Finding oesophageal or gastric varices at endoscopy means that the veins in the wall of the oesophagus or stomach have widened and become prominent.
These vessels mostly develop because of raised pressure in the portal venous system (portal hypertension).
Varices are not cancer; but they matter as an endoscopic finding because of the risk of bleeding.
Why do oesophageal and gastric varices form?
The most common cause is cirrhosis of the liver and the portal hypertension it causes. Less commonly, varices can be caused by:
- Portal vein thrombosis
- Splenic vein thrombosis
- Budd–Chiari syndrome
- Non-cirrhotic causes of portal hypertension
In isolated gastric varices in particular, other causes such as splenic vein thrombosis due to pancreatic disease may also be investigated.
What are oesophageal varices?
Oesophageal varices are seen mostly in the lower part of the oesophagus. At endoscopy they can appear as blue-purple, raised and tortuous vessels.
The size of the varices and certain markings on their surface matter in assessing the risk of bleeding.
What are gastric varices?
Gastric varices can be seen particularly in the upper part of the stomach, around the cardia and fundus.
They are less common than oesophageal varices. But bleeding from some gastric varices can be more severe.
Gastric varices have different types according to their location and their relationship with oesophageal varices. This distinction matters in deciding on treatment.
Does finding varices mean cirrhosis?
Not always.
Cirrhosis is the most common cause of oesophageal and gastric varices, but not the only one.
When varices are found, the portal vein and the splenic venous system are assessed as well as the liver disease.
Do varices cause symptoms?
Varices that have not bled mostly cause no symptoms at all.
So in some patients varices are found during an endoscopy done for another reason, or on screening carried out because of liver disease.
The really important problem is a varix bleeding.
How is variceal bleeding recognised?
Variceal bleeding is an urgent and serious situation.
Urgent medical assessment is needed if there is vomiting of blood or black stools
Vomiting blood · vomit that looks like coffee grounds · black, tarry stools · dizziness · fainting · palpitations · a drop in blood pressure · marked weakness.
Does every varix bleed?
No. Finding varices does not mean bleeding will necessarily happen.
In assessing the risk of bleeding, factors such as the size of the varix + endoscopic risk signs + the severity of the liver disease are taken into account.
Is treatment needed?
Treatment varies with whether the varix is in the oesophagus or the stomach, its size, its risk of bleeding and whether it has bled before.
In oesophageal varices at high risk of bleeding, non-selective beta-blocker treatment or endoscopic variceal ligation (banding) may be used in suitable patients.
Treatment of gastric varices can be different. Depending on the type of varix, endoscopic tissue-glue treatments, EUS-guided coil or glue application, or interventional radiological methods may be considered.
In some patients, procedures that lower portal pressure, such as TIPS, may be needed.
What is variceal banding?
During an endoscopy, small elastic bands are placed over an oesophageal varix. This cuts off the blood flow through the varix and allows it to shrink over time.
Banding is used more for oesophageal varices. Because gastric varices have a different structure, the approach to treating them differs too.
Can varices disappear completely?
With treatment, varices can shrink or be eliminated endoscopically. But as long as portal hypertension continues, they can form again.
So it is not only the varix itself that has to be assessed, but the condition causing it.
Is a follow-up endoscopy needed?
Most patients need follow-up. But the interval is not the same for everyone.
The follow-up programme is determined taking into account the size of the varices, the treatment given, the state of the liver disease and the patient’s risk of bleeding.
Remember
- Oesophageal / gastric varices Are not cancer.
- A varix Is a widened vein.
- The most common cause Is portal hypertension and cirrhosis of the liver.
- Not every varix bleeds But the risk of bleeding should be assessed.
- Vomiting blood or black stools Can be an emergency.
- Gastric and oesophageal varices Are not treated the same way.
- In a patient found to have varices The cause, the risk of bleeding and a plan for follow-up should be determined.
This is not enough to make a diagnosis
When oesophageal or gastric varices are found at endoscopy, the location, type and size of the varices; the risk of bleeding; the state of the liver disease; and the cause of the portal hypertension all have to be weighed together.
Sources
- Prof. Ali Tüzün İnce, MD