Esophageal varices

Esophageal varices

Definition:

Esophageal varices are abnormal, enlarged veins in the lower part of the esophagus — the tube that connects the throat and stomach. Esophageal varices occur most often in people with serious liver diseases.

Esophageal varices develop when normal blood flow to your liver is slowed. The blood then backs up into nearby smaller blood vessels, such as those in your esophagus, causing the vessels to swell. Sometimes, esophageal varices can rupture, causing life-threatening bleeding.

A number of drugs and medical procedures are available to stop bleeding from esophageal varices. These same treatments can help prevent bleeding in people diagnosed with esophageal varices.


Symptoms:


Esophageal varices usually don't cause signs and symptoms unless they bleed. Signs and symptoms of bleeding esophageal varices include:

• Vomiting blood
• Black, tarry or bloody stools
• Shock, in severe cases

When to see a doctor

Make an appointment with your doctor if you have any signs or symptoms that worry you. If you've been diagnosed with liver disease, ask your doctor about your risk of esophageal varices and how you may reduce your risk of these complications. Ask your doctor whether you should undergo an endoscopy procedure to check for esophageal varices.

If you've been diagnosed with esophageal varices, your doctor may instruct you to be vigilant for signs of bleeding. Bleeding esophageal varices are an emergency. Call 911 or your local emergency services right away if you experience bloody vomit or bloody stools.

Causes:

The enlarged veins of esophageal varices form when blood flow to your liver is slowed. Often the flow of blood is slowed by scar tissue in the liver caused by liver disease. When the blood to your liver is slowed, it begins to back up, leading to increased pressure within a major vein (portal vein) that carries blood to your liver. This pressure forces the blood into the nearby smaller veins, such as those in your esophagus. These fragile, thin-walled veins begin to balloon with the added blood. Sometimes the veins can rupture and bleed.

Liver diseases and other causes of esophageal varices
Esophageal varices are most often a complication of cirrhosis — irreversible scarring of the liver. Other diseases and conditions also can cause esophageal varices. Causes can include:

• Severe liver scarring (cirrhosis). A number of liver diseases can result in cirrhosis, such as hepatitis infection, alcoholic liver disease and a bile duct disorder called primary biliary cirrhosis.
  
• Blood clot (thrombosis). A blood clot in the portal vein or in a vein that feeds into the portal vein called the splenic vein can cause esophageal varices.
  
• A parasitic infection. Schistosomiasis is a parasitic infection found in parts of Africa, South America, the Caribbean, the Middle East and Southeast Asia. The parasite can damage the liver, as well as the lungs, intestine and bladder.
  
• A syndrome that causes blood to back up in your liver. Budd-Chiari syndrome is a rare condition that causes blood clots that can block the veins that carry blood out of your liver.

Complications:

Bleeding
The most serious complication of esophageal varices is bleeding. Once you have had a bleeding episode, your risk of another is greatly increased. In some cases, bleeding can cause the loss of so much blood volume that you go into shock. This can lead to death.

Treatments and drugs:


The primary aim in treating esophageal varices is to prevent bleeding. Bleeding esophageal varices are life-threatening. If bleeding occurs, treatments are available to try to stop the bleeding.

Treatments to prevent bleeding
Treatments to lower blood pressure in the portal vein may reduce the risk of bleeding esophageal varices. Treatments may include:

• Medications to slow flow of blood in the portal vein. A type of blood pressure drug called a beta blocker may help reduce blood pressure in your portal vein, reducing the likelihood of bleeding. These medications include propranolol (Inderal, Innopran) and nadolol.
  
• Using a scope to access your esophagus and treat varices. If your esophageal varices appear to have a very high risk of bleeding, your doctor may recommend some of the same treatments that are used to stop active bleeding. Treatments may involve using an endoscope to see inside your esophagus and inject a medication or tie off veins with an elastic band.

Treatments to stop bleeding
Bleeding varices are life-threatening, and immediate treatment is essential. Treatments used to stop bleeding include:

• Using elastic bands to tie off bleeding veins. During variceal ligation, your doctor uses an endoscope to snare the varices and wrap them with an elastic band, which essentially "strangles" the veins so they can't bleed. Variceal ligation carries a small risk of complications, such as scarring of the esophagus.
  
• Injecting a solution into bleeding veins. In a procedure called endoscopic injection therapy, the bleeding varices are injected with a solution that shrinks them. Complications can include perforation of the esophagus and scarring of the esophagus that can lead to trouble swallowing (dysphagia).
  
• Medications to slow blood flow into the portal vein. Medications can slow the flow of blood from the internal organs to the portal vein, reducing the pressure in the vein. A drug called octreotide (Sandostatin) is often used in combination with endoscopic therapy to treat bleeding from esophageal varices. The drug is usually continued for five days after a bleeding episode.
  
• Diverting blood flow away from the portal vein. A transjugular intrahepatic portosystemic shunt (TIPS) is a small tube that is placed between the portal vein and the hepatic vein, which carries blood from your liver back to your heart. By providing an additional path for blood, the shunt often can control bleeding from esophageal varices. But TIPS can cause a number of serious complications, including liver failure and mental confusion, which may develop when toxins that would normally be filtered by the liver are passed through the shunt directly into the bloodstream. TIPS is mainly used when all other treatments have failed or as a temporary measure in people awaiting a liver transplant.
  
• Replacing the diseased liver with a healthy one. Liver transplant is an option for people with severe liver disease or those who experience recurrent bleeding of esophageal varices. Although liver transplantation is often successful, the number of people awaiting transplants far outnumbers the available organs.