Oesophageal Varices

What are oesophageal varices?

Oesophageal varices are veins in the wall of the gullet, particularly its lower part, that have widened and become tortuous. They arise most often when liver disease obstructs the flow of blood through the liver and the pressure in the vein called the portal vein rises.

When pressure builds in the portal system, blood looks for alternative routes. One of these routes is the small veins around the gullet. Normally slender, these veins may widen over time and become varices.

Oesophageal varices matter because in some patients these veins can tear and cause serious bleeding.

Why do they form?

The commonest cause of oesophageal varices is cirrhosis of the liver and the portal hypertension that follows it. Certain diseases that obstruct the portal vein or the veins of the liver may also lead to varices.

Not every patient with liver disease develops oesophageal varices. The likelihood of varices forming, and the risk that they will bleed, depends on the severity of the liver disease, the portal pressure, the size of the varices and certain endoscopic features.

What are the symptoms?

Oesophageal varices usually cause no symptoms at all until they bleed. A person may therefore be unaware of having them, and the diagnosis may be made during an endoscopy carried out for some other reason.

When a variceal bleed occurs, there may be:

• Vomiting of blood,
• Dark vomit resembling coffee grounds,
• Black, tarry stools,
• Weakness and dizziness,
• A fall in blood pressure,
• Palpitations or fainting.

Vomiting blood or passing black stools requires emergency assessment. In a person known to have liver disease or oesophageal varices in particular, these symptoms call for medical attention without delay.

How is the diagnosis made?

One of the most important methods for assessing oesophageal varices is upper gastrointestinal endoscopy (gastroscopy).

During endoscopy it can be established whether varices are present in the gullet, how large they are, and whether they have features that suggest a risk of bleeding. If there is active bleeding, its source can be identified and treatment given during the same procedure.

Not every patient with chronic liver disease need now undergo endoscopy in the same way and at the same intervals. Liver stiffness measurement, the platelet count and other features of the disease can be assessed together to determine which patients need endoscopy.

Ultrasound, Doppler ultrasound, computed tomography and MRI may be used to assess the liver, the portal venous system and the portal hypertension itself.

How are they treated?

The aim of treatment is not merely to remove the varices. The real objectives are to prevent a variceal bleed, to lower the portal pressure and to bring the underlying liver disease under control as far as possible.

Before a bleed occurs

In patients at risk of bleeding, and where the doctor considers it appropriate, non-selective beta blockers may be used to help reduce the pressure in the portal system.

In patients who cannot take these drugs, or who have certain high-risk varices, endoscopic band ligation may be carried out.

In band ligation the widened varices are strangled with small elastic bands during endoscopy. Blood flow within the vein is thereby cut off and the varix shrinks over time.

If a variceal bleed occurs

Bleeding from oesophageal varices is a medical emergency and must be treated in hospital.

The patient’s circulation and general condition are secured first. Drugs that help lower the pressure in the portal circulation, and treatment to prevent infection, may be started.

Emergency endoscopy is then carried out at an appropriate time. Band ligation is one of the principal endoscopic treatments for bleeding oesophageal varices.

In certain high-risk patients, or where bleeding cannot be controlled by standard methods, an interventional radiological procedure called TIPS (transjugular intrahepatic portosystemic shunt) may be required. TIPS aims to reduce the high pressure in the portal system.

Once the bleeding is under control, regular follow-up, drug treatment and, where needed, repeated endoscopic band placement may be used to prevent a further bleed.

Do varices heal completely?

The course of oesophageal varices depends largely on the state of the liver disease that produced them and on the degree of portal hypertension.

Reducing or obliterating the varices by endoscopic means does not mean that the underlying portal hypertension has gone. For that reason the follow-up the doctor advises should be continued even after successful treatment.

Drug treatment, endoscopic band ligation, interventional radiological methods and, where needed, liver transplantation mean that effective options now exist for treating oesophageal varices and variceal bleeding.

When is emergency help needed?

In a person known to have oesophageal varices or chronic liver disease, vomiting blood, passing black tarry stools, sudden dizziness, fainting or marked weakness may be signs of a variceal bleed.

In that situation nothing should be awaited at home; the patient must go to hospital as an emergency.

This section is for general information. The plan for diagnosis, treatment and follow-up is determined individually by the doctor, taking account of the cause of the liver disease, the degree of portal hypertension, the features of the varices and the patient’s general health.