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Esophageal varicesBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/esophageal-varices/DS00820
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Esophageal varices are abnormal, enlarged veins in the lower part of the esophagus — the tube that connects the throat and stomach. Esophageal varices occur most often in people with serious liver diseases.
Esophageal varices develop when normal blood flow to the liver is obstructed by scar tissue in the liver or a clot. Seeking a way around the blockages, blood flows into smaller blood vessels that are not designed to carry large volumes of blood. The vessels may leak blood or even rupture, causing life-threatening bleeding.
A number of drugs and medical procedures can help prevent and 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:
- Vomiting blood
- Black, tarry or bloody stools
- Shock (in severe case)
Your doctor may suspect varices if you have any of the following signs of liver disease:
- Yellow coloration of your skin and eyes (jaundice)
- A cluster of tiny blood vessels on the skin, shaped like a spider (spider nevi)
- Reddening of the skin on the palm of your hands (palmar erythema)
- A hand deformity known as Dupuytren's contracture
- Shrunken testicles
- Swollen spleen
- Fluid buildup in your abdomen (ascites)
When to see a doctor
Make an appointment with your doctor if you have any signs or symptoms that worry you. If you've been diagnosed with liver disease, ask your doctor about your risk of esophageal varices and how you may reduce your risk of these complications. Ask your doctor whether you should undergo an endoscopy procedure to check for esophageal varices.
If you've been diagnosed with esophageal varices, your doctor may instruct you to be vigilant for signs of bleeding. Bleeding esophageal varices are an emergency. Call 911 or your local emergency services right away if you experience bloody vomit or bloody stools.
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Esophageal varices sometimes form when blood flow to your liver is obstructed, most often by scar tissue in the liver caused by liver disease. The blood flow to your liver begins to back up, increasing pressure within the large vein (portal vein) that carries blood to your liver. This pressure (portal hypertension) forces the blood to seek alternate 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 can rupture and bleed.
Causes of esophageal varices include:
- Severe liver scarring (cirrhosis). A number of liver diseases can result in cirrhosis, such as hepatitis infection, alcoholic liver disease, fatty liver disease and a bile duct disorder called primary biliary cirrhosis. Esophageal varices occur in about 40 percent of people who have cirrhosis.
- Blood clot (thrombosis). A blood clot in the portal vein or in a vein that feeds into the portal vein called the splenic vein can cause esophageal varices.
- A parasitic infection. Schistosomiasis is a parasitic infection found in parts of Africa, South America, the Caribbean, the Middle East and Southeast Asia. The parasite can damage the liver, as well as the lungs, intestine and bladder.
- Budd-Chiari syndrome. This rare condition causes blood clots that can block the veins that carry blood out of your liver.
Although many people with advanced liver disease develop esophageal varices, most won't 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 (portal hypertension).
- Large varices. The larger the varices, the more likely they are to bleed.
- Red marks on the varices. When viewed through an endoscope passed down your throat, 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.
- Continued alcohol use. Your risk of variceal bleeding is far greater if you continue to drink than if you stop, especially if your disease is alcohol related.
The most serious complication of esophageal varices is bleeding. Once you have had a bleeding episode, your risk of another bleeding episode is greatly increased. In some cases, blood loss is so great that you go into shock. This can lead to death.
Preparing for your appointment
Make an appointment with your family doctor or a general practitioner if you think you may have a disease or condition that could lead to esophageal varices. If you're experiencing signs and symptoms of internal bleeding, 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 doctor who specializes in digestive disorders (gastroenterologist).
Here's some information to help you get ready for an appointment.
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.
- Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
- 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 to help you remember questions to ask and what your doctor says.
- Write down questions to ask your doctor.
Questions to ask your doctor
Some basic questions to ask your doctor include:
- What is likely causing my symptoms?
- Are there any other possible causes for my symptoms?
- 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?
- Is there a generic alternative to the medicine you're prescribing?
- Are there any brochures or other printed material that I can take with me? What websites do you recommend?
Don't hesitate to ask other questions during your appointment.
What to expect from your doctor
Be ready to answer questions your doctor may ask:
- When did you 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
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If you have cirrhosis, your doctor should screen you for esophageal varices at the time you are first diagnosed. How often you'll undergo screening tests depends on your condition. Main tests used to diagnose esophageal varices are:
- Endoscope exam. A procedure called esophagogastroduodenoscopy is the preferred method of screening for the presence of varices. Your doctor inserts a thin, flexible, lighted tube (endoscope) through your mouth and into your esophagus and small intestine. The doctor will look for dilated veins, measure their size, if found, and check for red streaks (wales) and red spots, which usually indicate a significant risk of bleeding. Treatment can be performed during the exam.
- Imaging tests. Both CT and MRI scans may be used to diagnose esophageal varices. These tests also allow your doctor to examine your liver and circulation in the portal vein. CT is not recommended for detecting large esophageal varices, but it may be useful for screening for varices if endoscopy can't be done.
- Capsule endoscopy. In this test, you swallow a vitamin-sized capsule containing a tiny camera, which takes pictures of the esophagus as it passes. This may be an option for people who are unable or unwilling to undergo an endoscope exam. More experience is needed with this technology to confirm its value.
Treatments and drugs
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 prevent bleeding
Treatments to lower blood pressure in the portal vein may reduce the risk of bleeding esophageal varices. Treatments may include:
- Medications to reduce pressure in the portal vein. A type of blood pressure drug called a beta blocker may help reduce blood pressure in your portal vein, decreasing the likelihood of bleeding. These medications include propranolol (Inderal, Innopran) and nadolol (Corgard).
- Using elastic bands to tie off bleeding veins. If your esophageal varices appear to have a very high risk of bleeding, your doctor may recommend a procedure called band ligation. Using an endoscope, the doctor snares the varices and wraps them with an elastic band, which essentially "strangles" the veins so they can't bleed. Esophageal band ligation carries a small risk of complications, such as scarring of the esophagus.
Treatments to stop bleeding
Bleeding varices are life-threatening, and immediate treatment is essential. Treatments used to stop bleeding include:
- Using elastic bands to tie off bleeding veins.
- Medications to slow blood flow into the portal vein. Medications can slow the flow of blood from the internal organs to the portal vein, reducing the pressure in the vein. A drug called octreotide (Sandostatin) is often used in combination with endoscopic therapy to treat bleeding from esophageal varices. The drug is usually continued for five days after a bleeding episode.
Diverting blood flow away from the portal vein. Your doctor may recommend a procedure called transjugular intrahepatic portosystemic shunt (TIPS). The shunt is a small tube that is placed between the portal vein and the hepatic vein, which carries blood from your liver back to your heart. By providing an additional path for blood, the shunt reduces pressure in the portal vein and often stops bleeding from esophageal varices.
But TIPS can cause a number of serious complications, including liver failure and mental confusion, 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.
- Replacing the diseased liver with a healthy one. Liver transplant is an option for people with severe liver disease or those who experience recurrent bleeding of esophageal varices. Although liver transplantation is often successful, the number of people awaiting transplants far outnumbers the available organs.
Bleeding will recur in most people who have bleeding from esophageal varices. Beta blockers and esophageal band ligation are the recommended treatments to help prevent rebleeding.
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 do not keep esophageal varices from forming.
If you've been diagnosed with liver disease, ask your doctor about strategies to avoid liver disease complications. Some steps which may help keep your liver as healthy as possible include:
- Don't drink alcohol. People with liver disease are often advised to stop drinking alcohol, since alcohol is processed by the liver. Drinking alcohol may stress an already vulnerable liver.
- Eat a healthy diet. Choose a plant-based diet that's full of fruits and vegetables. Select whole grains and lean sources of protein. Reduce the amount of fatty and fried foods you eat.
- Maintain a healthy weight. An excess amount of body fat can damage your liver. Obesity is associated with a greater risk of complications of cirrhosis. Lose weight if you are obese or overweight.
- Use chemicals sparingly and carefully. Follow the directions on household chemicals, such as cleaning supplies and insect sprays. If you work around chemicals, follow all safety precautions. Your liver removes toxins from your body, so give it a break by limiting the amount of toxins it must process.
- Reduce your risk of hepatitis. Sharing needles and having unprotected sex can increase your risk of hepatitis B and C. Protect yourself by abstaining from sex or using a condom if you choose to have sex. Ask your doctor whether you should be vaccinated for hepatitis B and hepatitis A.
- Feldman M, et al. Sleisenger & Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 9th ed. Philadelphia, Pa.: Saunders Elsevier; 2010. http://www.mdconsult.com/books/about.do?eid=4-u1.0-B978-1-4160-6189-2..X0001-7--TOP&isbn=978-1-4160-6189-2&about=true&uniqId=229935664-2192. Accessed Sept. 12, 2010.
- Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Alexandria, Va.: American Association for the Study of Liver Diseases. http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/Prevention%20and%20Management%20of%20Gastro%20Varices%20and%20Hemorrhage.pdf. Accessed Sept. 12, 2010.
- Bope ET, et al. Conn's Current Therapy. Philadelphia, Pa.: Saunders Elsevier; 2013. Http://www.mdconsult.com/books/about.do?about=true&eid=$eid&isbn=978-1-4557-0295-4&uniqId=398813857-1936. Accessed Jan. 22, 2013.
- Coelho-Prabhu N et al. Current staging and diagnosis of gastroesophageal varices. Clinical Liver Disease. 2010; 14: 195.
- AskMayoExpert. Esophageal varices. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2012.
- What I need to know about cirrhosis. National Institute of Diabetes and Digestive and Kidney Diseases. http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis_ez/#prevent. Accessed Jan. 29, 2013.
- Schistosomiasis. Centers for Disease Control and Prevention. http://www.cdc.gov/parasites/schistosomiasis/gen_info/faqs.html. Accessed Jan. 29, 2013.