Bleeding Varices

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Bleeding Varices

Definition

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

Description

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 symptoms

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.

Diagnosis

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.

Treatment

The objective during treatment of bleeding varices is to stop and/or prevent bleeding and to restore/maintain normal blood circulation throughout the body. Patients with severe bleeding should be treated in intensive care since uncontrolled bleeding can lead to death.

KEY TERMS

Cirrhosis of the liver— A type of liver disease, most often caused by chronic alcohol abuse. It is characterized by scarring of the liver, which leads to an increase in the blood pressure in the portal veins.

Endoscopy— Medical imaging technique for visualizing the interior of a hollow organ.

Esophagus— The tube in the body which takes food from the mouth to the stomach.

Esophagogastroduodenoscopy (EGD)— An imaging test that involves visually examining the lining of the esophagus, stomach, and upper duodenum with a flexible fiberoptic endoscope.

Portal hypertension— Portal hypertension forces the blood flow backward, causing the portal veins to enlarge and the emergence of bleeding varices across the esophagus and stomach from the pressure in the portal vein. Portal hypertension is most commonly caused by cirrhosis, but can also be seen in portal vein obstruction from unknown causes.

Portal veins— The main veins that carry blood from the stomach and intestines to the liver.

Shock— A state of depression of the vital processes of the body characterized by pallor, a rapid and weak pulse, rapid and shallow respiration, and lowered blood pressure. Shock results from severe trauma, such as crushing injuries, hemorrhage, burns, or major surgery.

Transjugular intrahepatic portosystemic shunt (TIPS)— A transjugular intrahepatic portosystemic shunt (TIPS) is a radiology procedure in which a tubular device is inserted in the middle of the liver to redirect the blood flow.

Varices— A type of varicose vein that develops in veins in the linings of the esophagus and upper stomach when these veins fill with blood and swell due to an increase in blood pressure in the portal veins.

Initial treatment of bleeding varices begins with standard resuscitation, including intravenous fluids and blood transfusions as needed. Definitive treatment is usually endoscopic, with the endoscope used to locate the sites of the bleeding. An instrument, inserted along with the endoscope, is used either to inject these sites with a clotting agent or to tie off the bleeding sites with tiny rubber bands.

Repeated endoscopic treatments (usually four/six) are generally required to eliminate the varices and to prevent the recurrence of bleeding. These endoscopic techniques are successful in about 90 percent of cases.

Patients who cannot be treated endoscopically may be considered for an alternative procedure called TIPS (transjugular intrahepatic portosystemic shunt). This procedure involves placing a hollow metal tube (shunt) in the liver connecting the portal veins with the hepatic veins (veins that leave the liver and drain to the heart). This shunt lowers the pressure in the portal veins and prevents bleeding and portal hypertension. The TIPS procedure is performed by a radiologist and has become an accepted method for reducing portal vein pressure since 1992. Although the procedure continues to evolve, TIPS can routinely be created in more than 93% of patients.

Medications aimed at controlling bleeding may also be prescribed. These include propanolol, vasopressin, octreotide acetate, and isosorbide mononitrate.

Alternative treatment

Some alternative treatments are aimed at preventing the cirrhosis of the liver that often causes bleeding varices and most are effective. However, once a patient has reached the bleeding varice stage, standard intervention to stop the bleeding is required or the patient may die.

Prognosis

Bleeding varices represent one of the most feared complications of portal hypertension. They contribute to the estimated 32,000 deaths per year attributed to cirrhosis. Half or more of patients who survive episodes of bleeding varices are at risk of renewed esophageal bleeding during the first one to two years. The risk of recurrence can be lowered by endoscopic and drug treatment. Prognosis is usually more related to the underlying liver disease. Approximately 30 to 50 percent of people with bleeding varices will die from this condition within the six weeks of the first bleeding episode.

Prevention

The best way to possibly prevent the development or recurrence of bleeding varices is to eliminate the risk factors for cirrhosis of the liver. The most common cause of cirrhosis is prolonged alcohol abuse, and alcohol consumption must be completely eliminated. People with hepatitis B or hepatitis C also have an increased risk of developing cirrhosis of the liver. Vaccination against hepatitis B and avoidance of intravenous drug usage reduce the risk of contracting hepatitis.

Resources

BOOKS

Shannon, Joyce Brennfleck, editor. Liver Disorders Sourcebook. Detroit, MI: Omnigraphics, Inc., 2000.

PERIODICALS

Burroughs, Andrew K. and David Patch. "Primary prevention of bleeding from esophageal varices." New England Journal of Medicine 340 (April 1, 1999): 1033-5.

Hegab, Ahmed M., and Velimir A. Luketic. "Bleeding esophageal varices: How to treat this dreaded complication of portal hypertension." Postgraduate Medicine 109 (February 2001): 75-89.