro-intestinal bleeding. An elevated portal venous pressure (>10 mm Hg) distends the veins proximal to the site of the block and increases pressure in organs drained by the obstructed veins. A rise in portal vein pressure could be due to a problem before the liver (pre-hepatic), within the liver (hepatic) or beyond the liver (post-hepatic) and some common causes are: cirrhosis, portal vein thrombosis, primary biliary cirrhosis, Budd-Chiari syndrome and veno-occlusive disease. Endoscopy is required so that treatment may be planned. It diagnoses the problem (presence of active variceal bleeding or an adherent clot), can predict risk of bleeding and treat the problem by sclerotherapy or variceal ligation (banding). You need to talk to the doctor and discuss all the issues with him.