Esophageal varices

Overview

Esophageal varices are dilated veins in the lower wall of the esophagus. They form when pressure in the portal vein rises (portal hypertension), most often because of liver cirrhosis. Varices can rupture and cause life-threatening hemorrhage.

How they form

When the liver is damaged, blood does not pass freely through it. It looks for alternative (collateral) routes, and the small veins of the esophagus become overloaded and dilate. The risk of bleeding depends on the size of the varices, their signs on endoscopy and the severity of the liver disease.

Symptoms

They usually cause no symptoms until they bleed. Bleeding appears with:

• vomiting bright red blood or material like coffee grounds
• black, tar-like stools
• weakness, dizziness, fainting

Who should be checked

Every person with cirrhosis should be assessed for the risk of varices. In some patients with compensated cirrhosis, elastography and the platelet count help decide whether a gastroscopy is needed or whether preventive treatment can start directly.

Gastroscopy shows the presence, size and risk signs of varices.

Preventing bleeding

• Non-selective beta-blockers — carvedilol, propranolol or nadolol — lower portal pressure. Atenolol and other selective beta-blockers do not have the same effect.
• Endoscopic ligation — placing elastic bands over the varices during gastroscopy, depending on risk.

The dose of the beta-blocker is adjusted according to blood pressure, pulse, kidney function and the state of the liver. Do not start or stop them on your own.

Treating a hemorrhage

Bleeding from varices is treated only in hospital:

• stabilization of the patient and transfusion as needed
• medicines that lower portal pressure (vasoactive) and preventive antibiotics
• urgent endoscopy with ligation
• TIPS — creating a stented channel inside the liver to lower the pressure. It is used when bleeding is not controlled and, early, in selected high-risk patients. It is performed in specialized centers.

After a bleed

The risk of recurrence is high. A combination of a beta-blocker with repeated ligations, treatment of the underlying disease, complete abstinence from alcohol and regular follow-up is needed. In advanced disease, liver transplantation is considered.