Definition and Overview

Oesophageal varices are swollen or enlarged veins at the bottom of the oesophagus. They are a serious complication of advanced liver disease, particularly cirrhosis and portal hypertension.

Cirrhosis of the liver is a medical condition that often occurs due to excessive alcohol consumption and viral hepatitis. It is characterised by the scarring of liver tissues that prevents blood flow through the liver, causing blood pressure in the portal vein to rise. In an attempt to find new routes back to the heart, the blood causes thin-walled veins, including those at the lower end of the oesophagus, to open up. With added blood, these veins become abnormally dilated. Swollen or enlarged oesophageal varices do not produce symptoms until they leak blood and rupture. In such cases, the condition becomes a medical emergency because it can cause significant bleeding, which can result in shock and death.

Causes of Condition

Oesophageal varices occur when blood flow through the liver is blocked by scarred tissue. This causes the blood to back up and push through surrounding blood vessels, including those in the lower part of the oesophagus. Liver tissue scarring normally occurs in people suffering from the following medical conditions:

1.) Liver diseases, including:

  • Primary biliary cirrhosis - Also called primary biliary cholangitis, this liver disorder is caused by damage to the bile ducts.

  • Hepatitis infection

  • Alcoholic liver disease - Refers to the irreversible damage to the liver due to alcohol abuse.

  • Fatty liver disease - Commonly occurs in people who are overweight, have diabetes, and high cholesterol levels.

2.) Thrombosis or blood clot - Sometimes, the vein that delivers blood from the intestines and spleen to the liver is blocked due to a blood clot. This has the same effects as severe liver scarring as it also causes the blood pressure in the portal vein to rise.

3.) Schistosomiasis - A disease caused by parasitic worms, which produce eggs that usually travel to the internal organs, including the liver, where they cause scarring or inflammation.

Key Symptoms

Oesophageal varices are asymptomatic until they erupt and bleed. When this happens, the following symptoms will most likely occur:

  • Vomiting significant amount of blood

  • Lightheadedness

  • Fainting

  • Bloody or tarry stools

  • Shock - Unless immediate treatment is provided, the patient can lose a significant amount of blood, which can lead to a life-threatening condition called hypovolemic shock.

The majority of patients with oesophageal varices also suffer from a liver disease, which symptoms include:

  • Fatigue, bruising and bleeding easily, itchy skin, jaundice, and loss of appetite (symptoms of liver cirrhosis)

  • Gastrointestinal bleeding, tarry stools or blood in stools, and ascites (symptoms of portal hypertension)

Who to See and Types of Treatments Available

Oesophageal varices are commonly diagnosed with endoscopy, a procedure that uses a flexible tube equipped with a specialised camera and light to look for any signs of abnormality in the digestive tract. The endoscope is inserted through the mouth and gently advanced into the oesophagus. The device’s camera then begins to send images of the oesophagus to a monitor, which the doctor uses to look for signs of varices. If the veins are dilated and have red streaks, it means that their rupture and bleeding is imminent. To prevent serious complications, doctors usually take measures to treat them during the same procedure.

An alternative to this diagnostic test is capsule endoscopy. It does not require any form of anaesthetic and can be recommended for patients who are unwilling or unable to undergo an endoscopy exam. For this test, a vitamin-sized capsule containing a miniature camera is swallowed. As the camera advances into the digestive tract, it takes images of the oesophagus, providing the same information that can be obtained with traditional endoscopy.

Oesophageal varices can also be diagnosed using computed tomography (CT) scan and Doppler ultrasound.

Treatment of oesophageal varices focuses on preventing them from bursting and bleeding. Often, they are tied off using an elastic band (band ligation) during an endoscopy to cut their blood supply. This procedure has a small risk of complications including fever, infection, blood loss, damage to the oesophagus, abnormal heartbeat, and difficulty swallowing. However, in the majority of cases, its expected benefits outweigh the said risks.

Patients are also often prescribed with beta-blockers to reduce pressure in the portal vein.

Bleeding oesophageal varices require different forms of treatment as they are considered life threatening.

A procedure called transjugular intrahepatic portosystemic shunt (TIPS) can be considered but only in severe cases and if all other treatment methods have been tried but have been proven to be inadequate. For this procedure, a catheter is inserted into a vein in the neck and advanced in between the hepatic and portal vein where a shunt is left in place. The procedure is very effective in reducing pressure in the portal vein but can significantly increase the risk of liver failure and other serious complications. Thus, it is only performed if doctors believe that its expected benefits outweigh its complications. It is also considered in patients awaiting liver transplantation.

Blood transfusion may also be carried out if the patient has lost a significant amount of blood. Antibiotics are also prescribed to prevent infection.

In severe cases where oesophageal varices continue to bleed despite treatment, liver transplantation is recommended. This is a highly invasive procedure that removes and replaces a severely damaged liver with a healthy liver either from a deceased or living donor.

The prognosis of oesophageal varices depends on many factors including liver function and whether varices have already ruptured or are bleeding. Patients with bleeding oesophageal varices have a one-year overall mortality rate of 40% while those whose varices are dilated but not bleeding have a mortality rate of 3.4% per year.

References:

  • Judith E. Tintinalli, J. Stephan Stapczynski, O. John Ma, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. Upper Gastrointestinal Bleeding, chapter 78. New York: McGraw-Hill Medical, 2012.

  • LaBrecque D, et al. Global guidelines: Esophageal varices. World Gastroenterology Organisation. www.worldgastroenterology.org/…/esophageal-varices/esophageal-varices-English.

  • Varices. Merck Manual Professional Version. http://www.merckmanuals.com/professional/gastrointestinal-disorders/gi-bleeding/varices.

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