Table of ContentsView AllTable of ContentsRupture Emergency TreatmentPrognosis After RuptureLowering RisksSmall VaricesPreventive BandingHealing After Bleeding
Table of ContentsView All
View All
Table of Contents
Rupture Emergency Treatment
Prognosis After Rupture
Lowering Risks
Small Varices
Preventive Banding
Healing After Bleeding
Esophageal varicesare swollen, thin-walled veins in the loweresophagus, the tube that carries food from the mouth to the stomach. They develop in approximately 50% of people withportal hypertension, a severe complication ofcirrhosis(liver scarring).
Rupture, or bursting open of esophageal varices, leads to massive bleeding, which can be deadly.
This article reviews the emergent treatment (treatment performed in an emergency) of ruptured esophageal varices, including the medications and procedures utilized. It also explores the strategies used to prevent subsequent bleeding episodes.
Understanding Portal Hypertension in CirrhosisIn cirrhosis, liver scarring can impair blood flow through theportal vein, the central vein responsible for carrying blood from the intestines to the liver. As a result of the elevated pressure in the portal vein, new veins (varices) may form in the lower esophagus, allowing blood to find an alternative pathway.
Understanding Portal Hypertension in Cirrhosis
In cirrhosis, liver scarring can impair blood flow through theportal vein, the central vein responsible for carrying blood from the intestines to the liver. As a result of the elevated pressure in the portal vein, new veins (varices) may form in the lower esophagus, allowing blood to find an alternative pathway.
Emergency Ruptured Esophageal Varices: What Happens
Esophageal varices cause no symptoms until rupture, resulting in massive blood loss.
People at the highest risk for variceal bleeding include those who have:
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Emergency Symptoms to Recognize
The rupture of esophageal varices is a medical emergency, as the bleeding is often fatal if not treated immediately.
Symptoms of esophageal variceal bleeding include:
Symptoms and signs of hemorrhagic shock include:
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Immediate Treatment at Hospital
If you or a loved one is experiencing any of the above symptoms, call 911 immediately for emergency medical assistance.
Treating ruptured esophageal varices starts with administering fluidsintravenously(through a vein) and, oftentimes, one or moreblood transfusionsin a hospital setting.
Besides fluids and blood, two medications are also given intravenously:
While administering fluids, agastroenterologist(a physician specializing in digestive system diseases) performs anendoscopy—ideally, not more than 12 hours after the patient comes to the emergency room.
Upper Endoscopy: Diagnostic and TherapeuticDuring the endoscopy, an endoscope (a thin, flexible tube with a light and camera attached) is inserted through the person’s mouth and down the esophagus to visualize and treat the bleeding varices.
Upper Endoscopy: Diagnostic and Therapeutic
During the endoscopy, an endoscope (a thin, flexible tube with a light and camera attached) is inserted through the person’s mouth and down the esophagus to visualize and treat the bleeding varices.
There are two types of endoscopic treatment for esophageal variceal bleeding:
If an emergent endoscopic treatment fails to stop the bleeding, a repeat endoscopic therapy may be performed—for example, sclerotherapy for a failed ligation.
Alternatively, a more definitive treatment—atransjugular intrahepatic portosystemic shunt (TIPS)—may be performed before attempting another endoscopic treatment.
TIPS and Additional Surgical Options
TIPS is a minimally invasive procedure that has a high success rate of 90% to 100% in bleeding cessation. However, it cannot be performed in individuals with certain health conditions, such as:
Who Performs TIPS?
During a TIPS, a catheter containing a stent (metal tube) is threaded through a vein in a person’s neck until it reaches the liver.
The stent connects the portal vein to thehepatic vein, which drains blood away from the liver. Shunting blood away from the portal vein relieves pressure in the esophageal varices, helping prevent them from rupturing.
Emergency shunt surgeryto stop variceal bleeding may also be performed, although it’s not preferred compared to TIPS as it carries a higher complication rate.
Candidates for shunt surgery are those with well-preserved liver function who fail emergent endoscopic treatments and/or are unable to undergo a TIPS treatment.
One type of shunt surgery for bleeding esophageal varices is the placement of adistal splenorenal shunt (DSRS).
Prognosis After Ruptured Esophageal Varices
Even after successful treatment of bleeding esophageal varices, rebleeding can occur.
In fact, without a preventive strategy, people who recover from an initial episode of esophageal variceal bleeding have up to a 60% chance of rebleeding within the first or second year.
Lowering Risks of Future Rupture
Endoscopic variceal ligation combined with a drug class known as beta-blockers is the preferred strategy for preventing future bleeding after an initial esophageal variceal bleeding episode.
Endoscopic variceal ligationis performed after the person recovers, usually a week or two after hospital discharge.The procedure is repeated every two to four weeks for two or three sessions or more until the varices are obliterated.
Surveillance with an upper endoscopy is then performed every three to six months in the first year following the removal of the varices.
Beta-blockersare high blood pressure medications that lower pressure within the portal vein, reducing the likelihood that the walls of esophageal varices will thin and burst.
If rebleeding occurs a second time, despite a series of endoscopic variceal ligations and/or beta-blocker therapy, TIPS is the subsequent treatment of choice.
Something to Keep in MindIn some cases, an “early” preventive TIPS procedure is performed within 72 hours of the resolution of the initial bleeding episode. After TIPS, performing an EVL or taking a beta-blocker is unnecessary.
Something to Keep in Mind
In some cases, an “early” preventive TIPS procedure is performed within 72 hours of the resolution of the initial bleeding episode. After TIPS, performing an EVL or taking a beta-blocker is unnecessary.
Small Esophageal Varices Without Rupture
If a person has compensated cirrhosis (minimal symptoms and preserved liver function), and varices are present but are small and lacking “high-risk” bleeding signs, they are considered low risk for rupture.As such, no preventive endoscopic treatments or medications are indicated.
That said, repeat upper endoscopies every year or two are necessary for monitoring purposes. Moreover, managing the underlying cirrhosis is vital in helping slow or reverse the disease.
Examples of such management strategies include avoiding alcohol or drugs likenonsteroidal anti-inflammatory drugs (NSAIDs)that may further damage the liver.
Seeing ahepatologist(a physician specializing in liver disease) to review other specific therapies for cirrhosis (e.g., antiviral therapy) and candidacy forliver transplantationis also essential.
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Who Qualifies for Preventive Esophageal Variceal Banding?
For people with cirrhosis and high-risk esophageal varices that have never bled, preventive treatment with a beta-blocker is recommended.
If a person cannot take or tolerate a beta-blocker, endoscopic variceal ligation (also called banding) may be performed.
Examples of conditions that typically prevent a person from taking a beta-blocker include:
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Healing After Bleeding From Esophageal Varices
One potential complication of endoscopic variceal ligation is post-ligation ulcer bleeding. This complication develops when the dying variceal tissue forms large, deep sores that bleed, which can be fatal.
Aproton pump inhibitor (PPI)is prescribed to promote healing after an EVL. PPIs lower acid levels in the esophagus and stomach and have been found to reduce ulcer size and the occurrence of early bleeding after an EVL.
Summary
Esophageal varices are enlarged veins that develop as a result of portal hypertension, a complication of advanced cirrhosis. If esophageal varices break open (rupture), massive and life-threatening bleeding may occur, often in the form of vomiting bright red blood or passing dark stools.
Esophageal variceal bleeding is a medical emergency requiring immediate care, including an upper endoscopy to diagnose and ligate (band) the varices.
After recovery from an esophageal variceal bleeding episode, a person is usually started on a pressure-reducing medicine called a beta-blocker to help prevent rebleeding. They are also scheduled for multiple endoscopic variceal ligations over several weeks until the varices are destroyed.
If you have been diagnosed with varices as a result of cirrhosis and portal hypertension, speak with your provider about next steps, including preventive strategies.
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