Esophageal varices are swollen veins in the lining of the lower esophagus near the stomach. Gastric varices are swollen veins in the lining of the stomach. The swelling of these veins is caused by liver disease. Swollen veins in the esophagus or stomach resemble the varicose veins that some people have in their legs. Because the veins in the esophagus are so close to the surface of the esophagus, swollen veins in this location can rupture and cause dangerous bleeding.

Esophageal varices almost always occur in people who have cirrhosis of the liver. Cirrhosis causes scarring of the liver, which slows the flow of blood through the liver. Scarring causes blood to back up in the portal vein, the main vein that delivers blood from the stomach and intestines to the liver. This "back up" causes high blood pressure in the portal vein and other nearby veins, and this is called portal hypertension. The backup of blood forces veins to enlarge in the vicinity of the stomach and esophagus. Esophageal varices usually have enlarged, irregularly shaped bulbous regions (varicosities) that are interrupted by narrower regions. Because the blood pressure inside the varices is higher than inside normal blood vessels, and the walls of the vessels (and esophagus) are thin, the veins rupture easily and can bleed profusely.

Portal hypertension often does not cause any symptoms, and sometimes is discovered only when the varices bleed. When significant bleeding occurs, a person will vomit blood, often in large amounts. People with massive bleeding feel dizzy and may lose consciousness. Some people bleed in smaller amounts over a longer period, and they swallow the blood rather than vomit. Their stools may contain red or tarry-black blood. People with bleeding from the esophagus usually also have symptoms of cirrhosis of the liver.

To diagnose esophageal varices, a doctor will use an instrument called an endoscope, a thin, flexible tube with a camera at its tip that is inserted through the mouth so the doctor can see the walls of the esophagus and search for the source of bleeding. If bleeding is occurring in the esophagus, this procedure will be done as an emergency. Tiny instruments may be attached to the endoscope to provide treatment at the same time.

Bleeding from esophageal varices can stop on its own or with treatment. However, bleeding esophageal varices can be fatal, particularly in people with severe liver disease. Half or more of people who survive episodes of bleeding from esophageal varices will have the problem return during the first one to two years. The risk of recurrence can be reduced with treatment.

The best way to prevent esophageal varices is to reduce your risk of cirrhosis. The main cause of cirrhosis is alcohol abuse. Patients with hepatitis B or hepatitis C also are at risk of developing cirrhosis. Intravenous drug use is a major risk factor for hepatitis B and C. Children, young teens and all health care workers and older adults at risk of hepatitis B should be vaccinated against the disease. There is no vaccine to prevent people from contracting hepatitis C.

If you have esophageal varices, treatment may be able to prevent bleeding. This treatment includes endoscopic banding or sclerotherapy (described in the Treatment section) to shrink the varices. Drugs to reduce portal blood pressure -- such as propranolol (Inderal), nadolol (Corgard) and isosorbide mononitrate (Isordil, Sorbitrate) -- also can be used alone or in combination with endoscopic techniques.

Emergency treatment for bleeding esophageal varices begins with blood and fluids given intravenously (into a vein) to compensate for blood loss. At the same time, intravenous drugs may be given to decrease blood flow to the intestine. Efforts are then made to stop the bleeding. Endoscopy is done to identify the site of the bleeding.

If the bleeding is caused by ruptured esophageal varices, one of two endoscopic treatments may be used:

• Band ligation. A rubber band is used to tie off the bleeding portion of the vein.



• Sclerotherapy. A drug is injected into the bleeding vein, causing it to constrict (narrow). This slows the bleeding and allows a blood clot to form over the ruptured vessel.

Bleeding esophageal varices can result in a very large amount of blood loss and many units of blood may need to be transfused. Once the bleeding is controlled, treatment is done to try to prevent more bleeding in the future. In some cases, more band ligation procedures are done to try to get rid of the varices. For people with severe cirrhosis, a procedure to minimize pressure in the veins is sometimes necessary. Pressure is reduced by creation of a "shunt," which is a channel or "pipeline" that diverts blood away from the high-pressure veins. Options for creating a shunt include:

• Transjugular intrahepatic portal-systemic shunt (TIPS). Usually blood must trickle through liver tissue in order to travel from the veins below the liver (the portal veins) into the three veins that drain the liver from above (the hepatic veins). This "trickling" is too slow when the liver is scarred. A TIPS procedure implants a wide tube (a stent) within the liver so that much of the blood traveling through the liver can flow quickly through the liver.
  
  For this procedure, a catheter is threaded through a vein in the neck into the liver. The tip of the catheter holds a stent, a wire mesh tube which is designed to prop open a vein or artery. In this case, once the catheter and the stent it holds have been threaded from veins above the liver to the top surface of the liver, the tip of the catheter is used to purposefully puncture the wall of the vein, and a short span of the catheter is forced through the tissue of the liver itself. When the tip of the catheter nears the lower portion of the liver, it can be maneuvered into the portal vein. The stent is then expanded so that a tunnel is created between the veins above and below the liver, creating a pipeline for blood flow. Under X-ray guidance, the stent is placed within the liver to allow blood to flow more easily through the portal vein. This treatment reduces the excess pressure in the esophageal varices, and decreases the risk of bleeding in the future. A TIPS procedure is done by a specialized radiologist (interventional radiologist).



• Surgery. Rarely, patients need to have an operation to create a shunt to divert portal blood away from the liver into another vein. Like TIPS, this treatment reduces the pressure in the varices.

Bleeding from esophageal varices can be life threatening. Patients can lose massive amounts of blood in a short time, causing extremely low blood pressure and shock. If you vomit blood or notice blood in your stool, you should always seek immediate medical attention, especially if you have cirrhosis or a history of alcohol abuse or chronic hepatitis.

At least 50% of people who survive bleeding esophageal varices are at risk of more bleeding during the next one to two years. The risk can be reduced by endoscopic and drug treatments.

If a TIPS procedure or other shunt procedure is required, some blood will pass through the liver without being thoroughly detoxified by enzymes within the liver. Natural waste products in the blood can accumulate if the blood is not detoxified by the liver, and because of this some people who have had a TIPS procedure develop symptoms of confusion, called encephalopathy. Medication can reduce symptoms of encephalopathy.

American College of Gastroenterology (ACG)
P.O. Box 342260
Bethesda, MD 20827-2260
Phone: 301-263-9000
http://www.acg.gi.org/

American Gastroenterological Association
4930 Del Ray Ave.
Bethesda, MD 20814
Phone: 301-654-2055
Fax: 301-652-3890
E-mail: webinfo@gastro.org
http://www.gastro.org/