Esophageal varices

What is it?

Esophageal varices are swollen veins in the lining of the lower esophagus near the stomach. Gastric varices are swollen veins in the lining of the stomach. Swollen veins in the esophagus or stomach resemble the varicose veins that some people have in their legs. Because the veins in the esophagus are so close to the surface of the esophagus, swollen veins in this location can rupture and cause dangerous bleeding.

Esophageal varices almost always occur in people who have cirrhosis of the liver. Cirrhosis causes scarring of the liver, which slows the flow of blood through the liver. Scarring causes blood to back up in the portal vein, the main vein that delivers blood from the stomach and intestines to the liver. This backup causes high blood pressure in the portal vein and other nearby veins. This is called portal hypertension.

Less common causes of portal hypertension and esophageal varices include blood clots in the veins leading to and from the liver, and schistosomiasis. Schistosomiasis is a parasitic infection that can clog up the liver, causing pressure to back up in the portal vein.

The backup of blood forces veins to enlarge in the vicinity of the stomach and esophagus. The veins don't enlarge in a uniform fashion. Esophageal varices usually have enlarged, irregularly shaped bulbous regions (varicosities) that are interrupted by narrower regions. These abnormal dilated veins rupture easily and can bleed profusely because:

• the pressure inside the varices is higher than the pressure inside normal veins
• the walls of the varices are thin
• the varices are close to the surface of the esophagus.

Symptoms

Portal hypertension often does not cause any symptoms. Sometimes it is first discovered when the varices bleed. When significant bleeding occurs, a person will vomit blood, often in large amounts. People with massive bleeding feel dizzy and may lose consciousness.

Some people bleed in smaller amounts over a longer period, and they swallow the blood rather than vomit. Their stools may contain red or tarry-black blood.

People with esophageal varices caused by cirrhosis will usually have other symptoms related to their liver disease.

Diagnosis

To diagnose esophageal varices, a doctor will use an instrument called an endoscope. It is a thin, flexible tube with a camera at its tip. The doctor inserts the endoscope into the mouth. The scope is gently advanced into the esophagus to search for esophageal varices. If the varices are actively bleeding or have recently bled, this procedure will be done as an emergency. Tiny instruments may be attached to the endoscope to provide treatment at the same time.

Expected duration

Bleeding from esophageal varices usually does not stop without treatment. Bleeding esophageal varices is a life-threatening emergency. About 50% of people who have bleeding from esophageal varices will have the problem return during the first one to two years. The risk of recurrence can be reduced with treatment.

Prevention

The best way to prevent esophageal varices is to reduce your risk of cirrhosis. The main causes of cirrhosis include overuse of alcohol, hepatitis B, hepatitis C, and fatty liver.

Children, young teens, and all health care workers and older adults at risk of hepatitis B should be vaccinated against the disease. There is no vaccine to prevent people from contracting hepatitis C.

If you have esophageal varices, treatment may be able to prevent bleeding. This treatment includes endoscopic banding or sclerotherapy (described in the Treatment section) to shrink the varices. Drugs to reduce portal blood pressure — such as propranolol (Inderal) or nadolol (Corgard) — also can be used alone or in combination with endoscopic techniques.

Treatment

Emergency treatment for bleeding esophageal varices begins with blood and fluids given intravenously (into a vein) to compensate for blood loss. At the same time, intravenous drugs are usually given to decrease blood flow in the portal vein and help slow the rate of bleeding from the varices. Efforts are then made to stop the bleeding.

Endoscopy is done to identify the site of the bleeding. If the bleeding is caused by ruptured esophageal varices, one of two endoscopic treatments are often used:

• Band ligation. A rubber band is used to tie off the bleeding portion of the vein.
• Sclerotherapy. A drug is injected into the bleeding vein, causing it to constrict (narrow). This slows the bleeding and allows a blood clot to form over the ruptured vessel.

Bleeding esophageal varices can result in a very large amount of blood loss and many units of blood may need to be transfused. Once the bleeding is controlled, treatment is done to try to prevent more bleeding in the future. In some cases, more band ligation procedures are done to try to get rid of the varices. For people with severe cirrhosis, a procedure to minimize pressure in the veins is sometimes necessary. Pressure is reduced by creation of a shunt, which is a channel or pipeline that diverts blood away from the high-pressure veins. Options for creating a shunt include:

• Transjugular intrahepatic portal-systemic shunt (TIPSS). Usually blood must trickle through liver tissue in order to travel from the veins below the liver (the portal veins) into the three veins that drain the liver from above (the hepatic veins). This trickling is too slow when the liver is scarred. A TIPSS procedure implants a wide tube (a stent) within the liver so that much of the blood traveling through the liver can flow quickly through the liver. For this procedure, a catheter is threaded through a vein in the neck into one of the hepatic veins. The doctor guides the catheter inside the liver to a place where one of the portal veins sits close to the hepatic vein. The doctor threads a wire into the catheter. The tip of the wire is pushed through the wall of the hepatic vein into the portal vein. The wire and catheter come out. A different catheter with a balloon and stent at the tip moves into the newly created channel. The stent is a wire-mesh tube which is designed to prop open a vein or artery. The balloon is inflated. The stent opens when the balloon is inflated. It stays. The balloon is deflated and the catheter is removed. A tunnel has been created inside the liver that allows blood to flow faster through the portal vein into the hepatic vein. This treatment reduces the excess pressure in the esophageal varices, and decreases the risk of bleeding in the future. A TIPSS procedure is done by a specialized radiologist (interventional radiologist).
• Surgery. Rarely, patients need to have an operation to create a shunt to divert portal blood away from the liver into another vein. Like TIPSS, this treatment reduces the pressure in the varices.

When to call a professional

Bleeding from esophageal varices can be life-threatening. Patients can lose massive amounts of blood in a short time, causing extremely low blood pressure and shock. If you vomit blood or notice blood in your stool, you should always seek immediate medical attention.

Prognosis

At least 50% of people who survive bleeding esophageal varices are at risk of more bleeding during the next one to two years. The risk can be reduced by endoscopic and drug treatments.

If a TIPSS procedure or other shunt procedure is required, some blood will pass through the liver without being thoroughly detoxified by enzymes within the liver. Natural waste products in the blood can accumulate if the blood is not detoxified by the liver. Because of this some people who have had a TIPSS procedure develop symptoms of confusion, called encephalopathy. Medication can reduce symptoms of encephalopathy.

Additional info

American College of Gastroenterology (ACG)
https://gi.org/

American Gastroenterological Association
http://www.gastro.org/