Esophageal Varices - Abnormally Enlarged Veins

Introduction:

Esophageal varices are enlarged dilated veins in the lining of the esophagus. The esophagus is a part of the digestive tract that connects the throat to the stomach, and it is also known as the food pipe as it carries the food from the mouth to the stomach. Esophageal varices usually occur in patients with severe liver disease. This condition occurs when the normal blood flow to the liver is blocked or stopped because of scar tissue or a clot in the liver. This forces the blood to flow into the smaller blood vessels that can not carry large volumes of blood, leading to enlarged blood vessels. This condition is life-threatening as the blood vessels can leak blood or rupture.

What Is the Cause of Esophageal Varices?

Esophageal varices are often seen in people with liver disease. The liver is responsible for cleansing toxins from the blood, and the blood vessel that supplies blood to the liver is the portal vein. The blood flow to the liver is slowed or blocked because of liver disease. The blood flow builds up and increases the pressure in the portal vein. Because of the high blood pressure in the portal vein, called portal hypertension, blood is pushed into the nearby blood vessels, which include the blood vessels in the esophagus. These blood vessels are thin-walled and closer to the surface. The excess blood caused these blood vessels to expand and balloon. Sometimes these swollen veins rupture and bleed. Varices can also occur in the small blood vessels in the upper region of the stomach.

The causes of esophageal varices are:

• Blood Clot (Thrombosis) - A blood clot in the blood vessels supplying blood to the liver can cause esophageal varices.

• Scarring of the Liver (Cirrhosis) - A lot of liver diseases like hepatitis infection, fatty liver disease, alcoholic liver disease, and bile duct disorder can result in cirrhosis causing esophageal varices.

• Parasitic Infection - Parasitic infections like schistosomiasis can damage the liver and cause esophageal varices.

What Are the Signs and Symptoms of Esophageal Varices?

The signs and symptoms of esophageal varices are not visible, and the patients are unaware that they suffer from it until they bleed. The signs and symptoms of bleeding esophageal varices are :

1. Vomiting large amounts of blood when the bleeding is severe and sudden.

2. Black, tarry stools - When the bleeding is less severe, the person may swallow the blood.

3. When the bleeding is uncontrolled, the person might show the following symptoms -

• Irregular breathing.

• Clammy and pale skin.

• Loss of consciousness.

What Are the Risk Factors for Developing Esophageal Varices?

Not every patient who has esophageal varices will have bleeding. The chances of bleeding esophageal varices are high in patients with :

• Severe Cirrhosis or Hepatic Failure - Usually, the more severe the liver disease is, the patient is more likely to have bleeding esophageal varices.

• Red Marks on the Varices - When the esophageal varices are examined using an endoscope (a thin, flexible tube), some varices may show red spots or red marks. These red marks are indicative of a high risk of bleeding.

• Large Varices - The risk of bleeding increases with larger esophageal varices.

• High Portal Blood Pressure - As the blood pressure increases in the portal vein, the chances of bleeding also increase.

• Ongoing Alcohol Consumption - If the condition is alcohol-related and the person continues to drink alcohol, the risk of bleeding esophageal varices is far greater.

How to Diagnose Esophageal Varices?

The diagnostic test recommended by the doctor for the diagnosis of the esophageal varices are:

• Upper Gastrointestinal Endoscopy - It is the preferred method of screening for esophageal varices in which the doctor places an endoscope (a thin, long flexible tube with attached light and camera) into the esophagus, stomach, and the small intestine through the mouth. The doctor checks for dilated enlarged veins and red spots on them, which indicate a significant risk of bleeding. This procedure is helpful in diagnosis and also in treatment.

• Imaging Tests - Doppler ultrasound and abdominal CT (computed tomography) scan of the portal and splenic veins suggest the presence of esophageal varices. Transient elastography is an ultrasound test that measures scarring in the liver and portal hypertension that may lead to esophageal varices.

• Capsule Endoscopy - In this test, the patient is asked to swallow a vitamin-sized capsule containing a camera that takes pictures of the esophagus as it goes down the gastrointestinal tract. This option is for those patients who do not want to undergo an endoscopic procedure. This procedure is only diagnostic and not therapeutic.

What Are the Complications of Esophageal Varices?

The only and most serious complication of esophageal varices is bleeding. If the patient has a bleeding episode, the risk of another bleeding episode increases greatly. If the patient loses a lot of blood, he or she can go into shock, which can lead to death.

What Are the Treatment Options for Esophageal Varices?

The main focus during the treatment of the esophageal varices is to prevent the bleeding of the varices. The bleeding esophageal varices are life-threatening. In case the bleeding occurs, the focus of the treatment shifts to stopping the bleeding.

1. Treatment to Prevent Bleeding - In order to prevent bleeding esophageal varices, it is important to control the blood pressure in the portal vein. Treatment includes:

• Medicines for Reducing the Blood Pressure - Beta-blockers such as Propranolol, Nadolol, and Carvedilol are administered, which may help in reducing the blood pressure in the portal vein and reducing the risks of bleeding esophageal varices.

• Endoscopic Band Ligation - This procedure uses elastic bands to tie off bleeding veins. The doctor uses an endoscope to pull the varices into a chamber at the end of the scope through suction and wraps them with an elastic band, which strangles the veins so that they do not bleed. This procedure might have some complications, such as bleeding and scarring of the esophagus.

2. Treatment When the Varices Are Bleeding - Immediate treatment is needed in case of bleeding esophageal varices as the condition is life-threatening. Treatment focuses on stopping the bleeding and reversing the effects of blood loss. It includes:

• Using Elastic Bands to Tie off the Bleeding Veins - The doctor wraps elastic bands around the esophageal varices using an endoscope during endoscopy.

• Medicines to Slow Blood Flow Into the Portal Vein - Medicines such as Octreotide and Vasopressin help in slowing down the flow of the blood in the portal vein. The medication generally continues for five days after the bleeding episode.

• Transjugular Intrahepatic Portosystemic Shunt (TIPS) - When the endoscopic procedure and medicines are unsuccessful in controlling the bleeding, the doctors recommend a transjugular intrahepatic portosystemic shunt procedure. This procedure is done to divert the blood flow away from the portal vein. A shunt is an opening created between the portal vein and the hepatic vein. The blood vessel carrying blood from the liver to the heart is known as the hepatic vein. The shunt helps in reducing the blood pressure in the portal vein and stops bleeding from the esophageal varices. This procedure has some serious complications like mental confusion, and liver failure, which is caused due to the toxins that the liver normally would filter is passed through the shunt directly into the bloodstream. This procedure is used when all the other treatments have failed.

• Balloon Tamponade - when the endoscopic procedure and medicine fail, another treatment option that the doctors prefer is balloon tamponade. The doctors try to stop bleeding by applying pressure to the bleeding esophageal varices. It is done by inflating a balloon to put pressure on the esophageal varices for about 24 hours. This procedure has a high risk of bleeding recurrence after the balloon is deflated. Another serious complication attached to this procedure is a rupture in the esophagus, which can lead to death.

• Blood Transfusion - The patients are given a blood transfusion to replace the volume of the lost blood and a clotting factor that helps in stopping the bleeding.

• Antibiotics - The doctors give antibiotics to the patients to prevent infection as there is an increased risk of infection with bleeding.

• Liver Transplant - A liver transplant is an option for patients with severe liver disease and for those who have recurrent episodes of esophageal varices.

Conclusion:

Esophageal varices can generally be seen in patients with serious liver disease. As of now, there is no treatment that can prevent the development of esophageal varices in patients with cirrhosis. It is important to maintain a healthy liver by avoiding alcohol, eating a healthy diet, maintaining a healthy weight, and practicing habits that reduce the risk of hepatitis. The patients who had an episode of bleeding esophageal varices should take extra care as the recurrence rate of another episode of bleeding increases in such cases.