Esophageal Varices

Esophageal varices are dilated veins in the wall of the esophagus that protrude into the esophageal cavity. This is a potentially life-threatening condition as the varices can become a source of sudden fatal bleeding.

Causes

Esophageal varices are usually caused by portal hypertension, which is locally elevated blood pressure in the portal vein. The portal vein is located in the abdomen and it is formed as a confluence of veins running from the intestines and the spleen. The portal vein flows into the liver and the nutrients and toxic compounds absorbed from the guts enter the liver cells being further processed. If the portal blood can not flow through the portal vein or liver tissue, it accumulates under pressure in the portal system and tries to flow by alternate paths. Such path is the system esophageal veins that connect the portal system with the vena cava. In portal hypertension, the blood flows through these esophageal vein causing their dilatation.

 

Portal hypertension most commonly occur in cases of advanced liver cirrhosis. Cirrhotic liver tissue is puts too much resistance to the blood flow and this leads to accumulation of blood in the portal vein. Similar problem occurs in local tumor oppressing the portal vein (often a liver cancer, gallbladder cancer and bile duct cancers) or in portal vein thrombosis. Of course, the most frequent cause of them all is chronic alcoholism as the reason of liver cirrhosis.

Symptoms

The esophageal veins are unable to handle the massive blood flow. They dilate and protrude into the esophageal cavity. This is not associated with any major symptom, although larger varices can cause troubles with swallowing. The most feared situation is a rupture of the varices that causes massive hemorrhage with blood vomiting and presence of black tarry blood in stool (melena). Without urgent medical assistance, the patient bleeds relatively quickly to death.

 

Esophageal varices

Diagram - very simply drawn direction of blood flow in healthy liver and in case of liver cirrhosis

 

Diagnosis

The presence of esophageal varices is confirmed by the upper GI endoscopy. In addition to diagnosis, endoscopic devices are able to treat bleeding varices. Portal vein, the local blood flow and liver tissue are well-examinable by imaging methods such as the ultrasound.

Prevention

Given that the vast majority of cases are caused by chronic alcoholism, the best prevention is to drink alcohol only with caution.

Treatment

Smaller esophageal varices are only regularly endoscopically monitored, the patient should take some medications lowering the risk of bleeding (usually beta-blockers) and it is important to prevent progression of cirrhosis. Alcohol withdrawal is absolutely necessary.

 

Larges non-bleeding varices can be endoscopically solved by so-called ligation. The doctor attaches special device to the end of the endoscope and uses it to deploy special rubber bands that strangle the varices forcing them to disappear.

 

Bleeding varices must be treated urgently. The patient must be hospitalized and stabilized (infusions, blood transfusion) to prevent development of a shock condition. Special drugs are used to lower the blood flow through the guts and thereby to decrease the portal hypertension. Bleeding varices are treated endoscopically by using injections of substances stopping the bleeding (sclerotherapy) or acute ligation. When the bleeding is unstoppable, it is possible to use a special esophageal balloon or tubular stent that mechanically compress the varices and stop the bleeding. Bleeding varices non-responding to the treatment may be solved by acute TIPS. TIPS means introduction of a special tube into the liver tissue, which connects the portal vein with hepatic veins leaving the liver, thus bypassing the liver tissue and lowering the portal hypertension. This has a great effect in therapy of esophageal varices but it has many side effects such as progression of hepatic encephalopathy.