What are esophageal varices and why are they dangerous?

Esophageal varices are abnormal, enlarged veins that typically form in the esophagus or stomach. They arise when blood has difficulty flowing through the liver, most often due to liver cirrhosis. These varices are considered dangerous because they can suddenly rupture and bleed, which constitutes a life-threatening medical emergency [4]. Liver cirrhosis can lead to increased blood pressure in the portal vein, forcing blood to seek alternative paths through weaker blood vessels, such as those found in the esophagus and stomach, causing them to enlarge and become fragile [1].

Esophageal varices appear in about 9 out of 10 people with cirrhosis within 10 years [4]. If the varices in the esophagus are large, there is a 1 in 3 chance they will bleed in the future, while stomach varices have a 1 in 10 chance of bleeding [4]. Bleeding from varices can be fatal, so identifying their presence before bleeding occurs allows for treatment to prevent these serious complications [4].

Signs of Emergency Esophageal Variceal Bleeding

If esophageal varices bleed, they require immediate medical attention. Signs that necessitate calling emergency services immediately include [4]:

• Vomiting blood, which may be bright red or resemble "coffee grounds."
• Black, tarry, or bloody stools.

These symptoms indicate serious internal bleeding and should not be ignored [4].

Diagnosis of Esophageal Varices

The only way to diagnose esophageal varices before they bleed is through a procedure called a gastroscopy [4]. This procedure involves inserting a thin, flexible tube equipped with a camera through the mouth into the esophagus, stomach, and the first part of the intestine. This allows the doctor to examine the veins and determine their size and location, which helps in assessing the risk of bleeding [4].

Ultrasound, CT scans, or MRI cannot determine if varices are prominent in the esophagus or stomach in a way that puts the patient at risk of bleeding [4]. In some cases, additional diagnostic procedures may be needed, especially if the patient suffers from other complications such as ascites (fluid accumulation in the abdomen), which may make certain procedures like traditional liver biopsy more difficult [2].

Treatment Options and Prevention of Bleeding

The main goal of treating esophageal varices is to prevent bleeding or control it if it occurs. Common treatment options include:

• Medications: Such as beta-blockers (e.g., carvedilol), which help reduce blood pressure in the portal veins, thereby reducing the risk of bleeding. Doses usually start low and are gradually increased [4].
• Endoscopic Band Ligation: This procedure is performed during a gastroscopy, where small rubber bands are placed around the varices to seal them. This leads to the formation of scar tissue that stops blood supply to the varices, causing them to disappear [4]. Several banding sessions may be required until the varices disappear completely [5].
• Transjugular Intrahepatic Portosystemic Shunt (TIPS): In more complex cases or when other treatments fail, a TIPS procedure can be performed to create an alternative path for blood flow within the liver, reducing pressure on the esophageal varices [6]. This path is kept open by a small metal stent [6].

After undergoing band ligation, the patient may feel some mild chest discomfort or slight difficulty swallowing for a few days [4]. It is recommended to follow a soft diet (semi-liquid) for 24 hours after the procedure and take medications to reduce stomach acid to help heal any ulcers that may form [4].

For more information on how to manage this condition within the broader context of liver complications, you can view our article on Liver Cirrhosis: Its Advanced Complications (Ascites, Varices, Encephalopathy) (Arabic). Periodic follow-up with a specialist remains the first line of defense against the complications of liver cirrhosis.

Medical references

• Cirrhosis
• Liver Biopsy
• Oesophageal varices | CUH
• Gastroscopy with oesophageal variceal banding or injection | CUH
• TIPS - Transjugular Intrahepatic Portosystemic Shunt