Variceal Hemorrhage - Causes, Symptoms, and Management

Introduction

Varices are submucosal dilated veins found commonly in the proximal stomach or distal esophagus. The two factors determining the development of varices are the degree of portosystemic shunting and continued hepatic injury. Variceal hemorrhage is a life-threatening medical emergency that causes shock or death if bleeding is not controlled quickly. Even after the bleeding is controlled, there are complications such as pneumonia, sepsis, cirrhosis, bacterial infections, hepatorenal syndrome, confusion, and coma. Therefore, the treatment options for variceal hemorrhage aim to prevent bleeding.

What Is Variceal Hemorrhage?

Variceal hemorrhage or bleeding varices refers to the bleeding of varices in the gastrointestinal tract, such as the esophagus, stomach, and rectum. The varices bleed massively but do not cause other symptoms.

What Is the Pathophysiology of Variceal Hemorrhage?

Normally, veins carry deoxygenated blood from other organs to the heart. The veins get dilated when it is difficult for the blood to leave the organ due to narrowed or blocked veins. As a result, the pressure in the system of veins increases. Blood may be re-routed through small vessels, primarily in the stomach and esophagus. Some of the blood vessels may become swollen and large, which are called varices. Due to high blood pressure, the walls of the blood vessels get thinned and ruptured, causing bleeding. Depending on the location, variceal bleeding can be esophageal, rectal, retroperitoneal, and caput medusae (appearance of swollen veins around the belly button).

What Are the Causes and Risk Factors of Variceal Hemorrhage?

The causes of variceal hemorrhage include the following:

• Portal hypertension.

• Cirrhosis (liver scarring).

The diseases mentioned above are caused by the following factors, which may eventually lead to variceal hemorrhage:

• History of alcohol use.

• Hepatitis B or C infection.

• Hemochromatosis (iron overload).

• Long-term inflammation of the liver.

• Congestive heart failure.

• Hypercoagulable states.

• Arteriovenous malformations.

The important risk factors responsible for variceal hemorrhage include the following.

1. Portal Pressure - Hepatic venous pressure exceeding 12 millimeters of mercury causes bleeding from the esophageal varices.

2. Variceal Size - The size of varices is assessed endoscopically. The risk of variceal hemorrhage increases with the size of the varices.

3. Variceal Wall and Tension - The rupture of the varices depends on the tension and radius of the varices.

4. Severity - The severity of liver diseases.

What Are the Signs and Symptoms of Variceal Hemorrhage?

The signs and symptoms of variceal hemorrhage include the following:

• Sudden and painless gastrointestinal tract bleeding.

• Hematemesis (vomiting blood).

• Black or bloody stools.

• Lightheadedness.

• Pale skin.

• Decreased blood pressure.

• Reduced urination.

• Rapid heart rate.

• Shock in severe cases.

Symptoms of the other conditions associated with variceal bleeding include the following:

• Hepatic encephalopathy.

• Splenomegaly (enlargement of the spleen).

• Ascites (fluid in the abdomen).

• Weakness.

• Confusion.

• Weight loss.

• Abdominal pain.

• Yellow skin or jaundice.

• Decreased platelets.

How to Diagnose Variceal Hemorrhage?

The diagnostic tests for variceal hemorrhage include the following:

1. The standard diagnostic procedure for variceal hemorrhage is esophagogastroduodenoscopy (EGD).

2. Esophageal capsule endoscopy is a safe and cost-effective procedure for detecting varices.

3. Endoscopy is a procedure in which a thin, flexible tube is inserted into the mouth to diagnose esophageal and gastric varices. It also detects the varices at high risk of bleeding.

4. Evaluation of coagulopathy is important as varices are associated with hepatic diseases. Laboratory tests include a complete blood count with platelets, partial thromboplastin time (PTT), prothrombin time (PT), and liver tests to diagnose hepatic diseases.

5. Imaging tests like abdominal computed tomography (CT) scans and doppler ultrasounds of the portal and splenic veins detect esophageal varices.

6. Transient elastography measures the scarring of the liver and detects portal hypertension, which may further lead to esophageal variceal hemorrhage.

7. Patients with liver cirrhosis are at increased risk of having a variceal hemorrhage. So frequent endoscopic screening is recommended even after treatment because recurrence of bleeding is common.

How to Manage Variceal Hemorrhage?

The three phases in the management of variceal hemorrhage include the following:

• Prevention of first variceal hemorrhage (primary prophylaxis).

• Control of acute hemorrhage.

• Prevention of the second hemorrhage for patients who have already bled (secondary prophylaxis).

The strategies used in the three phases are listed below:

1. Primary Prophylaxis:

• Primary prophylaxis is indicated for patients with small or large varices at risk of rupture.

• The primary pharmacological strategy to prevent variceal hemorrhage is using non-selective beta-blockers.

• The most commonly used drugs are Propranolol and Nadolol, which reduce portal pressure by producing vasoconstriction and decreasing cardiac output.

• The recommended dose of Propranolol is 20 milligrams twice daily, and Nadolol is 40 milligrams daily.

• Beta-blockers have side effects such as fatigue, breathlessness, and lightheadedness.

• Prophylactic endoscopic variceal ligation is recommended for patients with an intolerance to beta-blockers.

2. Control of Acute Hemorrhage:

• Patients with acute variceal bleeding require immediate hospital admission.

• Intravenous fluids and transfusion of red blood cells are initiated to support the patient's blood pressure.

• Transfusion of clotting factors or platelets (fresh frozen plasma) is necessary for patients with clotting abnormalities.

• Octreotide is given by intravenous route to reduce the portal-systemic pressure.

• Emergency endoscopic therapy prevents and treats variceal bleeding without surgery.

• A portosystemic shunt is recommended for patients with severe bleeding.

• A surgical or radiological portosystemic shunt reduces blood flow through the varices and controls bleeding.

• Transjugular intrahepatic porta-systemic shunt (TIPS). It is the most commonly used non-surgical procedure to control life-threatening bleeding. Radiologists perform TIPS insertion in the X-ray department. First, a needle is inserted through the jugular vein in the neck, then enters the hepatic vein, and finally enters the portal vein. Next, an inflatable catheter tube with a balloon tip is used to widen and open the section between the portal and hepatic vein. As a result, it reduces the pressure within the portal veins and branches.

3. Secondary Prophylaxis:

• Patients who have already survived an acute variceal hemorrhage are at high risk of recurrence and death.

• A combination of endoscopy and pharmacological interventions is an effective option for secondary prophylaxis.

• Endoscopic variceal ligation (EVL) is repeated at regular intervals until the varices are completely obliterated.

• Esophagogastroduodenoscopy (EGD) is performed every three to six months to evaluate the complications and need for EVL.

Conclusion

The treatment of variceal bleeding is complex and depends on many factors. However, recent advancements in endoscopy and pharmacological options improved the outcomes. In addition, treating the underlying cause of variceal hemorrhage prevents the recurrence of bleeding, and earlier treatment of liver disorders prevents variceal hemorrhage.