Learn how to spot and what to do if you experience signs of this serious complication of liver disease.
Esophageal varices are abnormal, enlarged veins in the tube that connects the throat and stomach (esophagus). This condition occurs most often in people with serious liver diseases.
Esophageal varices develop when normal blood flow to the liver is blocked by a clot or scar tissue in the liver. To go around the blockages, blood flows into smaller blood vessels that aren't designed to carry large volumes of blood. The vessels can leak blood or even rupture, causing life-threatening bleeding.
A number of drugs and medical procedures can help prevent or stop bleeding from esophageal varices.
Esophageal varices usually don't cause signs and symptoms unless they bleed. Signs and symptoms of bleeding esophageal varices include:
Your doctor might suspect esophageal varices if you have signs of liver disease, including:
Make an appointment with your doctor if you have signs or symptoms that worry you. If you've been diagnosed with liver disease, ask your doctor about your risk of esophageal varices and what you can do to reduce your risk. Also ask your doctor whether you should get a procedure to check for esophageal varices.
If you've been diagnosed with esophageal varices, your doctor is likely to instruct you to watch for signs of bleeding. Bleeding esophageal varices are an emergency. Call 911 or your local emergency services right away if you have bloody vomit or bloody stools.
Esophageal varices sometimes form when blood flow to your liver is blocked, most often by scar tissue in the liver caused by liver disease. The blood flow begins to back up, increasing pressure within the large vein (portal vein) that carries blood to your liver.
This increased pressure (portal hypertension) forces the blood to seek other pathways through smaller veins, such as those in the lowest part of the esophagus. These thin-walled veins balloon with the added blood. Sometimes the veins rupture and bleed.
Causes of esophageal varices include:
Although many people with advanced liver disease develop esophageal varices, most won't have bleeding. Esophageal varices are more likely to bleed if you have:
If you've had bleeding from esophageal varices before, you're more likely to have varices that bleed again.
The most serious complication of esophageal varices is bleeding. Once you've had a bleeding episode, your risk of another bleeding episode greatly increases. If you lose enough blood, you can go into shock, which can lead to death.
Currently, no treatment can prevent the development of esophageal varices in people with cirrhosis. While beta blocker drugs are effective in preventing bleeding in many people who have esophageal varices, they don't prevent esophageal varices from forming.
If you've been diagnosed with liver disease, ask your doctor about strategies to avoid liver disease complications. To keep your liver healthy:
If you have cirrhosis, your doctor should screen you for esophageal varices when you're diagnosed. How often you'll undergo screening tests depends on your condition. Main tests used to diagnose esophageal varices are:
Endoscopic exam. A procedure called upper gastrointestinal endoscopy is the preferred method of screening for esophageal varices. Your doctor inserts a thin, flexible, lighted tube (endoscope) through your mouth and into your esophagus, stomach and the beginning of your small intestine (duodenum).
The doctor will look for dilated veins, measure them, if found, and check for red streaks and red spots, which usually indicate a significant risk of bleeding. Treatment can be performed during the exam.
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 lower blood pressure in the portal vein may reduce the risk of bleeding esophageal varices. Treatments may include:
Using elastic bands to tie off bleeding veins. If your esophageal varices appear to have a high risk of bleeding, or if you've had bleeding from varices before, your doctor might recommend a procedure called endoscopic band ligation.
Using an endoscope, the doctor uses suction to pull the varices into a chamber at the end of the scope and wraps them with an elastic band, which essentially "strangles" the veins so they can't bleed. Endoscopic band ligation carries a small risk of complications, such as bleeding and scarring of the esophagus.
Bleeding esophageal varices are life-threatening, and immediate treatment is essential. Treatments used to stop bleeding and reverse the effects of blood loss include:
Diverting blood flow away from the portal vein. If medication and endoscopy treatments don't stop the bleeding, your doctor might recommend a procedure called transjugular intrahepatic portosystemic shunt (TIPS).
The shunt is an opening that is created between the portal vein and the hepatic vein, which carries blood from your liver to your heart. The shunt reduces pressure in the portal vein and often stops bleeding from esophageal varices.
But TIPS can cause serious complications, including liver failure and mental confusion, which can develop when toxins that the liver normally would filter 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.
Placing pressure on varices to stop bleeding. If medication and endoscopy treatments don't work, doctors may try to stop bleeding by applying pressure to the esophageal varices. One way to temporarily stop bleeding is by inflating a balloon to put pressure on the varices for up to 24 hours, a procedure called balloon tamponade. Balloon tamponade is a temporary measure before other treatments can be performed, such as TIPS.
This procedure carries a high risk of bleeding recurrence after the balloon is deflated. Balloon tamponade may also cause serious complications, including a rupture in the esophagus, which can lead to death.
There is a high risk that bleeding will recur in people who've had bleeding from esophageal varices. Beta blockers and endoscopic band ligation are the recommended treatments to help prevent re-bleeding.
After initial banding treatment, your doctor will repeat your upper endoscopy at regular intervals and apply more bands if necessary until the esophageal varices are gone or small enough to reduce the risk of further bleeding.
Doctors are exploring an experimental emergency therapy to stop bleeding from esophageal varices that involves spraying an adhesive powder. The hemostatic powder is administered through a catheter during an endoscopy. When sprayed on the esophagus, hemostatic powder sticks to the varices and may stop bleeding.
Another potential way to stop bleeding when all other measures fail is to use self-expanding metal stents (SEMS). SEMS can be placed during an endoscopy and stop bleeding by placing pressure on the bleeding esophageal varices.
However, SEMS could damage tissue and can migrate after being placed. The stent should be removed within seven days and bleeding could recur. This option is experimental and isn't yet widely available.
You might start by seeing your primary care provider. Or you may be referred immediately to a doctor who specializes in digestive disorders (gastroenterologist). If you're having signs and symptoms of internal bleeding, call 911 or your local emergency number to be taken to the hospital for urgent care.
Here's some information to help you get ready for an appointment.
When you make the appointment, ask if there's anything you need to do in advance, such as fasting before a specific test. Make a list of:
Take a family member or friend along, if possible, to help you remember information you're given.
For esophageal varices, questions to ask your doctor include:
Don't hesitate to ask other questions.
Your doctor is likely to ask you questions, such as:
If you develop bloody vomit or stools while you're waiting for your appointment, call 911 or your local emergency number or go to an emergency room immediately.
February 20th, 2021