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Anatomy

Oesophageal Varices

Definition   

Bleeding oesophageal varices result from dilated veins in the walls of the lower part of the esophagus and sometimes the upper part of the stomach.

Causes, incidence, and risk factors   

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

Signs 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 localize bleeding and detect active bleeding include the insertion of a tube through the nose and down into the stomach to look for signs of bleeding (nasogastric or "NG" tube). Tests to visualize the varices include OGD (Oesophagogastroduodenoscopy).

Treatment   

The objective of therapy is to stop acute bleeding as soon as possible and manage persistent varices with medical and procedural therapies. 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 (a device with a light that can look inside of a body cavity) is used. The health care provider may directly inject the varices with a clotting agent 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 system to the systemic venous system and decreases portal venous pressure.

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

Emergency surgery may rarely be used to treat patients if other therapy fails. Portacaval shunts that pass blood to the vena cava from the portal vein by a graft or resection of the esophagus are two treatment options, but these procedures have a high death rate.

Expectations (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.

Complications   

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

Calling your health care provider   

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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ANZGOSA - Australia & New Zealand Gastric & Oesophageal Surgery Association Your Practice Online