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    Bleeding esophageal varices

    Bleeding esophageal varices are enlarged veins in the walls of the lower part of the esophagus (the tube that connects your throat to your stomach) that bleed.

    Causes

    Scarring (cirrhosis) of the liver is the most common cause of esophageal varices. This scarringreduces bloodflowing through the liver. As a result, more blood flows through the veins of the esophagus.

    This extra blood flow causes the veins in the esophagus to balloon outward. If these veins break open, they can bleed severely.

    Anytype of chronic liver disease can cause esophageal varices.

    Varices can also occur in the upper part of the stomach.

    Symptoms

    People with chronic liver disease and esophageal varices may have no symptoms.

    If there is only a small amount of bleeding, the only symptom may be dark or black streaks in the stools.

    If larger amounts of bleeding occur, symptoms may include:

    • Black, tarry stools
    • Bloody stools
    • Light-headedness
    • Paleness
    • Symptoms of chronic liver disease
    • Vomiting
    • Vomiting blood

    Exams and Tests

    Physical examination:

    • Bloody or black stoolin arectal 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--the use of a camera on a flexible tube to examine the upper gastrointestinal system)
    • Tube through the nose into the stomach (nasogastric tube) to look for signs of bleeding

    Some doctors recommend EGD for patients who are newly diagnosed with mild to moderate cirrhosis. This test screens for esophageal varices and treats them before there is 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.

    Treatments for acute bleeding:

    • A small lighted tube called an endoscope may be used. The health care provider may inject the varices directly with a clotting medicine, or place a rubber band around the bleeding veins.
    • A medication that tightens blood vessels (vasoconstriction) may be used. Examples include octreotide or vasopressin.
    • Rarely atube may be inserted through the nose into the stomach and inflated with air. This produces pressure against the bleeding veins (balloon tamponade).

    Once the bleeding is stopped, varices can be treated with medicines and medical procedures to prevent future bleeding:

    • Drugs called beta blockers, such as propranolol and nadolol, are used to reduce the risk of bleeding.
    • A rubber band can be placed around the bleeding veins during an EGD procedure.
    • Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure to create new connections between two blood vessels in your liver. This can decrease pressure in the veins and prevent bleeding episodes from happening again.

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

    Patients with bleeding varices from liver disease may needmore treatment for their liver disease, including a liver transplant.

    Outlook (Prognosis)

    Bleeding often comes back without treatment. Bleeding esophageal varices are a serious complication of liver disease and have a poor outcome.

    Possible Complications

    • Encephalopathy (sometimes called hepatic encephalopathy)
    • Esophageal stricture after surgery or endoscopic therapy
    • Hypovolemic shock
    • Infection (pneumonia, bloodstream infection, peritonitis)
    • Return of bleeding after treatment

    When to Contact a Medical Professional

    Call your health care provider or go to an emergency room 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

    Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD; Practice Guidelines Committee of American Association for Study of Liver Diseases; Practice Parameters Committee of American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007;102:2086-2102.

    Garcia-Tsao G. Cirrhosis and its sequelae. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 156.

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    • Digestive system

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    • Liver blood supply

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      • Digestive system

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      • Liver blood supply

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          Tests for Bleeding esophageal varices

            Review Date: 2/18/2012

            Reviewed By: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.

            The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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