Brief overview
- Treatment: vessel sclerotherapy or rubber band ligation, balloon tamponade in case of massive bleeding
- Symptoms: Bloody vomiting
- Causes and risk factors: The main cause is a shrunken liver (cirrhosis) and the resulting high blood pressure in the portal vein
- Diagnosis: esophagoscopy or gastroscopy
- Course and prognosis: A large proportion of esophageal varices bleed sooner or later, many bleedings are life-threatening
- Prevention: abstaining from alcohol lowers the risk of liver cirrhosis, the main cause of esophageal varices. Small meals prevent blood pressure from rising too high.
What are esophageal varices?
Varicose veins in the esophagus, called esophageal varices, are enlarged veins in the esophagus where blood backs up. They are caused by high blood pressure in the liver and in the area around the liver. In some of those affected, the esophageal varices rupture or burst – leading to life-threatening bleeding.
Esophageal varices are classified into different degrees of severity (classification by Paquet):
- Grade 1: The varices are extended just above mucosal level.
- Grade 3: The varices touch each other or protrude more than half the esophageal diameter into the esophageal cavity.
In addition to this classification, there are other factors that influence disease severity, according to the German Society for Digestive and Metabolic Diseases. These include the number of varicose vein strands, their localization and the presence of so-called “red color signs.” The latter are red spots or streaks on the varicose veins. They are considered a sign of an increased risk of bleeding.
Are esophageal varices curable?
If esophageal varices are discovered during an endoscopy, the physician scleroses them as a precaution. Another method to reduce the risk of esophageal variceal bleeding is the so-called rubber band ligation (variceal ligation): This involves tying off the dilated vein with a small rubber band or several rubber bands. As a result, it scars over, which prevents bleeding.
Therapy of esophageal variceal bleeding
If an esophageal variceal hemorrhage occurs, action must be taken quickly. The most important emergency measure is to stabilize the patient’s circulation. When an esophageal vein is ruptured, a lot of blood and fluid is lost in a very short time. Therefore, patients are given fluids directly into a vein and blood transfusions if needed.
In parallel, the doctor tries to stop the bleeding. Various procedures are available for this purpose:
Primarily, the physician uses endoscopic rubber band ligation (variceal ligation; as described above) for this purpose. In addition or as an alternative, in some cases he administers drugs to stop bleeding, such as somatostatin or terlipressin. They lower the blood pressure in the portal vein system.
Sometimes, in the case of esophageal variceal bleeding, the affected vessel is sclerosed during an endoscopy.
In cases of massive bleeding, a procedure known as balloon tamponade helps: a small, empty balloon is inserted into the lower esophagus and then inflated. The balloon compresses the blood vessels and thus stops the bleeding.
In the further course, patients often receive antibiotics as a precautionary measure to prevent a possible bacterial infection.
Since esophageal variceal bleeding usually occurs in cirrhosis of the liver, it is also important to prevent what is known as hepatic coma. Normally, the blood that runs into the gastrointestinal tract after bleeding is broken down with the help of liver cells. However, due to cirrhosis, the liver is no longer able to do this sufficiently. This is why toxic metabolic products often accumulate. If they enter the head via the blood, there is a risk that they will damage the brain (hepatic encephalopathy).
Therefore, the blood that is still present in the esophagus must be aspirated. The patient is also given lactulose – a mild laxative to clean out the intestines.
Prevention of rebleeding
In certain cases, it is also useful to insert a so-called “shunt” (TIPS). This means that a connection is surgically made between the portal vein and the hepatic veins, bypassing the scarred tissue of the liver. This prevents blood from taking a detour through the esophageal veins and causing new esophageal varices or enlarging existing ones.
What are the symptoms?
Esophageal varices usually do not cause any symptoms as long as they are intact. The affected persons themselves therefore do not notice them at all.
Only when esophageal varices rupture do they suddenly become noticeable: Patients then suddenly vomit a large amount of blood in gushes. Due to the loss of blood and fluid, symptoms of hypovolemic shock also develop quickly. These include, for example, cool and pale skin, a drop in blood pressure, palpitations, even shallow breathing and impaired consciousness.
Caution: An esophageal variceal hemorrhage must be treated by a doctor as quickly as possible – there is a high risk of death!
How do esophageal varices develop?
To understand this, one must take a closer look at the blood flow through the liver:
One of the ways blood is supplied to the liver is through the portal vein. This large vessel transports the blood from the intestines with the absorbed nutrients as well as from other abdominal organs such as the stomach or spleen to the liver. It functions as the central metabolic organ in which countless substances are constantly being built up, converted and broken down, and harmful substances detoxified. After passing through the liver, blood flows via the hepatic veins into the inferior vena cava and on to the right heart.
In cirrhosis of the liver, increasing scarring of the tissue causes the blood to no longer flow properly through the liver. It backs up in front of the liver in the portal vein. This causes the pressure inside the vessel to rise abnormally: portal hypertension develops.
There are also other diseases that cause portal hypertension and subsequently esophageal varices. These include right heart weakness (right heart failure) and blockage of the portal vein by a blood clot (portal vein thrombosis).
In addition to such esophageal varices caused by other diseases, there are also primary esophageal varices: these are not due to another disease, but to a congenital malformation of the vessels. However, they are very rare.
How are esophageal varices diagnosed?
Esophageal varices can be detected during an endoscopy, or more precisely, during an endoscopy of the esophagus (estrophagoscopy) or a gastroscopy (gastroscopy). A thin tube is inserted through the mouth into the esophagus and, in the case of gastroscopy, even further into the stomach. At its front end are a light source and a small camera. The camera continuously records images of the inside of the esophagus and transmits them to a monitor. Esophageal varices can usually be detected quite quickly on the images.
What is the prognosis for esophageal varices?
Over time, the increased blood flow causes the wall of the esophageal veins to thin out so much that they burst. The risk of bleeding from varicose veins in the esophagus is high. This limits the life expectancy of those affected. Life-threatening bleeding occurs in about 40 percent of esophageal varices. Fifteen percent of acute esophageal variceal bleeds result in death.
Esophageal variceal bleeding is among the leading causes of death in cirrhosis. The more advanced the cirrhosis, the more likely patients are to die from esophageal variceal bleeding.
Patients at highest risk for esophageal variceal bleeding are:
- Have already had an esophageal variceal bleed
- Continue to drink alcohol (major cause of cirrhosis).
- Have very large esophageal varices
How can esophageal varices be prevented?
Since esophageal varices most often develop as a result of cirrhosis of the liver, abstaining from alcohol – the main cause of cirrhosis – is one way to prevent varices in the esophagus.
