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Bleeding esophageal varices

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Bleeding esophageal varices are enlarged veins in the walls of the lower part of the esophagus that bleed. The esophagus is the tube that connects your throat to your stomach.

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Causes
Scarring (cirrhosis) of the liver is the most common cause of esophageal varices. This scarring cuts down on blood flowing through the liver. As a result, more blood flows through the veins of the esophagus.

The extra blood flow causes the veins in the esophagus to balloon outward. Heavy bleeding can occur if the veins break open.

Any type of chronic liver disease can cause esophageal varices.

Varices can also occur in the upper part of the stomach.

Symptoms
People with chronic liver disease and esophageal varices may have no symptoms.

If there is only a small amount of bleeding, the only symptom may be dark or black streaks in the stools.

If larger amounts of bleeding occur, symptoms may include:
Exams and Tests
Your doctor will do a physical exam which may show: Tests to find the source of the bleeding and determine if there is active bleeding include: Some doctors recommend EGD for patients who are newly diagnosed with mild to moderate cirrhosis. This test screens for esophageal varices and treats them before there is bleeding.

Treatment
The goal of treatment is to stop acute bleeding as soon as possible. Bleeding must be controlled quickly to prevent shock and death.

If massive bleeding occurs, a person may need to be put on a ventilator to protect the airways and prevent blood from going down into the lungs.

To treat acute bleeding: Once the bleeding is stopped, varices can be treated with medicines and medical procedures to prevent future bleeding including: Emergency surgery may be used (rarely) to treat patients if other therapy fails. Portocaval shunts or surgery to remove the esophagus are two treatment options, but these procedures are risky.

Patients with bleeding varices from liver disease may need more treatment for their liver disease, including a liver transplant.

Outlook (Prognosis)
Bleeding often comes back with or without treatment. Bleeding esophageal varices are a serious complication of liver disease and have a poor outcome. Placement of a shunt can result in a decrease of blood supply to the brain, leading to mental status changes or encephalopathy.

When to Contact a Medical Professional
Call your health care provider or go to an emergency room if you vomit blood or have black tarry stools.

Prevention
Treating the causes of liver disease may prevent bleeding. Preventive treatment of varices with drugs such as beta blockers or with endoscopic banding may help prevent bleeding. Liver transplantation should be considered for some patients.

References
Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD; Practice Guidelines Committee of American Association for Study of Liver Diseases; Practice Parameters Committee of American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol . 2007;102:2086-2102.

Garcia-Tsao G. Cirrhosis and its sequelae. In: Goldman L, Schafer AI, eds. Cecil Medicine . 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 156.

Update Date: 2/10/2014
Todd Eisner, MD, Private practice specializing in Gastroenterology, Boca Raton, FL. Affiliate Assistant Professor, Florida Atlantic University School of Medicine. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.
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