Oesophagus Varices

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately.

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Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

Esophageal varices, also commonly referred to as esophageal varices, are enlarged and swollen blood vessels that develop within the walls of the oesophagus. These varices are a direct consequence of increased pressure in the blood vessels supplying the liver, a condition known as portal hypertension.

The oesophagus is a muscular tube that connects the throat to the stomach and plays a crucial role in the digestion process. It obtains its blood supply from various sources, including the portal vein, which carries nutrient-rich blood from the digestive organs to the liver. However, when conditions such as cirrhosis or liver disease impair the liver's ability to function properly, blood flow through the portal vein can become obstructed, leading to an increase in pressure within the veins.

As a result, blood from the portal vein seeks alternative pathways to reach the heart. Esophageal varices begin to form as collateral vessels, acting as a bridge between the portal vein and the veins of the oesophagus. These varices are inherently fragile and prone to rupture, which can result in life-threatening bleeding.

The primary cause of esophageal varices lies in the increased pressure within the portal venous system, which carries blood from the intestines, stomach, and spleen to the liver. This elevated pressure, known as portal hypertension, results from the resistance to blood flow within the liver caused by liver cirrhosis. Over time, as liver tissues become scarred and stiff, the blood flow is impeded, leading to the development of collateral pathways to manage the blood circulation.

The formation of esophageal varices represents one of the most crucial collateral pathways. Due to the high pressure in the portal venous system, blood begins to find alternative routes to bypass the liver. This results in the dilation of small blood vessels around the oesophagus, commonly referred to as varices. As these varices continue to enlarge, they become fragile and prone to rupture, leading to potentially life-threatening complications such as haemorrhage.

The primary cause of esophageal varices is portal hypertension, which is characterised by elevated blood pressure within the portal vein. This elevated pressure occurs when there is resistance to blood flow through the portal vein, usually due to liver disease or cirrhosis. The liver plays an essential role in regulating blood flow through the portal vein, and any damage to the liver can impede this process.

When liver disease or cirrhosis occurs, the liver becomes scarred, leading to fibrosis. This fibrosis disrupts the normal architecture of the liver and impedes blood flow through the liver. As a result, blood pressure in the portal vein increases, and blood flow seeks alternative routes to return to the systemic circulation. This rerouting primarily occurs through collateral veins, one of which is the left gastric vein.

The left gastric vein connects the portal vein with the veins of the lower part of the oesophagus. As the pressure within the portal vein continues to rise, blood flow diverted into the left gastric vein, subsequently increasing the pressure within the veins of the lower oesophagus. These veins, not accustomed to high-pressure blood flow, dilate and enlarge, forming esophageal varices.

The pathophysiology of esophageal varices is closely linked to their propensity to rupture and cause severe bleeding. Due to the fragility of the dilated veins, any slight increase in pressure can result in rupture and subsequent bleeding into the oesophagus. Ruptured varices are a medical emergency, as they can lead to life-threatening haemorrhage and require immediate intervention.

1. Cirrhosis: The most common risk factor for esophageal varices is liver cirrhosis. Cirrhosis is a chronic liver disease characterised by scarring of the liver tissue, usually resulting from long-term liver damage, such as excessive alcohol consumption or chronic hepatitis. As cirrhosis progresses, the increased pressure within the liver's blood vessels can cause blood to divert into smaller blood vessels, including those in the oesophagus.

2. Portal Hypertension: Esophageal varices are primarily caused by increased pressure in the portal venous system, a network of blood vessels that carries blood from the intestine, spleen, and pancreas to the liver. When blood flow through the liver is obstructed, as in cirrhosis or liver disease, it leads to increased pressure within the portal vein, resulting in the development of varices in the oesophagus.

3. Alcohol Abuse: Excessive and chronic alcohol consumption can damage the liver, leading to cirrhosis and an increased risk of developing esophageal varices. Alcohol abuse is a significant contributor to liver disease and subsequent portal hypertension, making it an important risk factor to address in the prevention and management of esophageal varices.
4. Chronic Hepatitis B or C: Chronic viral hepatitis, particularly hepatitis B and hepatitis C, can cause progressive liver damage, ultimately leading to cirrhosis. Hepatitis B and C infections are significant risk factors for the development of esophageal varices. Timely diagnosis and treatment of these infections can help reduce the risk of liver damage and subsequent complications.
5. Family History: There is evidence to suggest that a family history of esophageal varices may increase the risk of developing this condition. Genetic factors and a predisposition to liver diseases can play a role in the development and severity of esophageal varices. Regular screening for those with a family history of esophageal varices can help detect the condition at an early stage.
6. Age: While esophageal varices can occur at any age, the risk tends to increase with age. Older individuals with a long history of liver disease or other risk factors are more likely to develop varices. Regular health check-ups and proper management of liver-related conditions become essential as one ages.
7. Previous Variceal Bleeding: Individuals who have had a bleeding episode from esophageal varices in the past are at higher risk of subsequent bleeds. Effective measures must be taken to prevent variceal rebleeding, such as medical therapy and, in some cases, invasive procedures.

1. Hematemesis:

One of the primary symptoms of esophageal varices is the presence of blood in vomit. This is known as hematemesis and is usually bright red or have a coffee ground-like appearance. If you notice any signs of blood in your vomit, it's essential to seek medical attention immediately.

2. Melena:

Melena refers to the passage of black, tarry stools, which occurs due to bleeding in the upper digestive tract. This can be an alarming sign of esophageal varices. If you experience melena, it is advised to consult a healthcare professional without delay.

3. Hematochezia:

Esophageal varices can also cause fresh, bright red blood to be passed through bowel movements. This condition is referred to as hematochezia. If you notice blood in your stool, it's important not to ignore it and consult a medical expert promptly.

4. Dysphagia:

Esophageal varices that become enlarged can gradually obstruct the oesophagus, leading to difficulty in swallowing, also known as dysphagia. If you experience persistent trouble swallowing solids or liquids, it may be a sign of esophageal varices, and medical advice should be sought.

5. Frequent heartburn:

People with esophageal varices often report experiencing frequent episodes of heartburn or acid reflux. This can be caused by the increased pressure in the veins, leading to acid regurgitation into the oesophagus. If you find yourself frequently experiencing heartburn, it's advisable to consult with a healthcare professional.

6. Unexplained weight loss:

Unintended weight loss can be indicative of various health conditions, including esophageal varices. The presence of varices can cause ongoing bleeding, leading to a loss of red blood cells and subsequent weight loss. If you're experiencing unexplained weight loss along with other symptoms, it's crucial to seek medical attention to determine the underlying cause.

7. Fatigue and weakness:

Due to ongoing bleeding and anaemia from esophageal varices, individuals may experience feelings of chronic fatigue and weakness. The loss of red blood cells reduces the capacity of the blood to carry oxygen, leading to these symptoms. If you notice persistent fatigue despite adequate rest, it is essential to consult a healthcare professional.

History taking:

Ask about vomiting blood or the presence of blood in the stools (black, tarry stools) in addition:

• Abdominal pain or discomfort

• Difficulty swallowing (dysphagia)

• Unintentional weight loss

• Fatigue and weakness

• Jaundice (yellowing of the skin and eyes)

Imaging:

1. Endoscopy: This is the gold standard for diagnosing esophageal varices. A thin, flexible tube with a camera (endoscope) is inserted through the mouth and into the oesophagus to visualise and assess the varices. An endoscopy also provides an opportunity to intervene by banding or sclerotherapy to help prevent bleeding.

2. Ultrasound: Abdominal ultrasound can be performed to evaluate the liver and portal vein system. It helps assess the blood flow in and around the liver, measure the portal vein diameter, and detect the presence of blood clots or liver masses.

3. Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Scan: These imaging studies can provide detailed images of the liver and surrounding blood vessels, helping identify liver damage, portal vein abnormalities, and the extent of varices.

4. Laboratory Tests: Blood tests are essential in evaluating liver function and assessing overall health. Liver function tests, full blood count (FBC), blood clotting tests, and viral hepatitis screening are common laboratory investigations.

The treatment approach for acute variceal haemorrhage includes the administration of vasoactive drugs such as Vasopressin, performing endoscopic band ligation, and providing prophylactic antibiotics. In cases where patients do not show a response or are unlikely to respond to the initial standard management, the option of Transjugular intrahepatic portosystemic shunt (TIPS) is considered (see below).

Transjugular Intrahepatic Portosystemic Shunt (TIPS): TIPS procedure involves the insertion of a stent-like device between the portal vein and hepatic vein to divert blood flow away from the liver. This reduces the pressure in the portal vein, relieving the strain on oesophageal varices and minimising the risk of bleeding.

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