Esophageal Varices

Definition

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.

The Esophagus

Causes

Increased pressure in the veins that deliver blood to the liver is known as portal hypertension. It 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:

Cirrhosis of the liver
Blood clots of the splenic, portal, or hepatic veins
Arterial-portal venous fistula—abnormal connections between arteries and veins in the liver or spleen
Certain drugs, including arsenic, azathioprine, methotrexate, and others
Certain infections, such as schistosomiasis, which is a parasite
Severe heart failure
Tumor in pancreas
Hodgkin's disease
Sarcoidosis

Risk Factors

Factors that increase your chance of developing bleeding esophageal varices include:

Chronic alcohol intake
Chronic vital hepatitis
NSAID use
Chronic hepatitis
Disorders of blood clotting
Certain parasitic infections

Symptoms

Esophageal varices are sometimes only diagnosed when bleeding occurs. Though bleeding from esophageal varices may not be severe and may stop on its own, first-time bleeding events may result in death in some cases. Bleeding esophageal varices recur in approximately half of all patients.

Signs of bleeding from esophageal varices include:

Vomiting or coughing up blood
Red, tarry, or very dark stools
Low blood pressure
Lightheadedness
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.

Diagnosis

Your doctor will ask about your symptoms and medical history. A physical exam will be done. 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:

Your bodily fluids may need to be tested. This can be done with blood tests.
Images may need to be taken of your bodily structures. This can be done with ultrasound.
Your bodily structures may need to be viewed. This can be done with endoscopy.

Treatment

Several treatments can help lower the risk of vessel rupture or stop bleeding if it starts. Treatment options include the following:

Endoscopic Band Ligation

During endoscopic band ligation , a rubber band is tied around bulging veins to prevent ruptures or stop bleeding. This is considered the first line of treatment.

Balloon Tamponade

This procedure involves the passage of a balloon through the nose to help compress the bleeding varices.

Sclerotherapy

During 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. It will increase blood flow through the portal vein and relieve blood pressure in the esophageal varices. This procedure can control bleeding in most cases.

Distal Splenorenal Shunt (DSRS)

DSRS is a surgical procedure that connects the main vein in the spleen to the left kidney vein. The procedure is done to lower blood pressure in the swollen vessels and to limit bleeding.

Esophageal Transection

This procedure is reserved for patients who fail to respond to 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.

If you are diagnosed with esophageal varices, follow your doctor's instructions .

Prevention

Take the following steps to help reduce your chances of getting esophageal varices:

Seek immediate treatment for long-term alcohol abuse.
Drugs such as beta-blockers or isosorbide mononitrate could prevent recurrent bleeding.
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 to prevent swollen vessels from developing.

RESOURCES

American College of Gastroenterology http://www.acg.gi.org

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

CANADIAN RESOURCES

The Canadian Association of Gastroenterology http://www.cag-acg.org

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.

Ferri F, ed. Ferri’s Clinical Advisor 2010. Philadelphia, PA: Mosby Elsevier; 2009.

Gastroesophageal varices. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed. Updated November 19, 2012. Accessed March 20, 2013.

Gastrointestinal hemorrhage, upper tract: variceal. EBSCO Nursing Reference Center website. Available at: http://www.ebscohost.com/healthLibrary/ . Updated March 16, 2012. Accessed March 20, 2013.

Goldman L, Ausiello D, eds. Cecil Textbook of Internal Medicine. 23rd ed. Philadelphia: Saunders, 2008

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.

Sleisenger M, Fordtran J, Feldman M, Scharschmidt B. Sleisenger & Fordtran's Gastrointestinal and Liver Disease. 8th ed. St. Louis, MO: Mosby; 2005.

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

Revision Information

Reviewer: Daus Mahnke, MD
Review Date: 09/2012 -
Update Date: 03/20/2013 -

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