Bleeding varices

Bleeding varices is a life-threatening complication of portal hypertension, an increase in the pressure within the portal vein in the liver.

Varices are dilated blood vessels usually in the oesophagus or stomach. They cause no symptoms unless they rupture and bleed.

This increased pressure in the portal vein causes the development of large, swollen veins or varices within the oesophagus and stomach. The varices are fragile and can rupture easily, resulting in a large amount of blood loss.

The most common cause of portal hypertension is cirrhosis of the liver. Cirrhosis is scarring which accompanies the healing of liver injury caused by hepatitis, alcohol, or other less common causes of liver damage. In cirrhosis, the scar tissue blocks the flow of blood through the liver and slows its processing functions.

What are the symptoms of bleeding varices?

Symptoms of bleeding varices include:

• Vomiting of blood
• Black, tarry, or bloody stools
• Low blood pressure
• Rapid heart rate
• Shock (in severe cases)

How are bleeding varices treated?

Bleeding from varices is a medical emergency and treatment should be sought immediately. If the bleeding is not controlled quickly, a person may go into shock or die. In severe cases, a person may need to be placed temporarily on a ventilator to prevent the lungs from filling with blood. Aside from the urgent need to stop the bleeding, treatment is also aimed at preventing future bleeding. Procedures that help treat bleeding varices include:

• Banding: A procedure performed by a gastroenterologist in which small rubber bands are placed directly over the varices. This will stop the bleeding and eradicate the varices.
• Sclerotherapy: A procedure in which a gastroenterologist directly injects the varices with a blood-clotting solution instead of banding them.
• Drugs – including terlipressin, somatostatin, and octreotide are used to control bleeding
• Variceal obturation – a glue-like substance called N-butyl-2-cyanoacrylate is injected causing embolisation (blocking of blood flow) of the varices.
• Sengstaken-Blakemore tube – a softened rubber tube is passed through the mouth into the stomach, inflated, and pulled against the varices.
• Transjugular Intrahepatic Portosystemic Shunt (TIPS): A radiological procedure in which a stent (a tubular device) is placed in the middle of the liver. The stent connects the hepatic vein with the portal vein. This procedure is done by placing a catheter through a vein in the neck. It is performed to relieve the high blood pressure that has built up in the liver.
• Distal Splenorenal Shunt (DSRS): A surgical procedure that connects the splenic vein to the left kidney vein in order to reduce pressure in the varices and control bleeding.
• Liver transplant: A liver transplant may be done in cases of end-stage liver disease.
• Devascularisation: A surgical procedure that removes the bleeding varices. This procedure is done when a TIPS or a surgical shunt is not possible or is unsuccessful in controlling the bleeding.

Can bleeding varices be prevented?

Treating the underlying cause of bleeding varices can help prevent their recurrence and treating liver disease earlier on may prevent their development. Certain medications including the class of heart medication called "beta-blockers" may reduce elevated portal pressure and reduce the likelihood of bleeding. Long acting nitrates are also used for this purpose.