Esophageal Varices

Esophageal Varices

Esophageal varices are varicose veins in the esophagus that are usually associated with advanced liver failure. Around 50 percent of liver cirrhosis cases are associated with esophageal varices, which in turn have an increased risk of life-threatening bleeding at 30 percent.

What are esophageal varices?

Varicose veins or expansions (varices) of the submucosal veins of the esophagus are referred to as esophageal varices, which are usually due to portal hypertension as a result of progressive liver damage (including liver cirrhosis ). For what is the definition of health center, please visit healthknowing.com.

When the liver is impaired, blood can no longer flow freely from the liver to the heart, so it seeks alternative routes via the veins of the esophagus. Sack-like enlargements develop, so-called varicose veins or varicose veins.

In many cases, oesophageal varices are discrete or asymptomatic and, in addition to the characteristic symptoms of liver cirrhosis (including ascites, liver skin signs such as varnish lips and tongue, dilatation of the arterial vessels in the skin), they manifest with a feeling of fullness and/or pressure in the upper abdomen and splenomegaly ( splenic enlargement) as an indicator of portal hypertension.

In addition, esophageal varices are associated with gastric varices and gastropathia hypertensiva (enlargement of the gastric mucosal veins) in some affected individuals.

Causes

In most cases, esophageal varices result from portal hypertension (increased pressure in the portal vein). Increased pressure in the vena portae (portal vein) is usually caused by cirrhosis of the liver (advanced liver disease), which can be caused by alcohol abuse or hepatitis.

Esophageal varices develop in about half of all those affected by liver cirrhosis. As a result of the damage, portal congestion forms in the liver as blood is no longer able to flow freely. As a result, bypass circulations, so-called portocaval anastomoses, manifest themselves in the area between the vena portae and the inferior vena cava, which include not only hemorrhoids but also esophageal varices.

In addition, cardiac insufficiency and thrombosis or tumors in the area of ​​the splenic vein, the inferior vena cava (vena cava inferior) and/or the portal vein can lead to esophageal varices.

Symptoms, Ailments & Signs

In the early stages, varicose veins in the esophagus do not cause any symptoms. Occasionally, a slight taste of blood is noticeable in minor injuries caused by regurgitated saliva. If esophageal varicose veins tear severely, those affected complain of sudden nausea. At the same time, they suddenly vomit larger amounts of blood.

The gushing sputum is often mixed with black stomach contents (coffee grounds vomit). Such an outbreak of symptoms is considered a medical emergency. A rapid heartbeat tries to compensate for the unexpected loss of blood. Without the support of companions, those affected are threatened with unconsciousness.

There is a high risk of death due to potential circulatory collapse for the patient if emergency measures are not taken. Moderate bleeding initially leads to a drop in performance. Pallor and breathing problems occur as a result. If the blood enters the digestive tract, it causes discomfort in the stomach area in many people.

Feelings of pressure and fullness are added. Contact with stomach acid causes the next bowel movement to turn black. The tarry stool is considered a sure warning sign of a cause of bleeding in the digestive tract. Since esophageal varices often arise as a complication of portal hypertension, people suffer from very specific signs of this underlying disease.

This includes ascites ( abdominal dropsy ), clearly protruding veins in the area of ​​the navel and changes in the skin (banknote skin). Visibly dilated blood vessels manifest themselves in fine or extensive red discoloration on the face, upper body, hands and feet. Distinctive features include the paint lip or the paint tongue.

Diagnosis & History

As a rule, esophageal varices are diagnosed using an endoscopic examination of the esophagus (esophagogastroduodenoscopy), which allows statements to be made about the characteristics of the esophageal structures and the specific stage of the disease.

In the first stage, there are ectasias (sac-like enlargements) of the affected veins, which disappear with endoscopic air insufflation. In the second stage, isolated varices appear, about 1/3 of which protrude into the lumen (interior) of the esophagus and do not disappear even with air insufflation. The third stage is characterized by an increasing narrowing of the esophageal lumen (up to 50 percent).

In addition, damage to the epithelium can become noticeable as reddish spots. In the fourth stage, the lumen of the esophagus is completely filled by the variceal cords and a large number of mucosal erosions can be detected. If left untreated, esophageal varices can perforate and lead to life-threatening bleeding, which has a mortality rate of about 30 percent even with treatment.

complications

Most esophageal varices have thin vessel walls. Bleeding as a result of ruptured vessels is therefore a possible complication, regardless of the therapy. Patients with larger bypass circuits are particularly affected.

Minor bleeding manifests itself in the form of symptoms such as black stool (tarry stool), while larger vascular ruptures as a result of high blood loss manifest themselves in life-threatening shock states and call for immediate emergency medical treatment. In order to prevent life-threatening bleeding, treating physicians assess the bleeding tendency of varicose veins in the esophagus using endoscopic findings and the pressure gradient in the area of ​​the portal vein.

From an endoscopic point of view, abnormalities such as so-called “cherry red spots” indicate an increased risk of bleeding and call for preventive measures such as the administration of beta-blockers. With regard to the pressure gradient, the same applies to values ​​from 12 mmHg, whereby greatly increased pressure values ​​speak for combined treatment approaches with beta-blockers and nitrate. These preventive treatment steps are not suitable for the treatment of acute bleeding. Specialists treat the acute event with success rates of up to 90 percent by shutting down the affected veins with agents such as polydocanol or histoacryl.

Although endoscopic treatment does not always prevent varicose vein bleeding in the esophagus, the risk of second bleeding after an untreated first bleeding increases to up to 80 percent. In patients with concomitant cirrhosis of the liver, bleeding from varicose veins in the esophagus is often associated with further complications such as liver coma if the liver disease is not treated in addition to varicose vein treatment. The highest risk of life-threatening complications arises from esophageal varices in patients with untreated coagulation disorders.

When should you go to the doctor?

Since the esophageal varices are pathological venous enlargements in the lower third of the esophagus, the disease only becomes apparent through pain and stinging in the upper abdomen at an advanced stage. The patient suffers from persistent nausea. There is also a constant feeling of pressure and fullness in the stomach area. Slight bleeding from the varices leads to a drop in performance and permanent states of exhaustion. The patient has a constant subliminal taste of blood in the mouth. His saliva is bloody.

The patient’s face shows a non-specific pallor. It is not uncommon for patients to suffer concomitantly from ascites and conspicuous liver skin signs. Skin and eyes show a yellow discoloration. The patient tends to bleed or bruise very quickly. Esophageal varices become clearly visible through gush-like vomiting of blood. The stool is tarry and black. The patient tends to become drowsy or even unconscious. The pulse is greatly increased. These are life-threatening warning signs. The cycle is about to collapse. Medical help should be sought as soon as possible and emergency measures initiated.

Treatment & Therapy

As part of a causal therapy for esophageal varices, the underlying disease should always be treated. In addition, various endoscopic surgical procedures are available for the treatment of esophageal varices.

As part of sclerosing therapy, a so-called sclerosant (hardening agent) is injected into the varix using an endoscope. As a result, the varix closes so that blood can no longer flow into it and the tissue dies. With the help of an obliteration therapy, which is usually used for bleeding varicose veins, the affected vein section is obliterated (blocked) with a liquid tissue adhesive that hardens immediately after the injection into the affected vein.

Another surgical measure is the so-called ligature procedure, in which the varix to be ligated is sucked in by means of a cap attached to the endoscope and then wrapped with a rubber ring or thread. As a result of this constriction, thrombosis develops, which leads to the death of the tissue. In addition, a balloon-like probe (including Sengstaken-Blakemore probe, Linton probe) can be used to stop bleeding.

Blood flow to the affected area can also be reduced by somatostatin or vasopressin. The general measures after perforation of esophageal varices include continuous monitoring of vital functions, intubation if necessary, preventive antibiotic therapy due to impending sepsis, and intravenous volume administration.

To avoid recurrence and/or bleeding of the esophageal varices, prophylactic medication ( beta- blockers, spironolactone, nitrates) or surgery (shunt surgery) can be indicated.

Prevention

The manifestation of esophageal varices can be prevented by consistent and early therapy of the underlying disease. If cirrhosis of the liver is present, strict alcohol abstinence should be observed to avoid esophageal varices.

You can do that yourself

People who have been diagnosed with esophageal varices should pay particular attention to the consumption of their food in everyday life. Foods that have any form of solid or sharp elements in them should not be eaten.

With fish, rusks or crispbread, the components of the food can lead to complications when swallowing. Likewise, when consuming stone fruit, care should be taken to ensure that the fruit stones have been removed beforehand. Not only raw foods but also processed products such as cakes should be checked before they are put in the mouth.

During eating, all the components of the food should be sufficiently ground in the mouth through the buying process. Swallowing larger amounts of food is not allowed. Damage to the vessel walls of the esophagus could occur at any time. Since this can lead to heavy bleeding within a short time, a life-threatening condition can develop within a few minutes.

Foreign objects such as toys, objects or coins should not be put in the mouth. There is a risk that these can unintentionally get into the throat and be swallowed. If the person concerned wears braces or dentures, it should be checked daily that they are secure. If loosening occurs, a doctor must be consulted immediately.

Esophageal Varices