Esophageal varices are enlarged veins in the esophagus, which can cause major bleeding.
Esophageal varices are caused by high blood pressure in blood vessels in and around the liver (portal hypertension).
Esophageal varices usually cause no symptoms but can bleed spontaneously.
Bleeding can be very severe and cause shock or even death.
Doctors diagnose and treat esophageal varices using endoscopy.
Varices also can form in the upper part of the stomach near where the esophagus enters. These are called gastric varices and they cause similar symptoms.
Causes of Esophageal Varices
Esophageal varices are caused by
The portal vein is the large vein that brings blood to the liver from the intestines and other abdominal organs such as the spleen, pancreas, and gallbladder. High blood pressure in the portal vein is called portal hypertension. The most common cause of portal hypertension in high-resource countries is liver scarring due to cirrhosis.
View of the Liver and Gallbladder
Portal hypertension leads to the development of new veins called collateral vessels that bypass the liver. Collateral vessels directly connect the portal blood vessels to veins that take blood away from the liver into the general circulation. Collateral vessels develop at specific places. The most dangerous places are at the lower end of the esophagus and at the upper part of the stomach. Development at these locations is dangerous because the vessels enlarge and become full of twists and turns and are known as varices or varicose veins. These enlarged varices are fragile and can rupture, causing massive gastrointestinal bleeding. Usually, there is no obvious trigger for the rupture.
Symptoms of Esophageal Varices
People with esophageal varices usually have no symptoms until the varices begin to bleed. Then, people vomit bright red blood, sometimes in large amounts. The bleeding is painless.
People who lose a lot of blood may have signs of shock, including feeling lightheaded, weak, and sweaty. Their heart may beat quickly and their blood pressure may be low.
Diagnosis of Esophageal Varices
Endoscopy
Doctors suspect bleeding esophageal varices when people who are known to have chronic liver disease, particularly cirrhosis, begin vomiting blood. Then doctors put a flexible viewing tube (endoscope) through the mouth to look at the esophagus. If they see varices, they can also do treatments through the endoscope to stop the bleeding.
Treatment of Esophageal Varices
Fluids given by vein (intravenously) and sometimes a blood transfusion
Endoscopic treatments to stop the bleeding
Intravenous octreotide
Sometimes antibiotics
Sometimes a portosystemic shunting procedure
People with variceal bleeding usually need fluids given intravenously to replace their blood loss. If they have lost a lot of blood, they may need a blood transfusion.
If bleeding continues despite these treatments, doctors may do a procedure called portosystemic shunting. This procedure connects the portal vein or one of its branches to a vein in the general circulation and reroutes most of the blood that normally goes to the liver so that it bypasses the liver. This bypass (called a shunt) lowers pressure in the portal vein so that bleeding is easier to control. There are various types of portosystemic shunt procedures. In one type, called transjugular intrahepatic portosystemic shunting (TIPS), doctors, using x-rays for guidance, insert a catheter with a needle into a vein in the neck and thread it to veins in the liver. The catheter is used to create a passage (shunt) that connects the portal vein (or one of its branches) directly with one of the hepatic veins. Less commonly, portosystemic shunts are created surgically.
If the person's life is in immediate danger from severe bleeding while waiting for the shunt procedure, doctors may place a tube with balloons down the person's esophagus. They inflate the balloons to squeeze (compress) the varices, which controls the bleeding. This tube is only a temporary measure. Expandable metal esophageal stents may be used to compress the varices to control the bleeding.
People who have cirrhosis and bleeding are at risk of bacterial infection and are given an antibiotic.
Even after successful treatment, esophageal varices can bleed again, particularly if the person's liver disease remains active. Doctors may give medications such as beta-blockers to help control portal hypertension, but people who continue to have problems may need liver transplantation.
