What Are Oesophageal Varices?

Do you know the hidden dangers of oesophagal varices? These intricate and dangerous veins can lurk silently within those with liver problems and go undetected until they suddenly erupt with potentially fatal bleeding. Join us on a thorough journey as we explore the causes, dangers, traits, consequences, and treatment of this dangerous condition, putting light on a subject that needs to receive immediate attention.

Overview

Oesophageal varices are enlarged and swollen blood vessels, specifically veins, that are usually located in the lower oesophagus, the muscular tube that carries food from the throat to the stomach. These varices are most commonly seen in individuals with serious liver diseases, such as their leading cause, liver cirrhosis. The size of varices can vary, and the larger they become, the more severe the condition. Varices without bleeding typically do not cause any noticeable symptoms. However, if they start to leak or rupture, they can result in uncontrolled bleeding that poses a threat to life. Therefore, bleeding varices are considered a medical emergency requiring urgent medical treatment.

Causes of oesophageal varices

Oesophageal varices develop due to portal hypertension, a condition characterised by increased blood pressure in the portal venous system.¹ This system is comprised of the portal vein, travelling through the liver, with some lesser branches. Together, they carry venous blood back to the heart. To compensate for portal hypertension, blood flow is redirected toward smaller veins in the oesophagus, stomach, and anus, which have thinner walls, not designed for higher pressure. These veins in the lower oesophagus dilate and may even rupture due to blood-seeking alternate pathways through them. Since certain hepatic disorders impair blood flow to the liver and increase pressure in the portal vein, they are frequently associated with the development of oesophagal varices. Those liver conditions are:

• Cirrhosis, marked by extensive liver scarring from chronic inflammation like hepatitis, is the primary cause of oesophagal varices. Scar tissue disrupts blood flow, leading to varices. Conditions like obesity-related fatty liver, alcohol abuse, chronic hepatitis B or C, autoimmune hepatitis, and primary biliary cholangitis can progress to cirrhosis if untreated
• Thrombosis - Portal vein thrombosis occurs when a blood clot blocks the portal vein, affecting liver blood inflow. Cirrhosis and malignancy contribute to this condition. Budd-Chiari syndrome obstructs hepatic veins, impairing liver blood outflow. This syndrome is linked to hypercoagulable states. Both conditions can cause portal hypertension, leading to oesophagal varices.
• Parasites - In chronic schistosomiasis, parasite eggs deposited in the liver cause inflammation and the formation of granuloma (tightly clustered immune cells). This can lead to hepatosplenomegaly (enlarged liver and spleen), scarring, and portal hypertension, resulting in oesophagal varices. This condition is more prevalent in Africa, South America, and the Caribbean.

Signs and symptoms of oesophageal varices

Oesophageal varices may not present any symptoms, especially when they are small (<5mm). These varices are not visible externally as they usually are situated in the lower part of the oesophagus. In cases where the varices are asymptomatic, healthcare professionals may suspect their presence based on the presence of other clinical features associated with the underlying conditions, such as cirrhosis.

Symptoms of oesophagal varices typically arise when there is a leakage or rupture of the varices, leading to severe bleeding. These symptoms may include:

• Vomiting blood  – may involve either fresh red blood or dried blood that appears similar to coffee grounds
• Bloody stool can be observed as a black and tarry stool, known as melena, or the passage of fresh red blood along with the stool, referred to as hematochezia. The presence of hematochezia usually indicates rapid and significant bleeding
• Lightheadedness  – can occur as a result of possible hypotension caused by acute blood loss.

Management and treatment for oesophageal varices

Depending on whether the oesophagal varices are bleeding or not, different therapeutic modalities are used. The major focus of treatment for nonbleeding varices is to prevent bleeding.

• Beta-blockers, such as propranolol (Inderal) and nadolol (Corgard), are frequently prescribed drugs for high blood pressure that can successfully lower pressure within the varices too.^2,3 Beta-blockers contribute to a 45–50% reduction in the risk of bleeding by reducing blood pressure in the portal vein
• Variceal band ligation is an endoscopic procedure where small rubber bands are placed around varices to prevent bleeding.⁴ It is commonly done in individuals with large varices or those at high risk of bleeding. Repeat endoscopy is usually done every 2-8  weeks to assess the need for additional band placement until eradicated.⁵ This treatment option is particularly beneficial for individuals who are unable to tolerate beta blockers or require additional preventive measures against bleeding

Bleeding oesophagal varices is a medical emergency, which is managed in clinical settings with:

• Initial stabilization – intravenous fluids, blood transfusion, mechanical breathing, and antibiotics (ceftriaxone) to avoid infections
• Intravenous (IV) medications – Octereotide, Vasopressin or somatostatin analogues to reduce the blood flow to the varices
• Endoscopic treatment – variceal ligation, is a common approach to managing bleeding oesophagal varices too.⁹ Variceal sclerotherapy is an alternative choice, albeit one that is less frequently used. With this technique, a specific solution is injected directly into the varices to halt the bleeding and encourage healing

Rare instances of extreme bleeding may call for the use of a "TIPS" technique. During this procedure, a thin tube is inserted through a vein in the neck and positioned inside the liver to improve blood flow. By reducing portal hypertension, variceal bleeding can be controlled and stopped.

Diagnosis

To mitigate the risk of bleeding and its complications, it is recommended that individuals with cirrhosis undergo the following testing to determine the presence of oesophageal varices:⁶

• Upper endoscopy – A common method to detect varices. To observe the oesophagus and stomach, a flexible tube with a camera is inserted into the mouth. After 2-3 years, a repeat operation is advised if no varices are discovered. The management of detected varices depends on their size
• Capsule endoscopy – The oesophagus and stomach lining are photographed by swallowing a camera capsule. It is more expensive, less often used, and might not be accessible everywhere
• CT or MRI –  Not routinely done, offers an advantage over endoscopy by providing a comprehensive evaluation of surrounding anatomical structures and assessing oesophagal varices severity, liver condition, and the entire portal circulation
• Transient elastography (Fibroscan) - Although it is not frequently used for diagnosis confirmation, this ultrasound technique can quantify liver scarring, helps in assessing portal hypertension and rule out high-risk oesophagal varices

Risk factors

The main risk factors for oesophagal varices to develop include liver cirrhosis, secondary to alcohol abuse, chronic viral hepatitis, portal vein thrombosis, non-alcoholic fatty liver disease, hereditary hemochromatosis, and Wilson's disease.

Variceal bleeding is more likely to occur in people with severe cirrhosis, portal hypertension, large varices (>5mm), persistent alcohol use, particular endoscopic red markings and a previous history of variceal bleeding.⁷

Complications

Varices can lead to serious complications if left untreated. Without intervention, approximately 25 to 40 per cent of individuals with varices may experience severe bleeding, which can result in significant illness or even death - in 15% of cases. Severe bleeding may lead to hemorrhagic shock, characterised by symptoms like a rapid heart rate, fast breathing, cold and clammy skin, sweating, anxiety, confusion, and loss of consciousness.

Other complications of varices can include anaemia, coagulopathy (blood clotting abnormality), thrombocytopenia (low platelets), oesophagal perforation, hepatic encephalopathy, infections (such as pneumonia and peritonitis), and acute kidney injury.  These are some of the most important complications associated with varices, but the list is not exhaustive.

FAQs

How can I prevent oesophageal varices?

Beta-blockers and variceal band ligation are therapies that can stop bleeding from oesophageal varices; however, as of present, we are unable to stop varices from developing in cirrhotic individuals. Liver stress can be decreased by living a healthy lifestyle that excludes alcohol, consuming a wholesome diet, and managing weight. Regular testing for alcohol-induced liver disease, viral hepatitis, and non-alcoholic fatty liver (NASH) in risk groups can identify liver issues early and aid in preventing cirrhosis and the emergence of oesophagal varices.

How common are oesophageal varices?

Around 30% of patients with cirrhosis already have oesophageal varices at the time of diagnosis, and within 10 years, this number rises to 90%.⁸ Males are more likely to have the disorder than females. Additionally, bleeding will occur in about 50% of oesophagal varices patients at some point.⁸

When should I see a doctor?

It is crucial to call an ambulance if you have liver disease and encounter symptoms like blood in your vomit, dark or black stools, bloody stools or diarrhoea, dizziness, or fainting. In such circumstances, avoid driving yourself or have someone else drive you to the hospital.

Summary

Oesophageal varices, or enlarged veins in the lower oesophagus, are a result of portal hypertension, which is primarily brought on by cirrhosis. Variceal bleeding can result in serious problems and even death. Nonselective beta-blockers and/or endoscopic ligation are two methods that can help stop variceal bleeding. Endoscopic ligation, vasoactive medications, or somatostatin analogues are all used in the management of acute haemorrhages. Transjugular intrahepatic shunt treatment and prophylactic antibiotics are possible further therapies. The diagnosis and continuous monitoring of oesophagal varices using endoscopy are essential components of their therapy.