Bleeding varices

Varices are dilated blood vessels usually in the esophagus or stomach. They cause no symptoms unless they rupture and bleed. Bleeding from varices is a life-threatening complication of portal hypertension. Portal hypertension is an increase in the pressure within the portal vein (the vein that carries blood from the digestive organs to the liver) due to blockage of blood flow throughout the liver.

This increased pressure in the portal vein causes the development of large, swollen veins (varices) within the esophagus and stomach. The varices are fragile and can rupture easily, resulting in a large amount of blood loss.

Engorged veins are called varices (plural of varix). Varices may occur in the lining of the esophagus, the tube that connects the mouth to the stomach, or in the upper part of the stomach. Such varices are called esophageal varices. These varices are fragile and can bleed easily because veins are not designed to handle high internal pressures.

Causes and symptons

The most common cause of portal hypertension is cirrhosis of the liver. Cirrhosis is scarring that accompanies the healing of liver injury caused by hepatitis, alcohol, or other less common causes of liver damage. In cirrhosis, the scar tissue blocks the flow of blood through the liver and slows its processing functions.

Bleeding varices are bleeding, dilated (swollen) veins in the esophagus (gullet), or the upper part of the stomach, caused by liver disease.

Liver disease often causes an increase in the blood pressure in the main veins that carry blood from the stomach and intestines to the liver (portal veins). As the pressure in the portal veins increases, the veins of the stomach and esophagus swell, until they eventually become varices. Bleeding varices are a life-threatening complication of this increase in blood pressure (portal hypertension). The most common cause of bleeding varices is cirrhosis of the liver caused by chronic alcohol abuse or hepatitis. Bleeding varices occur in approximately one in every 10,000 people.

Symptoms of bleeding varices include:

  • vomiting blood, sometimes in massive amounts
  • black, tarry stools
  • decreased urine output
  • excessive thirst
  • nausea
  • vomiting
  • blood in the vomit

If bleeding from the varices is severe, a patient may go into shock from the loss of blood, characterized by pallor, a rapid and weak pulse, rapid and shallow respiration, and lowered systemic blood pressure.

Treatment

Bleeding from varices is a medical emergency and treatment should be immediate. If the bleeding is not controlled quickly, a patient may go into shock or die. In severe cases, a patient may need to be placed temporarily on a ventilator to prevent the lungs from filling with blood. Aside from the urgent need to stop the bleeding, treatment is also aimed at preventing future bleeding. The following procedures help treat bleeding varices by reducing the pressure in these veins.

  • Banding: This procedure is performed by a gastroenterologist who places small rubber bands directly over the blood vessels (varices). This will stop the bleeding and eradicate the varices.
  • Sclerotherapy: This is a procedure in which a gastroenterologist directly injects the varices with a blood-clotting solution instead of banding them.
  • Transjugular Intrahepatic Portosystemic Shunt (TIPS): This is a radiological procedure in which a stent (a tubular device) is placed in the middle of the liver. The stent connects the hepatic vein with the portal vein. This procedure is done by placing a catheter through a vein in the neck. The TIPS relieves the high blood pressure that has built up in the liver.
  • Distal Splenorenal Shunt (DSRS): This surgical procedure connects the splenic vein to the left kidney vein in order to reduce pressure in your varices and control bleeding.
  • Liver transplant: A liver transplant may be done in cases of end-stage liver disease.
  • Devascularization: This surgical procedure removes the bleeding varices. This procedure is done when a TIPS or a surgical shunt is not possible or is unsuccessful in controlling the bleeding.

Prevention and diagnosis

Treating the underlying cause of bleeding varices can help prevent their recurrence and treating liver disease earlier on may prevent their development. Certain medications, including the class of heart drugs called beta blockers, may reduce elevated portal pressure and reduce the likelihood of bleeding. Long-acting nitroglycerines are also sometimes used for this purpose.

Bleeding varices may be suspected in a patient who has any of the above-mentioned symptoms, and who has either been diagnosed with cirrhosis of the liver or who has a history of prolonged alcohol abuse. The definitive diagnosis is established via a specialized type of endoscopy, namely, esophagogastroduodenoscopy (EGD), a procedure that involves the visual examination of the lining of the esophagus, stomach, and upper duodenum with a flexible fiberoptic endoscope.

Sources: Mayo Clinic, NLM

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