Bleeding esophageal varices

Definition

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

Causes

Bleeding varices are a life-threatening complication of portal hypertension (increased blood pressure in the portal vein caused by liver disease). The portal vein carries blood from the intestine to the liver. Increased pressure causes the veins to balloon outward. The vessels may rupture, causing vomiting of blood and bloody stools or tarry black stools. If a large volume of blood is lost, signs of shock will develop. Any cause of chronic liver disease can cause bleeding varices.

Symptoms

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

Exams and Tests

Physical examination:

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

Tests to determine where the bleeding is coming from and detect active bleeding include the insertion of a tube through the nose and down into the stomach to look for signs of bleeding.The tube is known as a nasogastric or "NG" tube. Tests to visualize the varices include EGD (esophagogastroduodenoscopy).

Treatment

The goal of treatment is to stop acute  bleeding as soon as possible, and treat persistent 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 airway and prevent blood from going down into the lungs.

In endoscopic therapy, 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 prophylactic (preventive) therapy.

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

In the transjugular intrahepatic portosystemic shunt (TIPS) procedure, a catheter is extended 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 .

Octreotide and vasopressin are medications that may be used to decrease portal blood flow and slow bleeding.

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

Outlook (Prognosis)

Bleeding recurs frequently without treatment. Bleeding esophageal varices are a serious complication of liver disease and carry a poor prognosis (probable outcome). Liver transplantation should be considered for patients with bleeding varices from liver disease.

Possible Complications

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

When to Contact a Medical Professional

Call your health care provider if significant episodes of vomiting blood or black tarry stools occur.

Prevention

Treatment of the underlying causes of liver disease may prevent bleeding. Preventive treatment of varices with medications such as beta blockers or with endoscopic banding may be helpful in preventing bleeding. Evaluation for liver transplantation should also be considered.

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