The 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?
My partner his mum and nephew all have portal hypotension which the consultants say is very rare to run in the family let alone 3 generations.my partners ruptured and he was bleeding not only from his bowel but vomiting large amounts of blood he had to have 15 bands and 8 blood transfusions in 24hrs it was madness he was extremly poorly and had to be transferred to another hospital for treament spent 7 days in hospital.he came home and about 5 days later they burst again i had to call an ambulance after finding him collapsed over our toilet vomiting large amounts of blood again he had another 7 bands and 2 blood transfusions.after that he had to have an endoscopy every 6 wks and more bands he also had a transjugula liver biopsy.after 2 yrs of this at his last appointment no bands were needed but he still needs to have a larger liver biopsy.also they want our children to have a liver biopsy to see if there liver shows signs of this condition not somthing i would like to put them through.hopfully they will get the all clear.
I’m very shocked and sorry to hear this. I’ve never heard of Portal Hypertension being genetic, but clotting conditions themselves can be. 2 of my own siblings have had clotting issues, but fortunately have not had a clot in the portal vein leading to the condition of portal hypertension. Please keep me informed of your partner and his families condition. In my thoughts and prayers, Clint
Hi! Thank you for this article. I am 6 years post PVT diagnosis and just learned yesterday I have grade 3 esophageal varices. I’m not a shunt candidate. I have naturally low blood pressure. The do wants to try betta blockers. I’m scared i’ll pass out all the time. Do you have any advice? Also, I have portal hypertensive gastropathy of the entire stomach lining. Do you know what that means? I can’t really make sense of what the risks are associated with that.
Hi Erica, As mentioned before I also have grade 3 varices with only one bleed (in the stomach) back in 2004. I am not a shunt candidate also. As for beta blockers this is the most common treatment protocol for people like us. Currently I am on 160 mg of Pro Nadolol and have been on that for a number of years now. Besides being occasionally tired (could be my age), I do very well and live a normal life. I know less of portal hypertensive gastropathy, but understand it is associated with cirrhosis of the liver. Although I have some liver deterioration due to PVT (my original diagnosis), the cause was not cirrhosis from alcohol, or hepatitis (A or B).
For the benefit of all here is what Wikipedia says about the specific condition (click link): https://en.wikipedia.org/wiki/Portal_hypertensive_gastropathy
After reading through this I thought that maybe this was the cause of the bleed I had in 2004? Looks like the cause is from changes in the mucosa inside the stomach lining which, if I’m understanding this correctly, can exacerbate the veins on the lining of the stomach causing a bleed. As this is the very first time I have heard about this, it may be that I need to update my blog to include this information in a clearer way.
My husband has had 2 liver transplants, a bile duck reconstruction, with results of having a shunt put in his portal vein. This was around 7 yrs. Ago. Now he is having encephalopathy & flapping problems unless he takes lactulose (45 ml. 3 or 4 X a day) & of course xifaxan 2 X. With all of that Dr. Wants him to hav a BM 2 or 3 X a day. So far he only goes once a day. They want him to up the Lactulose to 60 ml 3 x a day. It seems like so much. His ammonia level was 169 last checked.
I am wondering how long a person can live having watery stools forever. It’s been 4 mo. Now? His liver counts are good, so the Dr. Said the problem comes from the portal vein. Will it gets worse???
Sorry for the delayed response, but most of all I am sorry to hear of your husband’s condition. Let me encourage you my saying that I, and many others I know through this blog and other sites, have lived several years beyond our diagnosis. Although I can’t predict if your husbands condition will worsen, I still have watery stools and I am on Loperamide to slow down the intensity of these episodes. Along with the Loperamide I take probiotics and acidophilus on a daily basis which I believe has really helped me. I still get associated pain related to those dreaded episodes, and the pain of course is due to the veins in my intestines being engorged with blood due to the condition. Maybe you could try adding these supplements to see if it will help him? Before adding any supplement, I always encourage people to first check with there physicians in the event of interactions from meds. Thanks for contribution. If you have any other comments or questions please let me know! Best regards, Clint