Esophageal Varices

Esophageal_varices_waleThe subject of esophageal varices is by far the most dangerous aspect of portal hypertension.  Bleeding esophageal varices unfortunately is something some reader’s have already experienced, and no doubt do not want to experience again! Thankfully though there are endoscopic treatments and medications that can reduce the risk so there is hope.

Esophageal varices develop when normal blood flow to your liver is blocked by a clot to the liver  (portal vein thrombosis). The blood then backs up into smaller, more fragile blood vessels in your esophagus, and often in your stomach or rectum as well, causing the vessels to swell.  When the vessels swell there is risk for a rupture and subsequently bleeding will occur.

As mentioned above there are a number of drugs and medical procedures available to stop the bleeding.  Many of the drugs, such as some of the one’s I am on, are used to effectively prevent bleeding.  From what I understand about 1/3 of people with esophogeal varices can bleed.

Some of the symptoms of esophogeal bleeding range from mild to severe with some being more obvious such as vomiting blood, black, tarry, or bloody stools, and  in more severe cases shock.  Less obvious signs may be decreased urination from lower blood pressure, excessive thirst, or lightheadedness.  If you or someone you know is experiencing any or all of these symptoms please seek medical help immediately!

In December of 2004 I experienced a bleed, however it apparently did not originate from my esophagus but from the varices in my stomach.    A bleed of this nature is referred to in medical terms as a upper GI bleed (gastrointestinal bleed).   At the time of my bleed I came very close to having a blood tranfusion, but thankfully I did not lose enough blood for that to happen.  Due to advances in medications and endoscopic procedures, an upper GI bleed is commonly treated without surgery.  As in my particular case I am on a drug called Nadolol which is a common beta blocker prescribed to keep blood pressure low and prevent bleeding from varices such as these, or the esophagas.  Doctor’s also prescribed a drug for me called Pantoloc which reduces excessive acid in the stomach, thereby reducing the risk of acid wear on the varices in order to prevent bleeding.

When emergency treatment becomes necessary, blood and fluids are given intravenously to compensate for any loss.  Efforts are then made to stop the bleeding, and an endoscopy is performed to locate the actual site of the bleeding.

Although there are columns of varices in my esophagus that are classified as grade 3 (highest likelihood to bleed), at one time my doctor’s considered one of two methods which are usually performed on patients with ruptured varices.  One method involves banding (band litigation) whereby a rubber band is used to tie off the varices, and at some point the varices will fall off or “slough off”  in hopes to alleviate the danger.  In my case doctor’s decided against this procedure as they felt I would continue to bleed from the site which eventually would become ulcerated.  Because I have to be so highly anti-coagulated due to my underlying clotting condtion, banding is not possible as I would continue to bleed from the site where the varices fell off.

Another method used to treat the condition is called sclerotherapy. A drug, which I was told is somewhat like “Crazy Glue”, is injected into the bleeding vein, causing it to constrict (narrow). Sclerotherapy slows the bleeding and allows a blood clot to form over the ruptured vessel.

Bleeding esophageal varices can result in a very large amount of blood loss and many units of blood may need to be transfused. Once the bleeding is controlled, treatment is done to try to prevent additional bleeding in the future. In some cases, more banding is done to try to eliminate the varices.  Another consideration in severe cases can be the creation and insertion of a shunt.  A shunt could be best described as a pipeline or tube.  (At one time I was also considered as a candidate for this type of procedure, but it was decided that the danger would be far too great for me due to my underlying clotting condition).

A Transjugular intrahepatic portal-systemic shunt (TIPS for short) is a wide tube implanted within the liver so that blood is able to flow more quickly.  Usually blood must trickle through liver tissue in order to travel from the veins below the liver (the portal veins) into the three veins that drain the liver from above (the hepatic veins). This “trickling” is too slow when the liver is scarred – usually in the case of cirrosis.

A TIPS procedure is usually performed by a radiologist.  It involves placing a catheter in a vein in the neck and guided down through the liver creating a pipeline for blood flow.  At the end of the catheter a “stent” or wire mesh is placed within the liver to allow blood to flow more easily through the portal vein.  This treatment can reduce the excess pressure in the esophageal varices, and can decrease the risk of bleeding in the future.

Portacaval shunting is another option, but as I understand has been largely abandoned since the advent of TIPS.  Portacaval shunting is a major operation, requiring an abdominal incision.  Blood flow is diverted around the liver, usually creating a connection between the portal vein and the inferior vena cava (IVC).  The IVC is the large vein that carries de-oxygenated blood from the lower half of the body into the right atrium of the heart. Blood flow is diverted around the liver, usually by creating a connection between the portal vein and the inferior vena cava. This reduces pressure in the veins which drain the liver, decreasing the dilation of variceal veins in the esophagus, which otherwise are highly likely to rupture and bleed.  Portacaval shunting is generally reserved for patients who have failed TIPS.

If a TIPS procedure or other shunt procedure is required, some blood will pass through the liver without being totally detoxified by enzymes in the liver. Natural waste products in the blood can accumulate if the blood is not detoxified by the liver, and because of this some people who have had a TIPS procedure develop symptoms of confusion, called encephalopathy. There is medication though can reduce symptoms of encephalopathy.

Lastly … at least 50% of people who survive bleeding esophageal varices are at risk of more bleeding during the next one to two years. Just want to note that this topic by far is one that provokes strong emotions for me, as it is not the most positive aspect of portal hypertension. Nevertheless though it is one that needs to be discussed.       What is your story?

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