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?
Milk Thistle,
I don’t know if this works, but I have it from some of my hepatology friends that they would take it if they had cirrhosis. As far as Western medicine is concerned, NOTHING can reverse scarring which is the main problem with cirrhosis. But all the evidence is that milk thistle cannot harm you.
Please ask Clint to pass on any queries to me, I will do my best to help.
Thanks Clint,
I read so many amazing stories here, and from such wonderful people that I feel really close to them. I perhaps am not long for this earth, but I hope I can give the benefit of my knowledge to others. I think it must be one of the tragedies of mankind that we cannot pass on our life experiences. If only our old brains could be infused into new ones!
Clint, I have to say that you are one of my heroes. Everything you have done is amazing, and I am glad to help anyone (as a medical doctor, everything anyone tells me is confidential). Clint has my email if you want to contact me directly.
Dr Tony
Dear Dr. Tony,
Thank you for your very kind words of encouragement. I pray you will live long despite the odds, and continue to share your knowledge with many others. You’re on my list and I will refer you whenever the occasion arises.
Take care,
Clint
Good Morning Clint,
I’m glad to hear you are doing well. I am struggling greatly and miss my Jeff so much words cannot describe. I appreciate your prayers and there is nothing more you can do for me. This site has been of the greatest help and information for me and thank you greatly.
Heidi
Good Morning Clint,
I left a message the other day for you but do not see it. I want to thank you again for your thoughts and prayers. I have been doing as good as can be I suppose. There is nothing more you can do than what you have been doing and it is greatly appreciated and comforting. Have a great day and I will stay in touch.
Heidi
Good Morning Heidi,
I think of you often and so appreciate your thoughtful comments.
I am sorry I have not had the chance to post your comments as the last few days have been very busy for us. This past week has been crazy! Our son is graduating from high school this June, and is preparing to go to Germany in September for a 6 month term of school. He has a full-time job lined up for the summer to help with expenses, but we are trying to get all the things he needs to get done before school ends and he begins working. I have also been on the run as I am taking light treatments (narrow band UVB – 3 times per week) for psoriasis which I have been battling for the last 6 years or so. BTW – I am not complaining about being busy, but am grateful for the stability in my health, which I mostly attribute to prayer (thank you) and sticking to the regiment of my medications and associated treatments.
I am honoured that you would stay in touch – this means allot to me, especially after what you have been through with Jeff. I have relayed your story to many of my friends this past few weeks, as it is a sobering reality of what people are up against with this condition. Still praying for you that the Lord will comfort you and give you strength to carry on without your beloved husband.
In your corner, Clint
Hello Clint and all,
I have a conundrum. I was diagnosed with portal vein thrombosis in Sept. 2008. I have commented on this website before and my story is similar to many of you. I have had 9 endoscopes to band and check on esophageal varices over the last three and a half years. I just had a 6 month check up earlier this week and the good news is no new varices were found. I will have a follow up scope in one years time. Here is my concern: The surgeon suggested that I go off the beta blocker (propranolol 20mg/day) I was prescribed by a gastroenterologist/surgeon I was referred to in a larger hospital (Kelowna, B.C.) as we did not have a surgeon who did banding in my town when my varices were first discovered in Dec. of 2008. Fortunately, for me, a surgeon arrived at our hospital shortly after who was qualified to band esophageal varices. Said surgeon, thinks that the beta blocker is of minimal value to my condition. However, I am reluctant to follow this advice as everything I have read and been told previously indicated “the” standard treatment for varices is beta blockers and banding. I do not want to compromise my condition in any way yet do not want to take medication unnecessarily. As everyone has discovered our condition is rare and there is little information to be had even from the medical community. I have learned more from this site than almost anywhere else. So, Clint, if you or anyone else could shed some light on my concern it would be greatly appreciated.
Audra
Hi Audra,
Always appreciate your comments and support of this website. I am perplexed by your conundrum also, and because I am not a doctor I hesitate to advise you on this. There are a number of questions I would be asking though and the first one would be is this new surgeon a liver specialist? A gastroenterologist would be the best choice, but you said you had dealt with one in Kelowna. Would it be worth it to get an opinion from that doctor before following this new doctor’s advise? I say this because shortly after I was diagnosed in July of 2002, the gastroenterologist I was dealing with at the time wanted to remove my spleen as it was enlarged. Providentially both my wife and myself at the time thought this was drastic, so we ended up calling the haematologist who had come over to the hospital I was at a few months earlier, and he said “no way is anyone taking out your spleen – come see me here”, which was the U of A hospital. On the other hand the surgeon could be right in saying you don’t need beta blockers as you do not have varices to contend with. Maybe you were thinking more preventative, which I really can’t blame you for doing so in your case. Would your family doctor refer you to another specialist? Of course it all depends how accessible that person would be from where you are – correct? I had heard that there was a portal hypertension clinic in Victoria, and prior to that had always believed that Edmonton had the only one in the West. Let me know what happens?
Best, Clint
Good morning Clint,
Thank you for your prompt response. My next step was pretty much what you suggested. I plan on getting a referral from my GP back to the gastroenterologist in Kelowna to see what he recommends. I was very impressed with Dr. Borthistle as he seemed very knowledgeable about PVT and had seen many cases over the years (hope he hasn’t retired). It will be worth the wait and the 3.5 hour drive over mountain roads to have peace of mind.
Yes, my thinking is to continue taking beta blockers as a preventative measure. Although I do not have any varices at this time, through experience I know that more can develop and I do not want to put at greater risk for a bleed which I have avoided so far. Also, I will check to see if there is a portal hypertension clinic in Victoria in case I ever need its’ services.
In general, I am doing fine. I have learned to accept my condition and deal with the side effects as positively as possible. You have been very helpful in clarifying my problem and it also helps that you live in my neck of the woods and understand the medical system and the difficulty of receiving care in a rural location.
Thank-you for your time and I will keep you posted.
Audra
Good morning,
Just a quick update on my situation. I saw my GP yesterday and she discussed and gave me the surgeon’s report/results from the upper scope I underwent last week. This is a direct quote from the report: “Given the presence of gastric varices, I have recommended that she continue with her prophylactic propranolol.” To my recollection, there was no mention of gastric varices after any previous scopes (I’ve had 9 to date) or consultations. I have looked in my records and could not find any reference to the presence of “gastric ” varices . For me, the lesson re-learned here is, as a patient, one must constantly ask questions and not assume anything by omission. Clint thank you for your support. I am still optimistic that progress will be made in dealing with our conditions and have not ruled out the possibility of a complete recovery.
Take Care,
Audra
Thanks Audra … you are right – we need to constantly ask questions and not assume anything! Thanks for remaining optimistic through all this, besides myself others may be encouraged by this also. A thought just occurred to me that if one still has PVT, and there is no evidence of gastric varices, I think it would be far safer to be on propranolol that not to, as eventually that pressure is going to cause the varices to form in the end.
Stay positive and keep us posted on any changes!
Take care,
Clint