What Is Esophageal Variceal Bleeding?

Varicose Veins in the Base of the Esophagus

Stages of Liver Disease
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Esophageal varices are varicose veins in the esophagus. These veins, like any varicose veins, can rupture and bleed very easily. Esophageal variceal bleeding is a potentially life-threatening condition that must be recognized and treated quickly. 

Causes of Esophageal Varices

Varicose veins are veins that have become engorged and the walls stretched thin.

They’re commonly found in the legs and can develop with age because, well, gravity. Veins return blood to the heart and do not have the same thick, muscular walls as arteries. The longer we stand and walk (in years, that is) the more pressure our leg veins have been subjected to.

In the esophagus, varicose veins develop not because of age and gravity, but because of hepatic portal hypertension. The portal venous system is a collection of veins that moves blood into the liver, where it is processed and detoxified. After blood leaves the liver, all fresh and detoxed, it continues to the heart where it is then sent to the lungs for an oxygen bath and to offload carbon dioxide. It's like a spa day.

In a liver with cirrhosis—scarring from an injury or illness affecting the liver—blood flow is restricted and the blood backs up into the portal system, causing the pressure in the veins to increase.

This pressure can affect blood flow throughout the region, especially from the gastrointestinal system around the stomach and base of the esophagus.

Veins in the stomach (called gastric varices) and the esophagus become engorged just like the blue, squiggly veins on the legs do. The walls of the veins also become thin and very delicate.

With little pressure, they can burst and the resulting bleeding could be severe.

Esophageal Variceal Bleeding

Esophageal variceal bleeding is very dangerous. There aren’t any symptoms of esophageal varices until the bleeding starts. Once bleeding starts, however, there are signs and symptoms. Patients with upper gastrointestinal (GI) bleeding—bleeding that originates in the esophagus and stomach, rather than in the intestines—can look for the following signs and symptoms:

  • Vomiting bright red blood or coffee-ground emesis (very dark and granular, partially digested blood)
  • Dark, tarry or sticky stools
  • Bloating
  • Rapid pulse
  • Decreased blood pressure

Very quickly, esophageal variceal bleeding can lead to shock and decreased levels of consciousness.

Emergency Treatment

In the event of esophageal variceal bleeding, immediate emergency treatment is necessary. If treated quickly, esophageal variceal bleeding may be managed through various procedures. Endoscopy (a camera is inserted into the esophagus through the mouth) can be used to find and directly address the bleeding. In addition, vasoactive drugs (drugs that affect blood pressure in acute patients) can be used to address blood pressure in actively bleeding patients.

Patients in the emergency setting will likely also receive intravenous fluids and possibly antibiotics. 

When to Call 911

Patients with sudden onset of bleeding and vomiting frank red blood or large amounts of coffee ground vomitus should go to the hospital immediately. Call 911 for any patient who is lethargic, confused, weak, dizzy, pale, cool to the touch, or sweating (diaphoretic). These patients are exhibiting signs of shock, which means the bleeding is severe and there is a high risk of death.

Paramedics will treat esophageal variceal bleeding with IV fluids, proper positioning, and vasoactive drugs.

Rapid transport to the hospital is the definitive treatment for a patient with esophageal variceal bleeding. 

Long-Term Treatment

As stated above, there aren’t any symptoms of esophageal varices unless they rupture and begin bleeding. The patient just has to know he has cirrhosis or some other form of portal hypertension and doctors have to look for the varices in the esophagus with an endoscope in order to diagnose them. If found, the doc can treat the varices prophylactically by essentially tying a rubber band around them, called band ligation.

Besides directly fixing esophageal varices through endoscopic procedures, portal hypertension can be addressed with medication. Beta blockers are most commonly used. In most patients, some combination of band ligation and medication will be used to manage esophageal varices.

The Role of Cirrhosis

Cirrhosis has several causes. The most common is chronic hepatitis C, a viral infection that can lead to swelling and damage of the liver. Chronic heavy alcohol use is also associated with liver disease and can lead to cirrhosis from fatty buildup in the liver. Nonalcoholic fatty liver disease can cause damage and cirrhosis. It is possible in obese patients and those with metabolic disorders or diabetes. Chronic hepatitis B is a potential cause of cirrhosis, but is now uncommon due to the availability of a vaccine.

Awareness of the development of cirrhosis is the best defense against the possibility of esophageal varices. Causes of cirrhosis are the biggest indicators: known liver disease, alcoholism, obesity, and diabetes. Many people with early cirrhosis won't experience symptoms at all in the beginning. As it progresses, patients may develop some or all of the following: fatigue, weakness, loss of appetite, itching, or nausea.

Cirrhosis can cause decreased levels of white blood cells that fight infection or platelets that aid in forming blood clots, and the associated decrease in liver function can lead to high levels of toxins in the bloodstream. The toxins can cause confusion or encephalopathy.  As toxins accumulate in the bloodstream, patients can develop jaundice, which is a yellowing of the sclera (whites of the eyes) and of the skin.

The Role of Portal Hypertension

Eventually, all patients with cirrhosis will develop hepatic portal hypertension. As pressure builds in the portal system, tiny veins develop. These veins provide a way for blood to go around the congested portal system and is called collateral circulation. Collateral circulation provides a way for blood to skip the liver altogether and never get cleaned. 

Besides esophageal varices, portal hypertension may cause ascites, which is a fluid build up in the abdomen. Since toxins and some minerals aren't removed properly, other complications develop from the buildup of substances and from changes in pressure gradients, such as the shift of plasma from the bloodstream to surrounding tissues. Likewise, fluid can back up into the legs and ankles, causing swelling known as edema. Portal hypertension is diagnosed by observation of one of these complications.

Cirrhosis and Esophageal Varices

Cirrhosis does not always lead to esophageal varices, but there's no clear evidence on how many patients with cirrhosis develop esophageal or gastric varices. In some studies, the instance of esophageal varices in patients with cirrhosis varied from 8 percent to 83 percent. That's a big range.

Esophageal varices have to be diagnosed with endoscopy, but once they're found, they typically get bigger and more delicate over time. patients with diagnosed esophageal varices have about a 30% chance of esophageal variceal bleeding.

Depending on the cause of the cirrhosis, the potential for esophageal variceal bleeding might be reduced through various medication therapies. Antivirals have had some success in delaying the onset of bleeding in patients with chronic hepatitis B and beta blockers are the drugs of choice for regulating hepatic portal hypertension.

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