Esophageal variceal hemorrhage is bleeding from varicose veins within the esophagus. It is classified as a medical emergency and is life-threatening.
What is esophageal variceal bleeding?
Esophageal varices are varicose veins (varices) in the esophagus (food pipe). They are most often caused by portal hypertension. Esophageal varices cause dilatation of the veins within the esophagus. They are often a complication of advanced liver cirrhosis. However, other diseases can also be responsible for the occurrence of esophageal varices. In the course of liver cirrhosis, esophageal varices appear in about 50 percent of all patients. If esophageal variceal bleeding occurs, about 30 percent of all affected individuals die despite medical treatment. The risk of recurrence of esophageal bleeding is approximately 70 percent.
Causes
Esophageal variceal bleeding is caused by a tear in the varices in the esophagus. Varices in the esophagus form when proper drainage of blood from the liver is no longer possible, as in the case of advanced cirrhosis of the liver. The blood seeks an alternate circulation toward the heart. This creates increased pressure in the hepatic veins, resulting in blood backing up at the liver. Doctors then speak of portal hypertension. To ensure that the blood can still be transported to the heart, the blood seeks other routes via pre-existing collateral circulation. The heavy strain that occurs because of this eventually results in the formation of varicose veins. Esophageal variceal bleeding sets in when there is external injury to the thin vessel wall. These can be caused by solid food, among other things. Another trigger is increased vascular pressure during bowel evacuation, which results in abdominal compression. The varicose veins do not have muscles strong enough to regulate and stop the bleeding. Thus, the large volume of blood cannot get past the liver. This in turn causes the esophageal veins to wear out. As the disease progresses, the veins thin out more and more until they eventually burst. There are several risk factors for esophageal variceal bleeding. These include consumption of alcohol despite cirrhosis of the liver, the presence of very extensive esophageal varices, and previously experienced esophageal bleeding.
Symptoms, complaints, and signs
Symptoms appear late in esophageal varices. They are characterized by esophageal variceal bleeding, in which patients suddenly vomit blood. The blood presents gushily and in large quantities. From the esophagus, it may also flow directly into the stomach, again causing tarry stools. Because the blood comes into contact with stomach hydrochloric acid, it becomes black in color due to chemical changes. Another indication of esophageal variceal bleeding is pale skin of the affected person, which is due to significant blood loss. As a result, the drop in blood pressure occurs. Esophageal variceal bleeding is considered life-threatening and is a medical emergency. Thus, there is a risk that the patient will die in a short time. Esophageal bleeding forms the most common cause of death in liver cirrhosis. The more advanced the cirrhosis, the greater the risk of death from esophageal variceal bleeding.
Diagnosis and disease progression
Endoscopy is most commonly performed to diagnose esophageal variceal hemorrhage. For this purpose, the physician inserts a thin tube equipped with a camera into the esophagus via the oral cavity. With the aid of an attached monitor, the physician is able to examine the esophageal mucosa and identify the esophageal varices. It is also important to make a differential diagnosis with other possible causes of bleeding in the gastrointestinal tract. These may include inflammation of the gastric mucosa or gastric ulcers. It is not uncommon for esophageal variceal bleeding to take a negative course despite hemostasis. Around 30 percent of all patients die from it. In most cases, the reason for this is shock due to the massive bleeding. Even if the first hemorrhage is survived, approximately one-third of those affected die from recurrent hemorrhage.
Complications
Esophageal variceal hemorrhage is an extremely life-threatening emergency.Even with treatment, there is a high death rate. Thus, even under therapy, up to 30 percent of all patients die. Without treatment, of course, mortality is much higher, at almost 100 percent. In most cases, it is a very massive hemorrhage when the varicose veins in the esophagus, which are bulging with blood, burst open. Life-threatening blood loss occurs, which can only be stopped by quickly clamping or sclerosing the affected varices. Even if the bleeding is stopped, another 30 percent of those affected die from recurrent bleeding. The causes for the often lethal course of esophageal variceal hemorrhage are, in addition to the high blood loss and the resulting loss of fluids, asphyxiation, pneumonia due to blood aspiration during inhalation, or the development of sepsis with multiple organ failure. Because esophageal variceal hemorrhage is usually underlying severe cirrhosis of the liver, other serious and sometimes fatal complications often occur. In the acute stage, esophageal variceal hemorrhage can only be treated symptomatically. With the help of this therapy, only its immediate effects can be prevented. A real cure is only possible with the help of curative treatment of the liver insufficiency. If the cause is not eliminated, recurrent hemorrhage will always occur. Sometimes, only liver transplantation can save the patient’s life.
When should you see a doctor?
Vomiting blood or sudden acute health changes are considered to be of strong concern. Because esophageal variceal bleeding is an emergency, medical care must be sought immediately. If the affected person notices abnormalities in the area of the esophagus, if there is a sudden decrease in well-being, or if a feeling of illness appears, a physician should be consulted. If there is internal weakness, pale skin and abnormalities when going to the toilet, action is required. Blood in the urine or stool are alarm signals of the organism. If locomotion is impaired, the affected person experiences a loss of physical resilience or complains of muscle weakness, a doctor must be consulted as soon as possible. The disease can result in premature death if left untreated. Internal bleeding is present, leading to a loss of internal strength. If the affected person can no longer perform his usual physical activities without assistance or discomfort, he needs help. In acute cases, an ambulance service should be alerted and first aid measures should be applied in parallel. Characteristic is a change in the health condition within a few minutes. Therefore, a low blood pressure, a delay in the usual ability to react and cognitive impairment or disorientation should be examined and treated as soon as possible.
Treatment and therapy
In the event of esophageal variceal hemorrhage, immediate medical attention is required because of the highest risk of death. The most important therapeutic measures include stabilizing the circulation, because the patient loses a lot of blood and fluid in a short time. To counteract this condition, the patient receives fluids intravenously. If necessary, a blood transfusion can also be given. Furthermore, an attempt is made to stop the bleeding. In most cases, the physician performs an endoscopic ligation. This means that he ties off the esophageal varices with the help of clips made of plastic. Medicinal hemostasis is also possible. For this purpose, the patient is administered drugs such as somatostatin or terlipressin. They have a lowering effect on the blood pressure within the portal vein system. If severe bleeding is present, there is the option of inserting a balloon tamponade into the lower esophagus. The physician inflates the balloon in the esophagus, which compresses the blood vessels. However, because the risk of complications is considered high, endoscopy or administration of medications are primarily used. Another part of the therapy is the administration of antibiotics. In this way, a possible infection with bacteria is counteracted. Therefore, the patient receives ciprofloxacin for a few days. If esophageal variceal hemorrhage occurs in association with liver cirrhosis, it is important to prevent hepatic coma.
Prevention
Esophageal variceal hemorrhage cannot be prevented.For this reason, it is important to treat triggering underlying diseases in a timely manner.
What you can do yourself
If there is a taste of blood in the back of the throat, the affected person should consult a doctor immediately. It is an esophageal variceal bleeding medical emergency. Self-help measures are not sufficient to provide adequate health care on one’s own responsibility. Sufferers should pay more attention to their food intake in the future. Foods containing pointed or sharp elements should not be ingested under any circumstances. They include, for example, bones in fish, crispbread or rusks. These could cause damage to the esophagus. In addition, care should always be taken to optimize the purchasing process. Taken up food is to be ground sufficiently in the mouth by the teeth, before it is shifted into the throat. Even before that, it should be crushed into the smallest possible morsels. In the event of a drop in blood pressure, weakness or general malaise, a doctor should be consulted immediately or an ambulance service alerted. There is a potential threat to life that makes medical attention necessary as soon as possible. In addition, physical activities that exert a strong strain on the organism should be refrained from. The organization of leisure time as well as sporting activities should be optimized by the affected person on the basis of the organism’s possibilities.
