Bleeding Esophageal Varices

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 go to the nearest emergency room right away if you’re showing symptoms of bleeding esophageal varices.

Esophageal varices are unlikely to cause symptoms unless they have ruptured. When this happens, you may experience:

• hematemesis (blood in your vomit)
• stomach pain
• lightheadedness or loss of consciousness
• melena (black stools)
• bloody stools (in severe cases)
• shock (excessively low blood pressure due to blood loss that can lead to multiple organ damage)

Call 911 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. Esophageal varices are a direct result of high blood pressure in the portal vein. This condition is called portal hypertension. It 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 is the most common cause of portal hypertension. Cirrhosis is a severe scarring of the liver that often develops due to excessive alcohol consumption or serious infections, such as hepatitis. Another potential cause of portal hypertension is 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 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
• constipation
• severe coughing bouts

Speak with your doctor about your risk of developing esophageal varices, especially if you have a family history of liver disease.

To diagnose esophageal varices, your doctor 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: Your doctor may prescribe beta-blocker medications, such as propranolol, to lower your blood pressure.
• Endoscopic sclerotherapy: Using an endoscope, your doctor will inject a medication into your swollen veins that will shrink them.
• Endoscopic variceal ligation (banding): Your doctor 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, your doctor 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.

Transjugular intrahepatic portosystemic shunt (TIPS) procedure is another potential treatment option for recurrent bleeding esophageal varices. This is a procedure that uses an X-ray to guide the placement of a device that creates new connections between two blood vessels in your liver.

A small tube is used to connect the portal vein with the hepatic vein. The hepatic vein transports blood from the liver to the heart. This connection creates a diversion for the blood flow.

Distal splenorenal shunt procedure (DSRS) is another treatment option but is more invasive. This is a surgical procedure that connects the main vein from the spleen to the vein of the left kidney. This controls bleeding from esophageal varices in 90 percent of people.

In rare cases, a liver transplant may be necessary.

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 your doctor to make sure the treatment was successful.

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 healthy diet that largely consists of low salt, lean protein, whole grains, fruits, and vegetables.
• Stop drinking alcohol.
• Maintain a healthy weight.
• Lower your risk for hepatitis by practicing safe sex. Don’t share needles or razors, and avoid contact with the blood and other bodily fluids of an infected person.

It’s very important to stick with your treatment plan and attend regular appointments with your doctor if you have esophageal varices. Call 911 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.