Variceal bleeding refers to bleeding from abnormal vessels called varices. Varices are abnormal connections between two circulations present in the body namely the systemic (taking blood to and from the heart to supply all the organs) and portal (draining blood from the gut to pass through the liver before the rest of the body) circulations. The most common site of varices is the oesophagus but the can occur at other sites in the gastrointestinal tract such as the stomach and rectum (back passage) or around the umbilicus (belly button). The abnormal connections are weak and more prone to rupture and bleed which is a medical emergency.

Variceal bleeding develops when pressures in the portal venous system get too high, called portal hypertension. Blood leaks and may be present in vomit or bowel motions. If lots of blood loss occurs, patients can become very sick. Treatment aims to stop bleeding as quickly as possible and to keep the patient stable.

Definition

Variceal bleeding or haemorrhage refers to bleeding from abnormal vascular connections usually found in the oesophagus (esophagus) or stomach. Varices develop when blood pressure in portal veins becomes greater then 10mmHg so blood gets pushed back through alternative routes in order to reach the heart rather than going through the liver. Bleeding occurs when the pressures become even higher. Variceal bleeding is a life-threatening complication of portal hypertension affecting up to 30% of patients with chronic liver disease such as cirrhosis. Of those patients who bleed, nearly half of patients will die and approximately one third with each subsequent bleed. Nearly all patients who have a variceal bleed will have bleeds again in the future, therefore it is very important that these dangerous conditions are identified and treated early to prevent recurrence.

Causes of Variceal Bleeding

As fore mentioned, the mechanism for the formation of varices is an increase in the blood pressure within the portal venous system (portal hypertension). Normally blood pressure in the portal vein is only 5-10mmHg but obstruction to the outflow of the vein through the liver and beyond can cause pressures to exceed 10mmHg. This causes the blood vessels to dilate and new special shunts (varices) to form between different vessels so the blood can bypass the obstruction and get back to the systemic circulation and heart. If blood pressures continue to rise beyond 12 mmHg bleeding will occur at these shunt sites as the newly formed vessels have weaker walls than normal blood vessels. The most common cause of portal hypertension is cirrhosis of the liver which causes disturbed structure of the liver as it tries to regenerate and heal itself from injuries caused by alcohol, hepatitis and many other causes. Cirrhosis leads to nodule formation and scarring of the liver tissue which upsets the normal architecture. Blood vessels therefore become blocked and there is a build up of blood pressure back through the portal vein and other vessels. Very rarely the portal vein itself may be obstructed by a clot or the vessels leading from the liver may become obstructed. This will also lead to portal hypertension and the formation of varices.

Signs and Symptoms

If you suffer from bleeding varices you may notice the following symptoms:

  • Vomiting which may contain blood
  • Black, tarry or bloody stools.
  • Reduced urine output.
  • Light-headedness.
  • Paleness.
  • Excessive thirst.

Remember variceal bleeding is an emergency and urgent medical treatment should be sought if you experience the above symptoms. Your doctor will examine you looking for signs of shock (such as heart racing, low blood pressure and cool, clammy skin) due to excessive blood loss. They will also look for signs of liver disease such as clubbing of the fingernails, enlargement of the breasts in males, abnormal spider veins of the skin and an enlarged or nodular liver (felt in the right upper part of the abdomen). The doctor will also insert a gloved finger into the rectum (back passage) to see if there is any blood or dark stools present.

Treatment of Bleeding Varices

Variceal bleeding is a medical emergency so treatment will start immediately. The doctor will determine how severe a patient’s condition is and start resuscitation promptly. It is important that an adequate airway is maintained and oxygen is often given. Occasionally the patient may need to go onto a ventilator to prevent blood entering the lungs. Next, two large drips will be inserted into the patient’s arm and fluids given to help replace the blood volume been lost. Blood transfusion may be needed in severe cases. Once the patient is deemed stable further treatment of the bleeding is required. Drugs such as somatostatin can be given that lower the blood pressure in the portal vessels to help stop the bleeding. Probably the best treatments for bleeding varices are endoscopic procedures. For this a tube with a camera is inserted down the patient’s throat and the varices are either injected with substances that make them clot (sclerotherapy) or have an elastic band tied around them (banding) to stop the bleeding. If these methods fail a balloon may be inserted into the oesophagus or stomach which when inflated provides pressure on the bleeding surface. Sometimes a procedure which inserts a device called a Transjugular intra-hepatic portocaval shunt (TIPS) will be performed if the bleeding does not stop or in patients with recurrent bleeds. This uses x-ray guidance to insert a metal stent (tube) into the liver so blood can drain. Rarely surgery will be needed to tie the vessels feeding the varix or to insert stents at other places. The latter procedures are more permanent and reduce the rates of rebleeding. If you have had a previous bleed or are known to suffer cirrhosis and varices, your doctor can offer other treatments to reduce the chance of future bleeds. The main class of drugs used for this is beta-blockers such as propranolol. These drugs specifically reduce the pressures within the portal vessels. In addition, repeated courses of banding and transjugular intra-hepatic portocaval shunts (TIPS) can be used as long-term measures to prevent recurrence.

References

  1. Azer S, Esophageal varices, eMedicine. Web MD, 2006. available at URL: http://www.emedicine.com/med/topic745.htm
  2. DeCaestecker J, Straus J. Upper Gastrointestinal Bleeding: Surgical Perspective. eMedicine. Web MD, 2006. Available at URL: http://www.emedicine.com/med/topic3566.htm
  3. Kumar, Clark. Clinical Medicine. 5th Edition. Saunders. 2002.
  4. Longmore, Wilkinson, Rajagopalan. Oxford Handbook of Clinical Medicine. 6th Edition. Oxford University Press. 2004.
  5. Medline Plus- Medical Encyclopedia, Bleeding esophageal Varices. US National Library of Medicine, 2005. Available [online] at URL: http://www.nlm.nih.gov/medlineplus/ency/article/000268.htm
  6. Williams A, Westaby D. Fortnightly Review: Management of variceal haemorrhage. BMJ 1994;308:1213-1217.