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 husband has 3 column oesphageus varicies and was taking 20 mg propanol but the doctor has currently said him to increase the limit of 4o mg.i am so worried sinct the dose of medicine has been increased and as wel before 1 year it was only 2 column oesphageus varicie and nw its 3..is it getting worse?what can we do to bring it to normal??please help me
So sorry to hear about your husband’s condition. I hope this is encouraging but I have 3 columns of grade 3 varices and I have lived 10 years since my diagnosis. I am now on 160mg of propanol and this is a very high dose when compared to your husband. Each person is different I know and if your husbands doctor is monitoring his condition, it may be the correct dose. There are so many factors involved, and I always say – check first with your doctor before telling him/her that your husband needs to be on this dose also. Unfortunately over time the condition will progress, and the only time, according to what I learned from my specialist, is that the clot will dissolve in the acute stage shortly one is diagnosed. It is not true for everyone, but the possibility is there albeit slim. Propanol is the standard treatment for the prevention of bleeding worldwide, and if there is a bleed I know people who have survived and are still living years beyond these episodes. I had a bleed in the varices in the upper part of my stomach in 2004, and fortunately it stopped on its own, however they can band the varices in emergency situations – but only in the oesophagus. I monitor my pulse rate and doctor’s base the dosage of propanol on one’s individual tolerance for that level of medication. To say to what degree the varices will progress is something I just do not know, and I suspect the doctor’s may not even know this either. Do they know what caused his PVT? Is he also taking a blood thinner?
I know this may not be what you are wanting to hear, but please know I will pray for your husband as I fully understand what you are feeling. Please keep me posted on his condition, and if there are other questions I will do my best to answer them from personal experience, or learning from another. Hope this helps?
Congratulations on your sons graduation!!! How exciting that must be. I would really love to travel to Germany as well. I am very happy to hear that you are doing well.
I have been having a really hard time with the loss of my love, Jeffrey, but again I thank you for your thoughts and prayers and the great information you are providing for people with this condition as it is so hard to understand as each person reacts differently to medications.
You are truly a God send to me as you provided much needed information and a kind ear. I always wish to keep in contact with you as you make my heart happy. You are always in my thoughts and prayers. God Bless.
Thanks for your encouragement! I often think of you and have even mentioned you to some of my family, and a few trusted friends. The last few weeks have been extremely busy for me and my family, and quite literally we have been running from one event to another. The week of my son’s grad we had a 50th birthday celebration for my sister, the grad itself, a year end wrap up for the board I serve on, and it all ended with a family reunion. The weeks all have been busy in fact, and I feel bad because I have wanted to update my blog for quite awhile but have been unable to do so. I have a post I have been working on for a few months now, and although it is not wordy by any means, it has taken me awhile as I keep going back to it and modify it. I think it has something to do with my perfectionist personality!
Anyways I do pray for you and I really appreciate you keeping abreast of things on this blog despite being what you have been through with Jeffrey. I believe it is important for people to continue to talk about things and remember all the good memories that God allotted them through their loved ones. Some people will evade speaking about the person that passed away, for fear of bringing that person down. I’m not one to give “pat” answers to anyone, but want to honestly say that it is important for people to be able to grieve, and to be free to talk about the person. On the same stand people need to know the realities of PVT so to hide this is of no benefit to anyone.
I came naked from my mother’s womb,
and I will be naked when I leave.
The Lord gave me what I had,
and the Lord has taken it away.
Praise the name of the Lord!” Job 1:21
I pray that you continue to be comforted in the days/months/years ahead.
Thanks again for writing!
Good Morning Clint,
Thanks for getting back to me! I understand that you have been very busy and what a happy time it has been for you. Good to hear that you got to see family at a reunion.
As you said, I am grieving but talk about Jeffrey all the time. I was lucky to have him in my life for 19 years. I thank God for him. I learned alot from him as he loved American history. He had the biggest laugh that came from his heart. He loved to make people laugh and just loved to be goofy=)
I keep playing things over in my mind and just remember the doctor coming into the family room in ICU saying “We’ve done everything we can and we just can’t save him”.
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Just to let you know that I am still here and doing OK. I have had problems with
1. clotting – I bruise easily but still take vitamin K orally. I think the jury is still out on that one.
2. like many other things, the jury is still out on other supplements, but I believe it is important to keep all B vitamins high
3 I am often asked about milk thistle – most of the evidence suggests it is hepatoprotective for ethanol, but if you have cirrhosis there is no clear data one way or another
4 I am encouraged by a report in the Journal of Pathology which suggests that liver fibrosis (cirrhosis) may be reversible by a newly discovered mechanism which “eats” collagen. It may be, that with complete abstinence, that cirrhosis is reversible. I have always been amazed by the regenerative capacity of the liver, given a chance.
Best of luck to everyone.
You can contact me through Clint
Tony MB PhD FRCPath
Thanks Tony … I’m always intrigued by your comments and so appreciate the expertise you bring to the table on portal hypertension albeit through the eyes of a pathologist! I saw my hematologist yesterday and we discussed some of the variables that may have played apart in the latest episode I have had with clotting (Mesenteric Venous Thrombosis). They are not sure if the TPA worked or not at this point, however time will tell if the discomfort in my bowel region is alleviated. At any rate he told me that it may be likely someone has attempted this methodology for the clot I had, but in our hospital (maybe even Canada) that he had not heard of this before. I figured at the time it was offered that I had no choice so I went for it, as dangerous as it was, rather than have the bowel die and a dissection done!
Concerning B vitamins, I coincidentially asked him today about the recommended dosage, and he said that B75 is a good amount as opposed to B50 which I have take for many years. It really is important for the homocsysteine levels.
What is this newly discovered mechanism for reversing liver damage? I am interested in this one because I know of people who dealing with this aspect also.
Concerning Milk Thistle … are you still taking this?
Thanks again Tony!
Yes, I am still taking milk thistle. I don’t know if it works, but it doesn’t appear to do any known harm.
The paper I mentioned described a novel endocytic pathway for the breakdown of collagen in liver fibrosis. Here’s the link:
By the way, pathology is the study of disease. Only a very few actually dissect dead people!
Best wishes to all
As always thank you Tony! I will check out the link – I know someone right away that may be interested in this information.