Esophageal varices are varicose veins in the esophagus that are generally associated with advanced liver failure. For example, about 50 percent of cirrhosis cases are associated with esophageal varices, which in turn have an increased risk of life-threatening bleeding at 30 percent.
What are esophageal varices?
Esophageal varices are varicose veins or dilations (varices) of the submucosal veins of the esophagus, which are generally due to portal hypertension resulting from progressive liver damage (including cirrhosis). As a result of the impairment of the liver, blood can no longer flow unimpeded from the liver to the heart, so it seeks escape routes via the veins of the esophagus. Bag-like dilations, called varicose veins or varices, develop. In many cases, esophageal varices are discrete or asymptomatic and, in addition to the characteristic symptoms of liver cirrhosis (including ascites, hepatic skin signs such as lacquered lips and tongue, dilatation of the arterial vessels of the skin), are manifested by a feeling of fullness and/or pressure in the upper abdomen and splenomegaly (splenomegaly) as an indicator of portal hypertension. In addition, esophageal varices are associated with gastric varices in some affected individuals as well as gastropathia hypertensiva (dilatation of gastric mucosal veins).
Causes
Esophageal varices most commonly result from portal hypertension (increased portal pressure). Increased portal vein pressure is usually caused by cirrhosis (advanced liver disease), which can be caused by alcohol abuse or hepatitis. Thus, esophageal varices develop in about half of all people affected by cirrhosis. As a result of the damage, portal congestion forms in the liver because the blood is no longer able to flow freely. As a result, bypass circulations, so-called portocaval anastomoses, manifest in the area between the portal vein and the inferior vena cava, which include esophageal varices as well as hemorrhoids. In addition, cardiac regurgitation and thrombosis or tumors in the splenic vein, inferior vena cava, and/or portal vein can lead to esophageal varices.
Symptoms, complaints, and signs
Varicose veins in the esophagus do not call attention to themselves by any symptoms in the early stages. Occasionally, a slight taste of blood can be perceived in mild lesions caused by regurgitated saliva. If esophageal varices tear severely, affected persons complain of sudden nausea. At the same time, they suddenly vomit larger amounts of blood. The gushing sputum is often mixed with black stomach contents (coffee grounds vomiting). Such an outbreak of discomfort is considered a medical emergency. A rapid heartbeat attempts to compensate for the unexpected blood loss. Without assistance from companions, sufferers are at risk of unconsciousness. There is a high risk of death from potential circulatory collapse for the patient if emergency measures are not taken. Moderate bleeding initially leads to a drop in performance. Pallor and problems with breathing occur as a result. If the blood reaches the digestive tract, it triggers discomfort in the stomach area for many people. Feelings of pressure and fullness join in. Contact with stomach acid results in a distinctive black coloration of the next bowel movement. Tarry stools are considered a sure warning sign of a bleeding cause in the digestive tract. Because esophageal varices often develop as a complication of portal hypertension, people suffer from very specific signs of this underlying condition. These include ascites (abdominal dropsy), clearly protruding veins in the area of the belly button, and changes in the skin (bill skin). Visibly dilated blood vessels manifest themselves in fine or extensive red discolorations on the face, upper body, hands and feet. Distinctive features include the patent lip or patent tongue.
Diagnosis and course
In all cases, esophageal varices are diagnosed on the basis of an endoscopic examination of the esophagus (esophagogastroduodenoscopy), which provides information about the characteristics of the esophageal structures and the specific stage of the disease present. In the first stage, ectasias (sac-like dilations) of the affected veins are present, which disappear with endoscopic air insufflation.In the second stage, isolated varices manifest, which protrude about 1/3 into the lumen (inner space) of the esophagus and do not pass even with air insufflation. The third stage is characterized by increasing narrowing of the esophageal lumen (up to 50 percent). In addition, damage to the epithelium may become apparent by means of reddish spots. In the fourth stage, the lumen of the esophagus is completely filled by the variceal strands and a large number of mucosal erosions are detectable. If left untreated, esophageal varices can perforate and lead to life-threatening hemorrhage, with a lethality of about 30 percent even with treatment.
Complications
Most esophageal varices carry thin vessel walls. Bleeding as a result of vessel rupture is therefore a potential complication regardless of therapy. This primarily affects patients with bypass circuits of larger circumference. Smaller hemorrhages manifest themselves in the form of symptoms such as black-colored stools (tarry stools), while larger vascular ruptures as a result of high blood loss manifest themselves in life-threatening shock conditions and prompt emergency medical treatment. In order to prevent life-threatening bleeding, treating physicians assess the bleeding propensity of varicose veins in the esophagus via endoscopic findings and the pressure gradient in the portal vein area. From an endoscopic point of view, abnormalities such as so-called “cherry red spots” indicate an increased risk of bleeding and call for preventive measures such as the administration of beta-blockers. With regard to the pressure gradient, the same applies to values of 12 mmHg and above, with severely elevated pressure values suggesting combined treatment approaches with beta-blockers and nitrates. These preventive treatment steps are not suitable for the therapy of acute bleeding. Specialists treat the acute event at success rates of up to 90 percent by immobilizing affected veins with agents such as polydocanol or histoacryl. Although endoscopic treatment does not always prevent the onset of variceal bleeding in the esophagus, the risk of secondary bleeding after untreated initial bleeding increases to up to 80 percent. In patients with concomitant liver cirrhosis, varicose vein bleeding in the esophagus is often associated with further complications such as hepatic coma if no therapy for the liver disease is given in addition to varicose vein treatment. The highest risk of life-threatening complications results from esophageal varices for patient with untreated coagulation disorders.
When should you see a doctor?
Because esophageal varices are pathological vein dilatations located in the lower third of the esophagus, the disease is not recognizable by pain and stinging in the upper abdomen until it reaches an advanced stage. The patient suffers from persistent nausea. In addition, there is a constant feeling of pressure and fullness in the area of the stomach. Slight bleeding of the varices leads to a drop in performance and permanent states of exhaustion. The patient permanently has an underlying taste of blood in his mouth. His salivary expectoration is bloody. The patient’s face shows a non-specific pallor. It is not uncommon for patients to have concomitant abdominal dropsy and conspicuous hepatic skin signs. The skin and eyes show yellowing. The patient tends to bleed or bruise very quickly. Esophageal varices are clearly evident by gushing vomiting of blood. The stool is tarry and black. The patient tends to be dizzy or even unconscious. The pulse is greatly elevated. These are life-threatening warning signs. Circulatory collapse is imminent. In this case, medical assistance should be sought as soon as possible and emergency measures should be initiated.
Treatment and therapy
As part of causal therapy, the underlying disease should always be treated in esophageal varices. In addition, various endoscopic surgical procedures are available for the treatment of esophageal varices. In sclerotherapy, a so-called sclerosant (hardening agent) is injected into the varicose vein with the aid of an endoscope. As a result, the varicose vein closes so that blood can no longer flow into it and the tissue dies. Obliteration therapy, which is generally used for bleeding varicose veins, obliterates (blocks) the affected section of vein with a liquid tissue adhesive that hardens immediately after injection into the affected vein.Another surgical measure is the so-called ligation procedure, in which the varicose vein to be ligated is aspirated by means of a cap applied to the endoscope and then encircled with a rubber ring or thread. As a result of this constriction, thrombosis develops, leading to tissue death. In addition, a balloon-like probe (including the Sengstaken-Blakemore probe, Linton probe) can be used to stop bleeding in advance. Blood flow in the affected area can also be reduced by somatostatin or vasopressin. General measures after esophageal variceal perforation include continuous monitoring of vital signs, intubation if necessary, preventive antibiotic therapy because of the threat of sepsis, and intravenous volume administration. Prophylactic drug (beta blockers, spironolactone, nitrates) or surgical (shunt surgery) therapy may be indicated to prevent recurrence and/or bleeding of esophageal varices.
Prevention
The manifestation of esophageal varices can be prevented by consistent and early therapy of the underlying disease. If cirrhosis of the liver is present, strict abstinence from alcohol should be maintained to prevent esophageal varices.
What you can do yourself
People who have been diagnosed with esophageal varices should pay very special attention to their food consumption in everyday life. Foods that have solid or pointed elements in them in any form should not be eaten. In the case of fish, rusks or crispbread, the components of the food may cause complications during the act of swallowing. Likewise, when eating stone fruit, meticulous care should be taken to ensure that the fruit seeds have been removed in advance. Not only raw foods, but also processed products, such as cakes, should be checked before being ingested. While eating, all components of the food should be sufficiently ground in the mouth by the process of purchase. Swallowing large quantities of food should be refrained from. Damage to the vascular walls of the esophagus could occur at any time. Since this can lead to severe bleeding within a short time, a life-threatening condition can develop within a few minutes. Foreign objects, such as toys, objects or coins, should not be placed in the mouth. There is a risk that these can unintentionally enter the throat and be swallowed. If the person concerned wears braces or dentures, they should be checked daily to ensure that they are firmly in place. If looseness is evident, a doctor must be consulted immediately.
