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Varices, Esophageal

Definition:
Serious liver diseases such as cirrhosis can cause a number of complications, including esophageal varices — abnormally enlarged veins in the lower part of the esophagus, the tube that connects your throat and stomach. Esophageal varices develop when normal blood flow to the liver is blocked. The blood then backs up into smaller, more fragile blood vessels in the esophagus, and sometimes in the stomach or rectum, causing the vessels to swell.

Esophageal varices don't produce symptoms unless they rupture and bleed — a life-threatening condition that requires immediate medical care. When not controlled, esophageal bleeding can be fatal.

To help prevent esophageal varices from bleeding, doctors usually prescribe medications that lower blood pressure. In cases where drugs aren't effective, esophageal varices may be injected with a clotting solution or tied with elastic bands to prevent bleeding. These same procedures are often used to stop acute bleeding.

Causes:
Normally, blood from your intestine, spleen and pancreas enters your liver through a large blood vessel called the portal vein. But if scar tissue blocks circulation through the liver, the blood backs up, leading to increased pressure within the portal vein (portal hypertension). This forces blood into smaller veins in your esophagus, stomach and occasionally your rectum. The excess blood causes these fragile, thin-walled veins to balloon outward and sometimes to rupture and bleed. Once varices develop, they continue to grow larger.
 
Cirrhosis: A leading cause of esophageal varices
Esophageal varices are usually a complication of cirrhosis. This serious liver disorder, which is irreversible scarring of liver tissue, often results from alcoholic liver disease or hepatitis B or C infection. Another liver disorder, primary biliary cirrhosis, which destroys the small ducts that carry bile, can also cause scarring of liver tissue and lead to esophageal varices.

Sometimes chronic conditions other than cirrhosis lead to enlarged veins in the esophagus . These conditions include:
  • Severe congestive heart failure. This occurs when your heart can't pump enough blood to meet your body's needs. In congestive heart failure, blood backs up into the vein between the liver and the right side of the heart, increasing blood pressure in the portal vein.
  • Blood clot (thrombosis). A blood clot in the portal vein or in the splenic vein, which feeds into the portal vein, can cause esophageal varices.
  • Sarcoidosis. This inflammatory disease starts in the lungs but can affect almost any organ in the body, including the liver.
  • Schistosomiasis. This parasitic infection affects millions of people in the developing world, especially parts of Africa, South America, the Caribbean, the Middle East and Southeast Asia. It can damage the liver as well as the lungs, intestine and bladder.
  • Budd-Chiari syndrome. In this rare condition, blood clots obstruct the veins that carry blood out of the liver.

Risk Factor:
Although many people with advanced liver disease develop esophageal varices, only about one-third of them have varices that bleed. Bleeding varices are more likely if you have:
  • High portal vein pressure. The risk of bleeding increases with the amount of pressure in the portal vein.
  • Large varices. The larger the varices, the more likely they are to bleed.
  • Red marks on the varices. When viewed through an endoscope — a lighted, fiber-optic instrument — some varices show long, red streaks or red spots. These marks indicate a high risk of bleeding.
  • Severe cirrhosis or liver failure. Most often, the more severe your liver disease, the more likely varices are to bleed.
  • Fluid buildup. Liver disease can cause large amounts of fluid to accumulate in your abdominal cavity (ascites). Several factors play a role in fluid buildup, including portal hypertension and changes in the hormones and chemicals that regulate fluids in your body. Having this excess fluid increases your risk of variceal bleeding.
  • Continued alcohol use. If your liver disease is alcohol-related, your risk of variceal bleeding is far greater if you continue to drink than if you stop.
  • Acid reflux. Stomach or bile acids that back up (reflux) into the esophagus erode the esophageal lining, which can trigger bleeding.
When to seek medical advice:
See your doctor if you develop signs and symptoms of liver disease, such as:
  • Weight loss
  • Small, red spider veins under your skin or easy bruising
  • Weakness
  • Fatigue
  • Yellowing of your skin and eyes and dark, cola-colored urine
  • The buildup of fluid in your abdominal cavity, which causes it to swell (ascites)
  • Itching on your hands and feet and eventually on your entire body
  • Swelling of your legs and feet from retained fluid (edema)
  • Mental confusion, such as forgetfulness or trouble concentrating (encephalopathy)
If you've been diagnosed with esophageal varices and experience bloody vomit or stools, call 911 or your local emergency services right away.

Symptoms:
About one-third of people with esophageal varices have bleeding. The signs and symptoms of esophageal bleeding range from mild to severe and include:
  • Vomiting blood
  • Black, tarry or bloody stools
  • Decreased urination from unusually low blood pressure
  • Excessive thirst
  • Lightheadedness
  • Shock, in severe cases
Diagnosis:
If you have cirrhosis or other serious liver disease, your doctor may screen you for esophageal varices, sometimes as often as every year or two. These tests are usually used to look for varices:
  • Endoscopy. For this test, your doctor inserts a thin, flexible, lighted tube (endoscope) through your mouth and into your esophagus. If any dilated veins are found, they're graded according to their size and checked for red streaks, which usually indicate a significant risk of bleeding. An esophageal endoscopy takes about 20 to 30 minutes, and the risks are generally minor. The most common side effect is a sore throat from swallowing the endoscope.
  • Imaging tests. Both computerized tomography (CT) scans and magnetic resonance imaging (MRI) may be used to diagnose esophageal varices. Unlike an endoscopy, these noninvasive tests also allow your doctor to examine your liver and circulation in the portal vein. But imaging tests aren't as effective at finding varices as endoscopy is, and they're not as useful for determining which varices are likely to bleed. For that reason, they're most often used in addition to endoscopy or when endoscopy can't be performed.
Complications:
The most serious complication of esophageal varices is bleeding. Once you have had a bleeding episode, you're at greatly increased risk of another, especially during the first 48 hours. Recurrent bleeding is common in people with esophageal varices, and the likelihood of death increases with each episode. You're at greater risk of repeat bleeding if you are older, have liver or kidney failure, or drink alcohol.

Other complications of bleeding esophageal varices include:
  • Hypovolemic shock. This occurs when your body loses at least one-fifth of its blood volume. Symptoms include low blood pressure, a rapid pulse, weakness, sweating, anxiety, mental confusion and possibly unconsciousness.
  • Encephalopathy. A damaged liver is less effective at removing toxins from your body — normally one of the liver's key tasks. The buildup of toxins can damage your brain, leading to changes in your mental state, behavior and personality (hepatic encephalopathy). Signs and symptoms include forgetfulness, confusion and mood changes, and in the most severe cases, delirium and coma.
  • Infection. Aspiration pneumonia, which occurs when you inadvertently inhale vomit or other substance into your lungs, can be a life-threatening complication of bleeding varices or of certain treatments to control them.
Treatment:
The primary aim in treating esophageal varices is to prevent bleeding. To help achieve this goal, doctors usually prescribe high blood pressure drugs (beta blockers) to reduce pressure in the portal vein. Other drugs may be used for people who don't respond to beta blockers or who have severe side effects. Sometimes the varices may be injected directly with a solution that causes them to dissolve. Or they may be tied with elastic bands before they have a chance to bleed.

Treating bleeding
Bleeding varices are life-threatening, and immediate treatment is essential. To stop bleeding, you're likely to have one of the following procedures:
  • Variceal ligation. This is the preferred treatment for bleeding esophageal varices. During the procedure, your doctor uses an endoscope to snare the varices with an elastic band, which essentially "strangles" the veins. Variceal ligation usually causes fewer serious complications than do other treatments. It's also less likely to lead to episodes of repeat bleeding.
  • Endoscopic injection therapy. In this procedure, the bleeding varices are injected with a solution that dissolves them. Bleeding is usually controlled after one or two treatments, but complications can occur, including perforation of the esophagus and trouble swallowing (dysphagia).
  • Medications. When other therapies aren't available, your doctor may initially prescribe medications to control bleeding.
  • Shunt. In this procedure, called a transjugular intrahepatic portosystemic shunt (TIPS), a small tube called a shunt is placed between the portal vein and the hepatic vein, which carries blood from the liver back to your heart. The tube is kept open with a metal stent. By providing an artificial path for blood through the liver, the shunt often can control bleeding from esophageal varices. But TIPS can cause a number of serious complications, including liver failure and encephalopathy, which may develop when toxins that would normally be filtered by the liver are passed through the shunt directly into the bloodstream. TIPS is mainly used when all other treatments have failed or as a temporary measure in people awaiting a liver transplant.
  • Liver transplant. Because no treatment is entirely successful at preventing repeat bleeding episodes and because treatments themselves pose significant risks, liver transplant is an option for people with severe or recurrent bleeding of esophageal varices. Although liver transplantation is often successful, the number of people awaiting transplants far outnumbers the available organs. You may face additional hurdles if your liver disease is the result of alcoholic hepatitis. Some medical centers won't perform liver transplants on people with alcoholic liver disease or require that you abstain from alcohol for at least six months before you're eligible for transplant surgery.
Prevention:
It's not always possible to prevent esophageal varices in people with liver disease or portal hypertension. But treating the underlying problem — alcohol abuse, iron overload, or exposure to toxic chemicals, for instance — is of primary importance. Equally important is the use of beta blockers or other medications to prevent increased blood pressure in the portal vein.
 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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