What are esophageal varices?
Varicose veins are dilated or swollen veins. The esophagus is the tube that connects the throat to the stomach. When dilated veins appear in the lining of the esophagus, they are known as esophageal varices.
Who is at risk for ruptured and bleeding esophageal varices?
Not everyone who develops esophageal varices will bleed. Factors that increase the risk of bleeding include:
- Elevated portal blood pressure: The higher the portal pressure, the greater the risk of bleeding.
- large varicose veins: The risk of bleeding increases with the size of the varices.
- severe liver disease: Advanced cirrhosis or liver failure increase the risk.
- Persistent use of alcohol: In patients with alcohol-related varicose veins, continuous drinking increases the risk of bleeding.
symptoms and causes
What causes esophageal varices?
The liver is the organ that cleans toxins (poisons) from the blood. The portal vein supplies blood to the liver. Esophageal varices usually occur in people with liver disease. In people with liver disease, blood flow through the liver decreases. This increases the pressure in the portal vein.
High blood pressure in the portal vein (portal hypertension)pushes blood into surrounding blood vessels, including the esophageal vessels. These blood vessels are thin-walled and close to the surface. The extra blood causes them to expand and swell. Varicose veins can also develop in the small blood vessels in the upper part of the stomach.
If the pressure caused by excess blood builds up too much, varicose veins can rupture and bleed. Bleeding is an emergency that needs urgent treatment. Uncontrolled bleeding can quickly lead to shock and death.
Thrombosis (blood clots) in the portal vein or the splenic vein that connects to the portal vein can cause esophageal varices.
Two rare conditions that can cause esophageal varices are Budd-Chiari syndrome (obstruction of certain veins in the liver) and parasitic schistosomiasis infection.
What liver diseases can cause esophageal varices?
any kind of seriousliver diseasecan cause esophageal varices.cirrhosisIt is the most common type of liver disease. More than 90% of these patients will develop esophageal varices at some point in their lives and about 30% will bleed.
In patients with cirrhosis, large patches of scar tissue develop throughout the liver, causing decreased blood flow. Cirrhosis can be caused by alcoholic liver disease, fatty liver disease, viral hepatitis, or other liver diseases.
What are the symptoms of esophageal varices?
Most people don't know they have esophageal varices until the varices start bleeding. If the bleeding is sudden and heavy, the personvomitlarge amounts of blood. If the bleeding is lighter, the person may swallow the blood, which can result in dark, dark stools. If the bleeding is not controlled, the person may develop signs of shock, such as pale, clammy skin, irregular breathing, and loss of consciousness.
diagnosis and tests
How are esophageal varices diagnosed?
Regular screening for esophageal varices is recommended for patients with advanced liver disease. Sorting is done byendoscopy. An endoscope is a thin, flexible tube with a light and a small camera at the end. The doctor guides the endoscope down the esophagus, and the camera sends images of the inside of the esophagus to a monitor. The doctor looks at the images to identify the dilated veins and classifies them by size. Red lines in the veins are a sign of bleeding.
The doctor may also use the endoscope to examine the stomach and upper part of the small intestine. This is called an esophagogastroduodenoscopy (EGD).
computed tomographyoMRIit is also used to diagnose esophageal varices, often in combination with endoscopy. Images created by CT or MRI show the esophagus, liver, portal vein, and splenic vein. They give the doctor more information about the health of the liver than just the endoscopy.
management and treatment
How are esophageal varices treated?
The goals of treatment are:
- Prevent further liver damage.
- Prevents bleeding from varicose veins.
- Control bleeding if it occurs.
prevent liver damage
People with liver disease should avoid toxins that cause additional stress and damage the liver. Some suggestions for maintaining a healthy liver are:
- Avoid alcoholic beverages.
- Limit the use of cleaning products and household chemicals.
- Eat a healthier diet that is low in fat and rich in fruits and vegetables, whole grains and lean protein.
- Maintain a healthy weight (excess body fat puts a strain on the liver).
Medicines to lower blood pressure in the portal vein can reduce the risk of bleeding. The most commonly used drugs are in a group called beta-blockers. These include propranolol (Inderal®), nadolol (Corgard®) and carvedilol (Coreg®).
Patients at high risk of bleeding can undergo preventative treatment using the same techniques used to stop bleeding. The most used technique is the ligation of varicose veins.
control the bleeding
Bleeding from esophageal varices is an emergency that requires immediate treatment. In the hospital, patients are given large amounts of fluid and blood to replace what has been lost.
There are two different non-surgical treatments available to stop variceal bleeding: variceal ligation, performed through an endoscope, and transjugular intrahepatic portosystemic shunt (TIPS), performed by a radiologist using X-rays.
- varicose veins ligation: In this procedure, small elastic bands are wrapped around the varicose veins to stop the flow of blood through the varicose veins. This can be done on as many veins as needed in a single session. After the bleeding is controlled, people may be given a drug to prevent rebleeding. Varicose ligation should be repeated every 4 weeks until the bleeding stops. Thereafter, a new upper gastrointestinal endoscopy should be performed every 6 to 12 months to ensure that the varicose veins do not recur. Complications associated with variceal ligation include blood loss, perforation of the esophagus, difficulty swallowing, abnormal heart rhythms, infection, fever, and reduced or shallow breathing. All these complications are rare.
- Transjugular intrahepatic portal systemic shunt (TIPS): this is a portal blood pressure lowering procedure that can be used in patients with esophageal varices who bleed due to severe cirrhosis. A small, thin tube called a catheter is inserted into a jugular vein. The catheter is passed through the body to the liver, where the hepatic and portal veins are close together. (The hepatic vein carries blood from the liver to the heart.) Then a wire is threaded through the catheter. It is used to puncture the hepatic vein to the portal vein. The wire is removed and a stent (a small coil of wire) is threaded through the catheter to the connection site. The stent is inserted into the new channel between the portal vein and the hepatic vein. The stent holds the junction open, allowing blood to flow more easily from the portal vein into the hepatic vein and out of the liver. This reduces the pressure in the portal vein, which reduces the pressure on the varicose veins, reducing the risk of bleeding. TIPS can be very effective in preventing bleeding, but they can also cause serious complications, especially in people with advanced liver disease, such as confusion and liver failure.
Outlook / Forecast
What is the long-term prognosis (outlook) for people with bleeding esophageal varices?
Bleeding esophageal varices are potentially fatal and can be fatal in up to 50% of patients. People who have had a bleeding episode from esophageal varices are at risk for rebleeding.
Treatment with variceal ligation is effective in controlling the first episodes of bleeding in about 90% of patients. However, about half of patients treated with variceal ligation will have another bleeding episode within 1 to 2 years. Medications and lifestyle changes can help reduce the risk of relapse (recurrence of bleeding).
Transplanted Livermany are an option for patients with severe cirrhosis and/or recurrent episodes of variceal bleeding. Liver transplants are only performed at selected centers across the country that meet very strict criteria.