Bleeding esophageal varices
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.
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.
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:
- Black, tarry stools
- Bloody stools
- Symptoms of chronic liver disease
- Vomiting blood
Exams and Tests
Your doctor will do a physical exam which may show:
- Bloody or black stool (in a rectal exam)
- Low blood pressure
- Rapid heart rate
- Signs of chronic liver disease or cirrhosis
Tests to find the source of the bleeding and determine if there is active bleeding include:
- Esophagogastroduodenoscopy (EGD), which involves-the use of a camera on a flexible tube to examine the upper gastrointestinal system
- Insertion of a tube through the nose into the stomach (nasogastric tube) to look for signs of bleeding
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.
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:
- The health care provider may inject the varices directly with a clotting medicine, or place a rubber band around the bleeding veins. This procedure is done using a small lighted tube called an endoscope.
- A medication that tightens blood vessels (vasoconstriction) may be used. Examples include octreotide or vasopressin.
- Rarely, a tube may be inserted through the nose into the stomach and inflated with air. This produces pressure against the bleeding veins (balloon tamponade).
Once the bleeding is stopped, varices can be treated with medicines and medical procedures to prevent future bleeding including:
- Drugs called beta blockers, such as propranolol and nadolol that reduce the risk of bleeding.
- A rubber band can be placed around the bleeding veins during an EGD procedure.
- Transjugular intrahepatic portosystemic shunt (TIPS). This is a procedure to create new connections between two blood vessels in your liver. This can decrease pressure in the veins and prevent bleeding episodes from happening again.
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.
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.
- Encephalopathy (sometimes called hepatic encephalopathy)
- Esophageal stricture after surgery or endoscopic therapy
- Hypovolemic shock
- Infection (pneumonia, bloodstream infection, peritonitis)
- Return of bleeding after treatment
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.
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.
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.
Reviewed By: 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.