Bleeding esophageal varices

Definition

Bleeding esophageal varices occur when veins in the walls of the lower part of the esophagus and sometimes the upper part of the stomach are wider than normal (dilated).

Causes, incidence, and risk factors

Bleeding varices are a life-threatening complication of increased blood pressure in the portal vein caused by liver disease (portal hypertension). The portal vein carries blood from the intestine to the liver.

Increased pressure causes the veins to balloon outward. The vessels may break open (rupture). Any cause of chronic liver disease can cause bleeding varices.

Symptoms

• Black, tarry stools
• Bloody stools
• Decreased urine output
• Excessive thirst
• 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

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.

In endoscopic therapy, a small lighted tube called an endoscope is used. The health care provider may inject the varices directly with a clotting medicine, or place a rubber band around the bleeding veins. This procedure is used in acute bleeding episodes and as preventive therapy.

Acute bleeding may also be treated with a tube that is inserted through the nose into the stomach and inflated with air to produce pressure against the bleeding veins (balloon tamponade).

Once acute bleeding has been stopped, several treatments are available:

• Drugs called beta blockers, such as propranolol and nadolol, are used to reduce the risk of bleeding.
• A catheter is placed through a vein across the liver where it connects the portal blood vessels to the regular veins in the body, and decreases pressure in the portal vein system (transjugular intrahepatic portosystemic shunt, TIPS, procedure).
• Octreotide and vasopressin are medications that may be used to decrease portal blood flow and slow bleeding.

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

Patients with bleeding varices from liver disease may need 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

• Esophageal stricture after surgery or endoscopic therapy
• Hypovolemic shock
• Infection (pneumonia, bloodstream infection, peritonitis)
• Return of bleeding after treatment
• Worsening encephalopathy (confusion)

Calling your health care provider

Call your health care provider 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