Esophageal Varices

Esophageal varices are enlarged, swollen veins in the lower part of the esophagus, the tube that connects the throat to the stomach. They develop when blood flow to the liver is blocked, typically due to portal hypertension. The portal vein system normally carries blood from the digestive organs to the liver. When this flow is obstructed, blood backs up and seeks alternative routes, often through smaller, more fragile veins in the esophagus. These veins are not designed to handle high pressure, causing them to swell and become prone to rupture and severe bleeding, which is a life-threatening medical emergency.

Causes:

Esophageal varices are almost always a complication of severe liver disease, primarily cirrhosis, which leads to portal hypertension. The underlying cause is the increased pressure in the portal vein system.

• Portal Hypertension (Main Cause):
  • This is the elevated blood pressure in the portal vein and its branches.
  • It’s usually caused by an obstruction to blood flow through the liver.
• Cirrhosis (Most Common Underlying Condition):
  • Cirrhosis is the most frequent cause of portal hypertension, which in turn leads to varices. It results from chronic liver damage due to:
    • Chronic alcohol abuse.
    • Chronic viral hepatitis (Hepatitis B and C).
    • Non-alcoholic steatohepatitis (NASH).
    • Autoimmune hepatitis.
    • Hemochromatosis (iron overload).
    • Wilson’s disease (copper overload).
    • Bile duct diseases (e.g., primary biliary cholangitis, primary sclerosing cholangitis).
  • The extensive scarring in cirrhosis obstructs blood flow, increasing pressure in the portal vein.
• Other Causes of Portal Hypertension (Less Common):
  • Portal Vein Thrombosis: A blood clot forms in the portal vein, blocking blood flow.
  • Splenic Vein Thrombosis: A blood clot in the splenic vein can also lead to varices, often in the stomach (gastric varices).
  • Budd-Chiari Syndrome: Blockage of the hepatic veins (veins that drain blood from the liver), causing blood to back up.
  • Nodular Regenerative Hyperplasia: Abnormal growth within the liver that can compress blood vessels.

Symptoms:

Esophageal varices typically do not cause symptoms unless they rupture and bleed. Symptoms of bleeding varices are severe and indicate a medical emergency.

• No Symptoms Until Bleeding: Small or non-bleeding varices usually cause no symptoms. They are often discovered incidentally during an endoscopy performed for another reason or as part of a screening for cirrhosis complications.
• Symptoms of Bleeding Esophageal Varices (Medical Emergency):
  • Vomiting Large Amounts of Blood (Hematemesis): The most dramatic and serious symptom. Blood may be bright red or appear like “coffee grounds.”
  • Black, Tarry Stools (Melena): Due to digested blood passing through the digestive tract.
  • Lightheadedness or Dizziness.
  • Fainting (Syncope).
  • Signs of Shock: Rapid heart rate, low blood pressure, cold, clammy skin.
  • Abdominal Pain or Discomfort.
  • Confusion or Disorientation: If bleeding leads to significant blood loss or worsening hepatic encephalopathy.
• Symptoms of Underlying Liver Disease (e.g., Cirrhosis):
  • Jaundice (yellow skin/eyes).
  • Ascites (fluid in the abdomen).
  • Edema (swelling in legs).
  • Easy bruising and bleeding.
  • Fatigue.
  • Spider angiomas (spider-like blood vessels on skin).

Diagnosis:

Diagnosing esophageal varices involves assessing the presence of portal hypertension and directly visualizing the varices using endoscopy.

• Medical History and Physical Exam: The doctor will inquire about liver disease history, alcohol use, and symptoms. Signs of liver disease and portal hypertension (e.g., ascites, jaundice, enlarged spleen) may be noted.
• Endoscopy (Upper Endoscopy/Esophagogastroduodenoscopy – EGD):
  • This is the gold standard for diagnosing and evaluating esophageal varices.
  • A thin, flexible, lighted tube with a camera is passed down the throat into the esophagus and stomach.
  • Allows direct visualization of varices, assessment of their size, location, and presence of “red signs” (marks that indicate high risk of bleeding).
  • Often used for routine screening in patients with cirrhosis.
• Imaging Tests (to assess liver and portal system):
  • Abdominal Ultrasound with Doppler: Can evaluate liver damage (cirrhosis), portal vein flow, and detect ascites and splenomegaly (enlarged spleen).
  • CT Scan (Computed Tomography) or MRI (Magnetic Resonance Imaging): Provide detailed images of the liver, spleen, and portal venous system, helping to identify the cause of portal hypertension.
• Blood Tests:
  • Liver Function Tests (LFTs): To assess the degree of liver damage (e.g., elevated AST, ALT, bilirubin, prolonged INR, low albumin).
  • Complete Blood Count (CBC): To check for anemia (due to bleeding) and low platelet count (due to splenomegaly).
  • Tests for Underlying Liver Disease: e.g., viral hepatitis markers.

Treatment:

Treatment for esophageal varices focuses on preventing initial bleeding (primary prophylaxis), stopping active bleeding (acute management), and preventing re-bleeding (secondary prophylaxis). The underlying liver disease must also be managed.

• Preventing First Bleed (Primary Prophylaxis):
  • Non-selective Beta-Blockers: (e.g., propranolol, nadolol) Medications that reduce blood pressure in the portal vein system, lowering the risk of variceal bleeding. Often first-line treatment.
  • Endoscopic Variceal Ligation (EVL) / Banding: For high-risk varices (large size, red signs), elastic bands are placed around the varices during an endoscopy to constrict them and prevent bleeding.
• Managing Acute Variceal Bleeding (Medical Emergency):
  • Immediate Hospitalization and Resuscitation: IV fluids, blood transfusions to stabilize the patient.
  • Vasoconstrictor Medications: (e.g., octreotide, vasopressin) Given intravenously to constrict blood vessels, reducing blood flow to the portal system and varices.
  • Endoscopic Variceal Ligation (EVL): Performed urgently during endoscopy to band bleeding varices and stop the hemorrhage.
  • Balloon Tamponade: (Temporary measure) A balloon is inflated in the esophagus to compress bleeding varices if endoscopy is delayed or unsuccessful.
  • Antibiotics: Often given to prevent bacterial infections, which are common and serious complications of variceal bleeding.
• Preventing Re-bleeding (Secondary Prophylaxis):
  • Combination of non-selective beta-blockers and repeated endoscopic variceal ligation sessions until varices are obliterated.
• TIPS (Transjugular Intrahepatic Portosystemic Shunt):
  • A procedure where a shunt (tube) is placed through the liver, connecting the portal vein directly to a hepatic vein, bypassing the liver and significantly reducing portal pressure.
  • Used for patients with recurrent variceal bleeding despite other treatments, or for refractory ascites. Can worsen hepatic encephalopathy.
• Liver Transplantation:
  • The definitive treatment for underlying end-stage liver disease, which, if successful, resolves portal hypertension and its complications.

Regular surveillance endoscopy is recommended for patients with cirrhosis to detect varices early and initiate preventive measures. Anyone experiencing symptoms of variceal bleeding requires immediate medical attention.