Bleeding esophageal varices occur when swollen veins (varices) in your lower esophagus rupture and bleed.
The esophagus is the muscular tube that connects your mouth to your stomach. The veins in your lower esophagus near the stomach can become swollen when blood flow to the liver is reduced. This may be due to scar tissue or a blood clot within the liver.
When liver blood flow is obstructed, blood builds up in other blood vessels nearby, including those in your lower esophagus. However, these veins are much smaller, and they’re incapable of carrying large amounts of blood. They dilate and swell as a result of the increased blood flow.
The swollen veins are known as esophageal varices.
Esophageal varices may leak blood and eventually rupture. This can lead to severe bleeding and life threatening complications, including death. When this happens, it’s a medical emergency.
Call 911 or local emergency services, or go to the nearest emergency room immediately, if you’re showing symptoms of bleeding esophageal varices.
Esophageal varices often don’t cause any symptoms until they rupture and bleed. Once they rupture, symptoms vary depending on the severity of the bleeding.
If the bleeding is mild, you might only notice black, tarry stools (melena) that results from swallowing the blood.
Severe bleeding can cause:
- blood in your vomit (hematemesis)
- stomach pain
- lightheadedness or fainting
- rectal bleeding
- bloody stools (in severe cases)
Left uncontrolled, severe bleeding can cause extremely low blood pressure and lead to shock.
Symptoms of shock include:
- pale, clammy skin
- irregular breathing
- loss of consciousness
Call 911 or local emergency services, or go to the nearest emergency room immediately, if you experience any of the above symptoms.
The portal vein transports blood from several organs in the gastrointestinal tract into the liver. High blood pressure in the vein causes blood to build up in nearby blood vessels, including those in your esophagus. Veins begin to dilate and swell as a result of increased blood flow.
Cirrhosis — a severe scarring of the liver that often develops due to excessive alcohol consumption or serious infections, such as hepatitis — is the most common cause of portal hypertension. They can also be caused by portal vein thrombosis, a condition that occurs when blood clots inside the portal vein.
In some cases, the cause of portal hypertension is unknown. This is referred to as idiopathic portal hypertension.
Esophageal varices don’t always bleed. Factors that can increase the risk of bleeding include:
- Higher portal blood pressure. The higher the portal blood pressure, the greater the risk of bleeding.
- The size of the varices. The risk of bleeding increases with size. Larger varices have a higher risk of bleeding.
- Advanced liver disease. People with severe liver disease, including advanced cirrhosis or liver failure, are at higher risk of bleeding esophageal varices.
- Continued consumption of alcohol. If the varices are due to alcohol consumption, continuing to drink increases the risk of bleeding.
To diagnose esophageal varices, a doctor or other healthcare professional (HCP) will perform a physical examination and ask you about your symptoms.
They may also use one or more of the following tests to confirm the diagnosis:
- Blood tests. These are used to evaluate blood cell counts and liver and kidney function.
- Endoscopy. During this procedure, a small lighted camera scope is inserted into the mouth and used to look down the esophagus, into the stomach, and into the beginning of the small intestine. It’s used to look more closely at dilated veins and organs. It can also be used to take tissue samples and treat bleeding.
- Imaging tests, such as CT and MRI scans. These are used to examine the liver and abdominal organs and evaluate the blood flow in and around these organs.
The main goal of treatment is to prevent esophageal varices from rupturing and bleeding.
Controlling portal hypertension
Controlling portal hypertension is usually the first step in lowering the risk of bleeding. This may be achieved through the use of the following treatments and medications:
- Beta-blockers. A doctor or other HCP may prescribe beta-blocker medications, such as propranolol, to lower your blood pressure.
- Endoscopic sclerotherapy. Using an endoscope, a doctor or other HCP will inject a medication into your swollen veins that will shrink them.
- Endoscopic variceal ligation (banding). A doctor or other HCP will use an endoscope to tie off the swollen veins in your esophagus with an elastic band so they can’t bleed. They’ll remove the bands after a few days.
You may need additional treatments if your esophageal varices have already ruptured.
After bleeding has begun
Endoscopic variceal ligation and endoscopic sclerotherapy are generally preventive treatments. However, a doctor or other HCP can also use them if your esophageal varices have already begun to bleed.
A medication called octreotide may be used as well. This drug will lower the pressure in the swollen veins by tightening the blood vessels and reducing blood flow.
If the bleeding recurs, a doctor or other HCP will likely recommend a surgical shunting procedure.
There are two main types of shunting procedures used for bleeding esophageal varices. These include:
- Transjugular intrahepatic portosystemic shunting (TIPS). The TIPS procedure uses an X-ray to guide the placement of a device that creates new connections between the portal vein and hepatic vein in your liver. This connection creates a diversion for the blood flow.
- Distal splenorenal shunt procedure (DSRS). DSRS is a more invasive surgical shunting procedure than TIPS. It involves connecting the main vein from the spleen to the vein of the left kidney.
In rare cases, a liver transplant may be necessary if a person has severe cirrhosis and/or rebleeding continues to occur after treatment.
Esophageal varices are more likely to bleed if you have:
- large esophageal varices
- red marks on the esophageal varices as seen on a lighted stomach scope (endoscopy)
- portal hypertension
- severe cirrhosis
- a bacterial infection
- excessive alcohol use
- excessive vomiting
- severe coughing bouts
Speak with a doctor or other HCP about your risk of developing esophageal varices, especially if you have a family history of liver disease.
The best way to prevent esophageal varices is to correct the underlying cause.
If you have liver disease, consider the following preventive measures to reduce your risk of developing esophageal varices:
- Eat a balanced diet that largely consists of low salt, lean protein, whole grains, fruits, and vegetables.
- Avoid drinking alcohol.
- Maintain a healthy weight.
- Lower your risk for hepatitis by practicing safer sex. Don’t share needles or razors, and avoid contact with the blood and other bodily fluids of a person who has hepatitis.
It’s important to stick with your treatment plan and attend regular appointments with a doctor or other HCP if you have esophageal varices.
Call your local emergency services, such as 911 in the United States, or go to the hospital immediately if you believe your esophageal varices have ruptured.
Bleeding esophageal varices are life threatening and can lead to serious complications.
Bleeding will continue to occur if the condition isn’t treated promptly. Without treatment, bleeding esophageal varices can be fatal.
After you receive treatment for bleeding esophageal varices, you must attend regular follow-up appointments with a doctor or other HCP to make sure the treatment was successful.