The esophagus connects the mouth to the stomach. Esophageal varices are abnormally swollen veins within the lining of the esophagus. If undiagnosed or untreated, esophageal varices can rupture and lead to life-threatening bleeding.
Causes
Increased pressure in the veins that deliver blood to the liver (known as portal hypertension) leads to the formation of esophageal varices. The increased pressure causes blood to back up into other smaller vessels, including those of the esophagus.
The medical conditions that lead to the development of portal hypertension and esophageal varices include:
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Cirrhosis of the liver
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Blood clots (of the splenic, portal, or hepatic veins)
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Arterial-portal venous fistula (abnormal connections between arteries and veins in the liver or spleen)
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Certain drugs (arsenic, azathioprine, methotrexate, and others)
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Certain infections (for instance, schistosomiasis, a parasite)
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Severe heart failure
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Tumor in pancreas
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Hodgkin's disease
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Sarcoidosis
Risk Factors
The following factors increase your chance of developing bleeding esophageal varices. If you have any of these risk factors, tell your doctor:
Symptoms
Esophageal varices are sometimes only diagnosed upon the occurrence of bleeding—a consequence in roughly half of all people with the condition. Though bleeding from esophageal varices may not be severe and may stop on its own, first-time bleeding events result in death in 30%-50% of cases. Bleeding esophageal varices recur in approximately half of all patients.
Signs of bleeding from esophageal varices include:
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Vomiting or coughing up blood
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Red, tarry, or very dark stools
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Low blood pressure
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Dizziness
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Rapid heartbeat
If you experience any of these symptoms, do not assume it is due to esophageal varices. These symptoms may be caused by other health conditions. If you experience any one of them, see your physician.
Diagnosis
Your doctor will ask about your symptoms and medical history, and perform a physical exam. Your doctor may also refer you to a gastroenterologist, a specialist skilled in the treatment of diseases of the digestive system.
Tests may include the following:
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Blood Tests–complete blood count, liver and kidney function, and coagulation tests
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Endoscopy–a small, flexible tube attached to a light and camera is inserted into the mouth down into the esophagus and stomach to view the source of any bleeding and swollen vessel
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Ultrasound–useful imaging modality to study blood flow in the portal system
Treatment
Several treatments can help lower the risk of vessel rupture or to stop bleeding if it starts. Treatment options include the following:
Endoscopic Band Ligation
During endoscopy, a rubber band is tied around the bulging veins to prevent ruptures or stop bleeding. This is considered the first line treatment.
Ballon Tamponade
This procedure involves the passage of a balloon through the nose to help compress the bleeding varces.
Sclerotherapy
Drugs intended to slow bleeding are injected into the bleeding vein and sometimes into the surrounding area. The drugs cause clots to form and harden the vein to stop bleeding.
Drug Therapy
Drugs used to relieve blood pressure include terlipressin, vasopressin, nitroglycerin, octreotide, and somatostatin.
Transjugular Intrahepatic Portosystemic Shunting (TIPS)
TIPS involves threading a catheter from a neck vein to the liver. A stent, a small tube designed to keep veins open, is bound to the catheter and inserted into the liver to increase blood flow through the portal vein and relieve blood pressure in the esophageal varices. This procedure can control bleeding in over 90% of cases.
Distal Splenorenal Shunt (DSRS)
A surgical procedure connecting the main vein in the spleen to the left kidney vein. The procedure is done to lower blood pressure in the swollen vessels and limit bleeding.
Esophageal Transection
This procedure is reserved for those patients who fail to respond to either drug or endoscopic treatment and are not considered good candidates for a shunting procedure.
Liver Transplant
Liver transplantation is the only way to completely cure esophageal varices.
Prevention
To help reduce your chances of getting esophageal varices, take the following steps:
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Seek immediate treatment for long-term alcohol abuse.
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Drugs such as beta-blockers (propanolol or nadolol) or isosorbide mononitrate could prevent recurrent bleeding.
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Tell your doctor if you are at risk for chronic liver disease, blood clots, or are on medications that may damage the liver.
If you already have chronic liver disease, your doctor may prescribe drugs intended to prevent swollen vessels from developing.
RESOURCES:
American College of Gastroenterology
http://www.acg.gi.org
American Gastroenterological Association
http://www.gastro.org
National Institute of Digestive and Diabetes and Kidney Diseases
http://www.niddk.nih.gov
CANADIAN RESOURCES:
Canadian Liver Foundation
http://www.liver.ca
References:
Berry PA, Wendon JA. The management of severe alcoholic liver disease and variceal bleeding in the intensive care unit. Curr Opin Crit Care. 2006;12:171-7.
Bhasin DK, Siyad I. Variceal bleeding and portal hypertension: new lights on old horizon. Endoscopy. 2004;36(2):120-129.
D’Amico G. The role of vasoactive drugs in the treatment of oesophageal varices. Expert Opinion Pharmacotherapy. 2004;5(2):349-360.
Kamath PS. Esophageal variceal bleeding: primary prophylaxis. Clin Gastroenterol Hepatol. 2005;3(1):90-93.
Lubel JS, Angus PW. Modern management of portal hypertension. Intern Med J. 2005;35(1):45-9.
Villanueva C, Piqueras M, Aracil C, et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol .2006;45:560-7
