Overview

Esophageal varices are enlarged or swollen veins in the lining of the lower esophagus, typically caused by increased pressure in the portal vein system, a condition known as portal hypertension. These dilated veins are fragile and prone to rupture, which can lead to life-threatening bleeding. Esophageal varices most commonly occur in individuals with advanced liver disease, especially cirrhosis. Because of the significant risk of bleeding, esophageal varices are considered a serious medical condition that requires prompt diagnosis, close monitoring, and preventive treatment to reduce complications.

Causes

The primary cause of esophageal varices is portal hypertension, which develops when normal blood flow through the liver is obstructed. This increased pressure causes blood to be diverted into smaller veins, such as those in the esophagus, leading to swelling and variceal formation. Common causes include:

• Cirrhosis of the Liver: The most frequent cause, resulting from chronic liver diseases such as hepatitis B, hepatitis C, alcohol-related liver disease, and nonalcoholic fatty liver disease (NAFLD).
• Portal Vein Thrombosis: Blood clots in the portal vein can lead to increased pressure in surrounding veins.
• Schistosomiasis: A parasitic infection common in some tropical regions that can cause liver damage and portal hypertension.
• Congenital Liver Disorders: Rare inherited conditions, such as biliary atresia, may also contribute to varices.

Symptoms

Esophageal varices may not cause symptoms until they rupture and bleed. When bleeding occurs, it presents as a medical emergency.

Signs and Symptoms Before Rupture:

• Often asymptomatic, especially in early stages.
• Mild discomfort or pressure in the chest or upper abdomen in some cases.

Signs and Symptoms of Bleeding Varices:

• Vomiting Blood (Hematemesis): Bright red blood or coffee-ground-like vomit.
• Black, Tarry Stools (Melena): Due to digested blood passing through the intestines.
• Lightheadedness or Dizziness: Resulting from blood loss and low blood pressure.
• Shock: Severe blood loss can cause shock, characterized by rapid heartbeat, pale skin, and unconsciousness.
• Fatigue and Weakness: Due to anemia from chronic or acute bleeding.

Diagnosis

Diagnosing esophageal varices involves identifying underlying liver disease and visualizing the varices directly through medical procedures.

• Upper Endoscopy (Esophagogastroduodenoscopy - EGD): The most definitive diagnostic tool, allowing doctors to see and assess the severity of varices.
• Imaging Tests: Ultrasound, especially Doppler ultrasound of the liver, can detect portal hypertension and liver abnormalities.
• CT or MRI Scans: Provide detailed images of the liver and surrounding blood vessels.
• Blood Tests: Evaluate liver function, platelet count, and coagulation status.
• Capsule Endoscopy: A less commonly used method involving swallowing a camera capsule to visualize the esophagus.

Treatment

Treatment of esophageal varices focuses on preventing rupture, controlling active bleeding, and treating underlying liver disease.

Prevention of Bleeding:

• Beta-Blockers: Non-selective beta-blockers like propranolol or nadolol reduce portal hypertension and decrease bleeding risk.
• Endoscopic Variceal Ligation (EVL): A procedure to tie off varices during endoscopy, preventing bleeding.
• Lifestyle Changes: Managing liver disease by avoiding alcohol, following a healthy diet, and treating viral hepatitis.

Treatment of Acute Bleeding:

• Endoscopic Therapy: Emergency endoscopy to perform variceal band ligation or sclerotherapy to stop bleeding.
• Medications: Intravenous vasoactive drugs such as octreotide or somatostatin reduce portal pressure during acute bleeding.
• Antibiotics: Prevent infections, which are common in bleeding episodes in cirrhotic patients.
• Blood Transfusions: To replace lost blood and stabilize the patient.
• Transjugular Intrahepatic Portosystemic Shunt (TIPS): A minimally invasive procedure that creates a channel in the liver to reduce portal vein pressure, used in cases of recurrent bleeding.

Prognosis

The prognosis for esophageal varices depends on the severity of liver disease, the size of varices, and the occurrence of bleeding episodes.

• Without Bleeding: With proper monitoring and preventive treatment, many patients can avoid bleeding and manage their liver disease.
• With Bleeding: Bleeding from esophageal varices has a high risk of recurrence and significant mortality, especially if liver function is severely impaired.
• Long-Term Outlook: Patients with controlled liver disease and no recurrent bleeding have a better prognosis. Regular screening and preventive measures significantly improve survival rates.
• Complications: Common complications include recurrent bleeding, hepatic encephalopathy, and progression of liver failure.

Overall, early detection, effective treatment, and proactive management of liver disease are key to improving the prognosis for individuals with esophageal varices.