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Definition

Esophageal varices which occur mostly in people with serious liver malfunction, is a life-threatening condition of abnormal and enlarged veins of the lower esophagus [the food pipe which connects the throat and the stomach].

Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism. In the later stages of cirrhosis, varices can occur.

When normal blood flow to the liver gets obstructed by scar tissue in the liver or a clot, blood can't flow through the liver properly, which causes an increase in blood pressure in the vein that carries blood from the gut to the liver (portal vein).The increase in blood pressure forces blood through smaller, fragile vessels that line the stomach and food pipe These smaller vessels , were originally not designed to carry a large volume of blood. This results in a leak or rupture , making the bleeding life-threatening.

Symptoms

The usual symptoms don't kick in till there are signs of bleeding which include:

  • Bleeding, in the form of vomiting blood
  • Tarry black or blood in the stools
  • Shock, in extreme cases

If a person already has liver disease, chances of varices are high if the patient displays the following which are indicative of cirrhosis.

  • Jaundice of the skin and the eyes
  • Spider nevi or formation of clusters of tiny blood vessels under the skin resembling a spider
  • Palmar erythema or reddening of the skin on the palm of hands
  • Dupuytren's contracture which is a hand deformity
  • Shrunken testicles
  • Swollen spleen
  • Ascites or fluid build-up in the abdomen

Risks of bleeding in varices

  • Portal hypertension – which is high portal vein pressure which can trigger bleeding.
  • Large varices – which are more prone to bleeding.
  • Red marks on the varices – On endoscopic examination, some varices display long red streaks and spots which are indicative of high risk of bleeding
  • Liver failure or severe cirrhosis – the severity of the liver disease increases the chance of bleeding.
  • Prolonged alcohol use – the risks of variceal bleeding go up significantly if drinking is a compulsive habit.

Diagnosis

Once cirrhosis is confirmed , the doctor will run a test to check for esophageal varices. The main tests are:

  • Esophagogastroduodenoscopy – This is the preferred procedure of endoscopy to check for dilated veins and their sizes, and presence of red streaks and spots to ascertain the risk of bleeding in the esophagus and the small intestine.
  • Imaging tests – CT and MRI scans to examine the liver and circulation in the portal vein.
  • Capsule endoscopy – Those unwilling to undergo an endoscope exam are given a vitamin-sized capsule which contains a tiny camera to take pictures of the esophagus as it passes.

Treatment

The first level of treatment is to stop and prevent bleeding which is life-threatening. Some of the treatments are:

  • Medications to lower blood pressure in the portal vein – A blood pressure drug called beta blocker is used to reduce blood pressure thereby lowering the chances of bleeding.
  • Esophageal band ligation – This procedure is performed in cases of high risk of bleeding with the aid of an endoscope that ties bleeding veins with elastic bands so that the bleeding is strangled. There is a minor risk of complication involved with this which is scarring of the esophagus.
  • Medications to slow blood flow into the portal vein – After a bleeding episode, a drug called octreotide in combination with endoscopic therapy is continued for 5 days to treat the bleeding by slowing down blood from the internal organs to the portal vein.
  • TIPS which stands for transjugular intrahepatic portosystemic shunt is a procedure that provides an additional path for blood to flow from the liver and back to the heart thereby reducing the pressure in the portal vein and stopping bleeding. But TIPS comes with its share of complications that range from liver failure to mental confusion. It is a last resort in terms of treatment or a stop-gap arrangement for someone awaiting a liver transplant.
  • Liver transplant – Those with severe liver disease or recurrent bleeding of esophageal varices are better off with a liver transplant.
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