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Esophageal varices
By Mayo Clinic staffMayo Clinic Health Manager
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Definition
Serious liver diseases such as cirrhosis can cause a number of complications, including esophageal varices — abnormally enlarged veins in the lower part of your esophagus, the tube that connects your throat and stomach.
Esophageal varices develop when normal blood flow to your liver is blocked. The blood then backs up into smaller, more fragile blood vessels in your esophagus, and often in your stomach or rectum as well, causing the vessels to swell. Sometimes, esophageal varices can rupture, causing a life-threatening condition.
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
About one-third of people with esophageal varices will develop bleeding. The signs and symptoms of esophageal bleeding range from mild to severe and include:
- Vomiting blood
- Black, tarry or bloody stools
- Decreased urination from unusually low blood pressure
- Excessive thirst
- Lightheadedness
- Shock, in severe cases
When to see a doctor
See your doctor if you develop signs and symptoms of liver disease, such as:
- Weight loss
- Small, red spider veins under your skin or easy bruising
- Weakness
- Fatigue
- Yellowing of your skin and eyes and dark, cola-colored urine
- The buildup of fluid in your abdominal cavity (ascites)
- Itching of your hands and feet and eventually of your entire body
- Swelling of your legs and feet from retained fluid (edema)
- Mental confusion, such as forgetfulness or trouble concentrating (encephalopathy)
When it's an emergency
If you've been diagnosed with esophageal varices and experience bloody vomit or stools, call 911 or your local emergency services right away. These may indicate that esophageal varices have ruptured — a life-threatening condition that requires immediate medical care.
Causes
Normally, blood from your intestine, spleen and pancreas enters your liver through a large blood vessel called the portal vein. But if scar tissue blocks circulation through your liver, the blood backs up, leading to increased pressure within the portal vein (portal hypertension). This forces blood into smaller veins in your esophagus, stomach and occasionally your rectum. The excess blood causes these fragile, thin-walled veins to balloon outward and sometimes to rupture and bleed. Once varices develop, they continue to grow larger.
Cirrhosis: A leading cause of esophageal varices
Esophageal varices are usually a complication of cirrhosis. This serious liver disorder, which is irreversible scarring of liver tissue, often results from alcoholic liver disease or hepatitis B or C infection. Another liver disorder, primary biliary cirrhosis, which destroys the small ducts that carry bile, can also cause scarring of liver tissue and lead to esophageal varices.
Sometimes chronic conditions other than cirrhosis lead to enlarged veins in the esophagus. These conditions include:
- Severe congestive heart failure. This occurs when your heart can't pump enough blood to meet your body's needs. In congestive heart failure, blood backs up into the vein between your liver and the right side of your heart, increasing blood pressure in the portal vein.
- Blood clot (thrombosis). A blood clot in the portal vein or in the splenic vein, which feeds into the portal vein, can cause esophageal varices.
- Sarcoidosis. This inflammatory disease starts in your lungs, but can affect almost any organ in your body, including your liver. It rarely causes cirrhosis.
- Schistosomiasis. This parasitic infection affects millions of people in the developing world, especially parts of Africa, South America, the Caribbean, the Middle East and Southeast Asia. It can damage the liver as well as the lungs, intestine and bladder.
- Budd-Chiari syndrome. In this rare condition, blood clots obstruct the veins that carry blood out of your liver.
Risk factors
Although many people with advanced liver disease develop esophageal varices, less than half experience bleeding. Varices are more likely to bleed if you have:
- High portal vein pressure. The risk of bleeding increases with the amount of pressure in the portal vein.
- Large varices. The larger the varices, the more likely they are to bleed.
- Red marks on the varices. When viewed through an endoscope — a lighted, fiber-optic instrument — some varices show long, red streaks or red spots. These marks indicate a high risk of bleeding.
- Severe cirrhosis or liver failure. Most often, the more severe your liver disease, the more likely varices are to bleed.
- Fluid buildup. Liver disease can cause large amounts of fluid to accumulate in your abdominal cavity (ascites). Several factors play a role in fluid buildup, including portal hypertension and changes in the hormones and chemicals that regulate fluids in your body. Having this excess fluid increases your risk of variceal bleeding.
- Continued alcohol use. If your liver disease is alcohol related, your risk of variceal bleeding is far greater if you continue to drink than if you stop.
- Acid reflux. Stomach or bile acids that back up (reflux) into the esophagus erode the esophageal lining, which can trigger bleeding.
Complications
The most serious complication of esophageal varices is bleeding. Once you have had a bleeding episode, you're at greatly increased risk of another, especially immediately following the first episode.
Recurrent bleeding is common in people with esophageal varices — up to 70 percent will bleed again within one year of the first episode of bleeding without treatment. The likelihood of death increases with each episode. You're at greater risk of repeat bleeding if you are older, have liver failure or kidney failure, or drink alcohol.
Other complications of bleeding esophageal varices include:
- Hypovolemic shock. This occurs when your body loses some, often at least one-fifth, of its blood volume. Symptoms include low blood pressure, a rapid pulse, weakness, sweating, anxiety, mental confusion and possibly unconsciousness.
- Encephalopathy. A damaged liver is less effective at removing toxins from your body — normally one of the liver's key tasks. The buildup of toxins can damage your brain, leading to changes in your mental state, behavior and personality (hepatic encephalopathy). Signs and symptoms include forgetfulness, confusion and mood changes, and in the most severe cases, delirium and coma.
- Infection. Aspiration pneumonia, which occurs when you inadvertently inhale vomit or other substances into your lungs, can be a life-threatening complication of bleeding varices or of certain treatments to control them.
Preparing for your appointment
You're likely to start by first seeing your family doctor or a general practitioner for signs or symptoms of liver disease or another condition that can lead to esophageal varices. However, in some cases when you call to set up an appointment, you may be told to immediately call 911 or your local emergency number to be taken to the hospital for urgent care. There you will be evaluated by a digestive disorders specialist called a gastroenterologist.
Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready and learn what to expect from your doctor.
What you can do
- Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance. For example, you may need to stop eating and drinking the night before your appointment. You also may be asked to stop taking certain medications in the days leading up to your appointment.
- Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment. For example, your doctor will want to know about changes such as new itching and swelling in your hands, legs and feet, or if you've noticed a decline in your concentration or memory.
- Write down key personal information, including any major stresses, recent life changes or recent travels. Also note your diet and exercise habits, including whether you use alcohol and if so, how much.
- Make a list of your key medical information, including other conditions you're being treated for and the names of the medications that you're taking. Include on your list every prescription and over-the-counter drug you use, as well as any vitamins and supplements.
- Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
- Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out.
For esophageal varices, some basic questions to ask your doctor include:
- What is likely causing my symptoms or condition?
- Are there any other possible causes for my symptoms or condition?
- What kinds of tests do I need?
- What treatments do you recommend right now?
- What is the risk of my symptoms recurring?
- If I develop bleeding again, what treatments will we try next?
- What are the side effects of the treatments for this condition?
- I have these other health conditions. How can I best manage them together?
- Are there any restrictions that I need to follow?
- Is there anything I can do to prevent a recurrence of this problem?
- Should I see a specialist? What will that cost, and will my insurance cover seeing a specialist?
- Is there a generic alternative to the medicine you're prescribing me?
- Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to talk about in-depth. Your doctor may ask:
- When did you first begin experiencing symptoms?
- Have your symptoms stayed the same or gotten worse?
- How severe are your symptoms?
- What have your stools looked like recently? Have they contained blood or are they black?
- Have you been vomiting blood or black material?
- Have you had symptoms of vomiting blood in the past?
- Have you noticed a decrease in how often you urinate?
- Have you been more thirsty than usual?
- Have you felt fatigued or lightheaded?
- Have you felt more forgetful, confused or less able to concentrate?
- Have you lost weight?
- Have you noticed any swelling of your abdomen or legs?
- Have you ever had hepatitis or yellowing of your eyes or skin (jaundice)?
- Have you traveled recently? Where?
- Have you been diagnosed or treated for any other medical conditions? When?
- What medications are you currently taking?
- Do you or did you drink alcohol? How much?
What you can do in the meantime
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.
Tests and diagnosis
If you have cirrhosis or other serious liver disease, your doctor may screen you for esophageal varices, sometimes as often as every year or two. These tests are usually used to look for varices:
- Endoscopy. For this test, your doctor inserts a thin, flexible, lighted tube (endoscope) through your mouth and into your esophagus. If any dilated veins are found, they're graded according to their size and checked for red streaks, which usually indicate a significant risk of bleeding. An esophageal endoscopy takes about 20 to 30 minutes, and the risks are generally minor. The most common side effect is a sore throat from swallowing the endoscope.
- Imaging tests. Both computerized tomography (CT) scans and magnetic resonance imaging (MRI) may be used to diagnose esophageal varices. Unlike an endoscopy, these noninvasive tests also allow your doctor to examine your liver and circulation in the portal vein. But imaging tests aren't as effective at finding varices as endoscopy is, and they're not as useful for determining which varices are likely to bleed. For that reason, they're most often used in addition to endoscopy or when endoscopy can't be performed.
Treatments and drugs
The primary aim in treating esophageal varices is to prevent bleeding. To help achieve this goal, doctors usually prescribe high blood pressure drugs (beta blockers) to reduce pressure in the portal vein once your initial episode of bleeding has resolved. Other drugs may be used for people who don't respond to beta blockers or who have severe side effects. Sometimes the varices may be injected directly with a solution that causes them to shrink. Or they may be tied with elastic bands before they have a chance to bleed.
Treating bleeding
Bleeding varices are life-threatening, and immediate treatment is essential. To stop bleeding, you're likely to have one of the following procedures:
- Variceal ligation. This is the preferred treatment for bleeding esophageal varices. During the procedure, your doctor uses an endoscope to snare the varices with an elastic band, which essentially "strangles" the veins. Variceal ligation usually causes fewer serious complications than do other treatments. It's also less likely to lead to episodes of repeat bleeding.
- Endoscopic injection therapy. In this procedure, the bleeding varices are injected with a solution that shrinks them. Bleeding is usually controlled after one or two treatments, but complications can occur, including perforation of the esophagus and scarring of the esophagus that can lead to trouble swallowing (dysphagia).
- Medications. A drug called octreotide (Sandostatin, Sandostatin LAR) is often used in combination with endoscopic therapy to treat bleeding from esophageal varices. Octreotide works by reducing pressure in the varices. The drug is usually continued for five days after a bleeding episode.
- Balloon tamponade. This procedure is sometimes used to stop severe bleeding while waiting for a more permanent procedure. A tube is inserted through your nose and into your stomach and then inflated. The pressure against your veins can temporarily stop bleeding.
- Shunt. In this procedure, called transjugular intrahepatic portosystemic shunt (TIPS), a small tube called a shunt is placed between the portal vein and the hepatic vein, which carries blood from your liver back to your heart. The tube is kept open with a metal stent. By providing an artificial path for blood through the liver, the shunt often can control bleeding from esophageal varices. But TIPS can cause a number of serious complications, including liver failure and encephalopathy, 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.
- Liver transplant. Because no treatment is entirely successful at preventing repeat bleeding episodes and because treatments themselves pose significant risks, liver transplant is an option for people with severe or recurrent bleeding of esophageal varices. Although liver transplantation is often successful, the number of people awaiting transplants far outnumbers the available organs. You may face additional hurdles if your liver disease is the result of alcoholic hepatitis. Some medical centers won't perform liver transplants on people with alcoholic liver disease or require that you abstain from alcohol for at least six months before you're eligible for transplant surgery.
Prevention
It's not always possible to prevent esophageal varices in people with liver disease or portal hypertension. But treating the underlying problem — alcohol abuse, iron overload, or exposure to toxic chemicals, for instance — is of primary importance. Equally important is the use of beta blockers or other medications to prevent increased blood pressure in the portal vein.
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