Bleeding esophageal varices

Answer 1

Definition

Bleeding esophageal varices are very swollen veins in the walls of the lower part of the esophagus (the tube that connects your throat to your stomach) that begin to bleed.

Causes, incidence, and risk factors

Scarring (cirrhosis) of the liver is the most common cause of esophageal varices. This scarring prevents blood from flowing through the liver. As a result, more blood flows through the veins of the esophagus.

This extra blood flow causes the veins in the esophagus to balloon outward. If these veins break open (rupture), they can cause severe bleeding.

Any cause of chronic liver disease can cause varices.

The swollen veins (varices) can also occur in the upper part of the stomach.

Symptoms

People with chronic liver disease and esophageal varices may have no symptoms.

If there is only a small amount of bleeding, the only symptom may be dark or black streaks in the stools.

If larger amounts of bleeding occur, symptoms may include:

• Black, tarry stools
• Bloody stools
• Light-headedness
• Paleness
• Symptoms of chronic liver disease (such as cirrhosis)
• Vomiting
• Vomiting blood

Signs and tests

Physical examination:

• Bloody or black stool on rectal exam
• Low blood pressure
• Rapid heart rate
• Signs of chronic liver disease or cirrhosis

Tests to determine where the bleeding is coming from and detect active bleeding include:

• Esophagogastroduodenoscopy (EGD)
• Tube through the nose into the stomach (nasogastric tube) to look for signs of bleeding

Some doctors recommend EGD for patients who are newly diagnosed with mild-to-moderate cirrhosis to screen for esophageal varices and treat them before there is bleeding.

Treatment

The goal of treatment is to stop acute bleeding as soon as possible, and treat varices with medicines and medical procedures. Bleeding must be controlled quickly to prevent shock and death.

If massive bleeding occurs, the patient may be placed on a ventilator to protect the airways and prevent blood from going down into the lungs.

Treatments for acute bleeding:

• A small lighted tube called an endoscope may be used. The health care provider may inject the varices directly with a clotting medicine, or place a rubber band around the bleeding veins.
• A medication that tightens blood vessels (vasoconstriction) may be used. Examples include octreotide or vasopressin.
• A tube may be inserted through the nose into the stomach and inflated with air. This produces pressure against the bleeding veins (balloon tamponade).

Once the bleeding is stopped, varices can be treated with medicines and medical procedures to prevent future bleeding:

• Drugs called beta blockers, such as propranolol and nadolol, are used to reduce the risk of bleeding.
• A small lighted tube called an endoscope may be used to place a rubber band around the bleeding veins.
• Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure to create new connections between two blood vessels in your liver. This can decrease pressure in the veins and prevent bleeding episodes from happening again.

Emergency surgery may be used (rarely) to treat patients if other therapy fails. Portocaval shunts or surgery to remove the esophagus are two treatment options, but these procedures are risky.

Patients with bleeding varices from liver disease may need additional treatment of their liver disease, including a liver transplant.

Expectations (prognosis)

Bleeding often comes back without treatment. Bleeding esophageal varices are a serious complication of liver disease and have a poor outcome.

Complications

• Encephalopathy (sometimes called hepatic encephalopathy)
• Esophageal stricture after surgery or endoscopic therapy
• Hypovolemic shock
• Infection (pneumonia, bloodstream infection, peritonitis)
• Return of bleeding after treatment

Calling your health care provider

Call your health care provider or go to an emergency room if you vomit blood or have black tarry stools.

Prevention

Treating the causes of liver disease may prevent bleeding. Preventive treatment of varices with medications such as beta blockers or with endoscopic banding may help prevent bleeding. Liver transplantation should be considered for some patients.

References

Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD; Practice Guidelines Committee of American Association for Study of Liver Diseases; Practice Parameters Committee of American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007;102:2086-2102.

Garcia-Tsao G. Cirrhosis and its sequellae. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 157.

Answer 2

Definition

Bleeding esophageal varices are very swollen veins in the walls of the lower part of the esophagus (the tube that connects your throat to your stomach) that begin to bleed.

Causes, incidence, and risk factors

Scarring (cirrhosis) of the liver is the most common cause of esophageal varices. This scarring prevents blood from flowing through the liver. As a result, more blood flows through the veins of the esophagus.

This extra blood flow causes the veins in the esophagus to balloon outward. If these veins break open (rupture), they can cause severe bleeding.

Any cause of chronic liver disease can cause varices.

The swollen veins (varices) can also occur in the upper part of the stomach.

Symptoms

People with chronic liver disease and esophageal varices may have no symptoms.

If there is only a small amount of bleeding, the only symptom may be dark or black streaks in the stools.

If larger amounts of bleeding occur, symptoms may include:

• Black, tarry stools
• Bloody stools
• Light-headedness
• Paleness
• Symptoms of chronic liver disease (such as cirrhosis)
• Vomiting
• Vomiting blood

Signs and tests

Physical examination:

• Bloody or black stool on rectal exam
• Low blood pressure
• Rapid heart rate
• Signs of chronic liver disease or cirrhosis

Tests to determine where the bleeding is coming from and detect active bleeding include:

• Esophagogastroduodenoscopy (EGD)
• Tube through the nose into the stomach (nasogastric tube) to look for signs of bleeding

Some doctors recommend EGD for patients who are newly diagnosed with mild to moderate cirrhosis to screen for esophageal varices and treat them before there is bleeding.

Treatment

The goal of treatment is to stop acute bleeding as soon as possible, and treat varices with medicines and medical procedures. Bleeding must be controlled quickly to prevent shock and death.

If massive bleeding occurs, the patient may be placed on a ventilator to protect the airways and prevent blood from going down into the lungs.

Treatments for acute bleeding:

• A small lighted tube called an endoscope may be used. The health care provider may inject the varices directly with a clotting medicine, or place a rubber band around the bleeding veins.
• A medication that tightens blood vessels (vasoconstriction) may be used. Examples include octreotide or vasopressin.
• A tube may be inserted through the nose into the stomach and inflated with air. This produces pressure against the bleeding veins (balloon tamponade).

Once the bleeding is stopped, varices can be treated with medicines and medical procedures to prevent future bleeding:

• Drugs called beta blockers, such as propranolol and nadolol, are used to reduce the risk of bleeding.
• A small lighted tube called an endoscope may be used to place a rubber band around the bleeding veins.
• Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure to create new connections between two blood vessels in your liver. This can decrease pressure in the veins and prevent bleeding episodes from happening again.

Emergency surgery may be used (rarely) to treat patients if other therapy fails. Portocaval shunts or surgery to remove the esophagus are two treatment options, but these procedures are risky.

Patients with bleeding varices from liver disease may need additional treatment of their liver disease, including a liver transplant.

Expectations (prognosis)

Bleeding often comes back without treatment. Bleeding esophageal varices are a serious complication of liver disease and have a poor outcome.

Complications

• Encephalopathy (sometimes called hepatic encephalopathy)
• Esophageal stricture after surgery or endoscopic therapy
• Hypovolemic shock
• Infection (pneumonia, bloodstream infection, peritonitis)
• Return of bleeding after treatment

Calling your health care provider

Call your health care provider or go to an emergency room if you vomit blood or have black tarry stools.

Prevention

Treating the causes of liver disease may prevent bleeding. Preventive treatment of varices with medications such as beta blockers or with endoscopic banding may help prevent bleeding. Liver transplantation should be considered for some patients.

References

Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD; Practice Guidelines Committee of American Association for Study of Liver Diseases; Practice Parameters Committee of American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007;102:2086-2102.

Garcia-Tsao G. Cirrhosis and its sequellae. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 157.

Reviewed By

Review Date: 01/20/2010

David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine; and George F. Longstreth, MD, Department of Gastroenterology, Kaiser Permanente Medical Care Program, San Diego, California. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.