Esophageal Varices – Diagnosis and Treatment
Diagnosis
Doctors check for esophageal varices when a person is diagnosed with liver cirrhosis, because they are at higher risk. Screening may occur regularly, depending on the patient’s health.
Key Diagnostic Methods:
- Upper Endoscopy: This is the main test. A flexible tube with a small camera goes through the mouth to view the esophagus, stomach, and duodenum. The doctor looks for swollen veins, called varices, and checks for signs such as red streaks or spots, which could mean a higher chance of bleeding. The doctor can sometimes provide treatment during this procedure.
- Imaging Studies: Tests like abdominal CT scans and Doppler ultrasounds show enlarged veins and signs of portal hypertension. Transient elastography, a type of ultrasound, assesses liver scarring.
- Other Tests: Doctors may use capsule endoscopy in special cases. Blood tests, including liver function tests and the Model for End-Stage Liver Disease (MELD) score, help evaluate liver health.
Common symptoms in people with esophageal varices may include vomiting blood, black stools, or unclear symptoms until bleeding starts. Doctors use a variety of tests together to confirm a diagnosis and plan the next steps for care.
Treatment
Lowering the Chance of Bleeding
To reduce the risk of bleeding from esophageal varices, doctors use both medicines and procedures.
1. Medications to Lower Portal Pressure
Doctors often prescribe beta blockers—such as propranolol and nadolol. These medicines lower the blood pressure in the portal vein, making it less likely for the varices to burst and helping to prevent new bleeding in at-risk patients.
2. Banding the Varices
A key method to stop varices from bleeding is endoscopic variceal band ligation. During this procedure, an endoscope enters the esophagus, and the doctor places small rubber bands around the enlarged veins.
The bands cut off blood flow to the varices. This method is usually safe, but possible side effects include irritation, small ulcers, or bleeding at the banded site.
Comparison Table: Preventive Treatments
| Method | How It Works | Main Purpose | Possible Side Effects |
|---|---|---|---|
| Beta Blockers | Lowers portal pressure | Prevent bleeding | Slow heart rate, fatigue |
| Band Ligation | Ties off varices | Prevent bleeding | Bleeding, ulcers, pain |
Sometimes, doctors use these two treatments together based on the person’s condition and risk.
Steps for When Bleeding Happens
If bleeding from esophageal varices begins, it is a medical emergency. Immediate action saves lives and reduces the risk of complications.
1. Stop the Varices from Bleeding
- Band Ligation: Doctors may quickly use endoscopic band ligation to tie off the bleeding vein.
- Endoscopic Sclerotherapy: The doctor injects a special substance like ethanolamine oleate into or beside the varices to cause them to shrink.
2. Medicines to Slow Blood Flow
Doctors commonly use IV medicines such as octreotide or vasopressin. These medicines narrow blood vessels, reducing blood flow to the portal vein and making bleeding less severe.
3. Creating a Shunt
If medicine and banding do not stop the bleeding, doctors may perform a transjugular intrahepatic portosystemic shunt (TIPS) procedure. In TIPS, the doctor creates a pathway (shunt) between the portal and hepatic veins.
This helps blood avoid the high-pressure area, lowers pressure in the portal vein, and usually stops the bleeding.
However, the TIPS procedure can cause serious complications, such as hepatic encephalopathy—trouble thinking clearly due to toxins in the blood—and even liver failure.
4. Applying Direct Pressure
Doctors may use a balloon tamponade as a short-term fix if bleeding cannot be controlled another way. The doctor inserts and inflates a balloon within the esophagus to put pressure directly on the varices.
This only works for up to 24 hours and comes with risks, including the chance of the esophagus tearing.
5. Blood Transfusions and Other Support
If a lot of blood is lost, doctors often provide transfusions to stabilize the patient. They may also give clotting factors, fluids, and antibiotics to prevent infection.
6. Liver Transplant
If bleeding continues or the liver is very damaged, a liver transplant may be necessary. Liver transplants can be life-saving, but there may be long wait times because donor livers are not always available.
Preventing Bleeding Again
People who have had bleeding from esophageal varices have a high chance of bleeding again.
- Ongoing Beta Blockers: Patients usually continue taking beta blockers to lower portal hypertension.
- Repeated Band Ligation: Doctors may repeat endoscopic band ligation every few weeks. Over time, this makes the varices shrink or disappear.
- Regular Monitoring: Doctors schedule follow-up endoscopies to check for the return of varices and perform more banding as needed.
New and Experimental Approaches
Researchers are studying possible treatments for severe or hard-to-treat cases.
1. Hemostatic Powder
During endoscopy, doctors can spray an adhesive powder onto the bleeding varices through a catheter. The powder creates a physical barrier that seals off the bleeding area almost instantly.
Early research shows promise, but this method is still being tested and is not widely available.
2. Self-Expanding Metal Stents (SEMS)
In some cases, doctors use a self-expanding metal stent to control bleeding. They place the stent in the esophagus during endoscopy, and it expands and presses against the varices, stopping blood flow.
This treatment is generally reserved for cases where all other options have failed. Possible problems include stent movement or damage to nearby tissue. Doctors usually remove stents within a week.
Table: Experimental Options
| Treatment | Goal | Main Risks | Availability |
|---|---|---|---|
| Hemostatic Powder | Seals bleeding quickly | Not fully studied | Limited, research |
| Metal Stent (SEMS) | Compresses varices | Tissue damage, movement | Limited, research |
Researchers continue working to make these treatments safer and more widely available.
Getting Ready for Your Visit
Steps You Can Take Before Your Visit
Before seeing a healthcare provider about esophageal varices or possible liver disease, prepare ahead.
- Keep a list of any symptoms you have noticed, even if they do not seem linked to your main concern.
- Write down when your symptoms started, how often they happen, and if you have noticed issues like abdominal pain, jaundice, chest pain, swollen abdomen, or gastrointestinal bleeding such as blood in vomit (hematemesis) or stool.
List key information about your health, including:
- Medical History: conditions like cirrhosis, fatty liver, hepatitis B or C, or past infections (including schistosomiasis).
- Alcohol Consumption: how much and how often, as alcohol abuse can damage the liver and raise portal pressure.
- Family History: especially if anyone has had liver disease or blood clots.
- Recent travels to areas where liver infections are more common.
- Medications, vitamins, or supplements with dosages.
- Additional questions you want to ask. These might include testing recommendations, treatment side effects, if hospital stays are needed, and how to manage both liver-related problems and other health issues together.
If possible, bring a friend or family member with you. They can help you recall what was discussed and ask questions you might miss.
Below is a sample table for your notes:
| Information to Bring | Details to Include |
|---|---|
| Symptoms | Date started, severity, triggers |
| Current Medications | Name, dose, frequency |
| Alcohol Use | Kind, amount, frequency |
| Medical & Family History | Liver disease, hepatitis, alcohol use, blood clots |
| Recent Travel | Countries, dates |
Topics Your Healthcare Provider May Discuss
At the visit, the healthcare provider will ask about:
- When symptoms started and if they have changed.
- Bleeding signs, like blood in your stool or vomit.
- Possible risk factors, such as a history of hepatitis, yellowing of the eyes or skin, a history of portal hypertension, or past chest and abdominal pain.
- Travel history, which can raise risk for certain infections.
- Alcohol use and duration of use.
These questions help rule out causes, such as liver cirrhosis, blood clots in the portal vein, or effects from infections and fatty liver.
