Esophageal varices are enlarged, fragile veins located in the lower section of the swallowing tube, known as the esophagus. These swollen vessels form as a direct consequence of severe liver disease, most commonly cirrhosis. A rupture of these varices is a serious medical emergency that results in catastrophic internal bleeding. This article provides information regarding the physiological experience during a terminal variceal rupture and the comfort care provided.
Understanding Esophageal Varices
The formation of esophageal varices begins with a condition called portal hypertension, which is an abnormally high blood pressure in the portal vein system. The portal vein collects blood from the digestive organs and carries it to the liver. When scar tissue from cirrhosis blocks the normal flow of blood, pressure builds up in the portal vein.
The body attempts to relieve this increasing pressure by rerouting the blood through smaller, collateral vessels that are not designed to handle high volume or pressure. These bypass channels often form in the thin-walled veins of the lower esophagus. As these veins swell from the excessive pressure, they become the fragile, dilated vessels known as varices.
A threshold for rupture occurs when the pressure within the portal system rises significantly, often exceeding 12 millimeters of mercury. The variceal walls are thin and cannot withstand this constant, elevated pressure, leading to a high risk of tearing. This explains why a rupture results in a sudden and massive hemorrhage into the gastrointestinal tract.
The Immediate Physical Experience of a Rupture
The moment a varix ruptures is typically not described as a sharp, localized pain in the esophagus itself. The esophageal lining does not contain the same density of pain receptors found in other areas of the body. The intense distress experienced is instead caused by the rapid, massive internal bleeding that follows the rupture.
The overwhelming sensation is often extreme nausea and the forceful vomiting of large amounts of blood, known as hematemesis. This sudden event triggers significant panic and anxiety. As blood volume decreases rapidly, the body quickly enters hypovolemic shock, which is the primary source of physiological collapse.
Symptoms of shock manifest as rapid heart rate, lightheadedness, and dizziness as blood pressure drops precipitously. The massive blood loss quickly leads to confusion, paleness, and clammy skin. In cases where the bleeding is uncontrolled, the rapid decline in blood pressure ultimately causes a loss of consciousness relatively quickly, limiting the duration of suffering.
Acute Medical Intervention and Comfort Care
When an acute variceal bleed occurs, the medical response is immediate and aggressive, focusing on stopping the hemorrhage and stabilizing the patient. Initial measures include administering intravenous fluids and blood transfusions to restore lost volume and maintain blood pressure. Medications known as vasoactive drugs are also started immediately to help reduce the blood pressure within the portal vein system.
Emergency endoscopy is performed to directly treat the source of the bleeding, often using a procedure called endoscopic variceal ligation (EVL). This involves using small elastic bands to tie off the bleeding veins, stopping the blood flow. If these measures fail to control the bleed, or if the patient’s underlying liver disease is too advanced, the focus of care shifts entirely to comfort.
In these terminal scenarios, palliative care prioritizes the management of all distressing symptoms. High doses of opioid analgesics, such as morphine, and sedatives, including benzodiazepines, are administered to manage discomfort, anxiety, and panic. This approach ensures that the patient remains calm, comfortable, and often sedated, allowing for a peaceful transition without the conscious experience of the physiological collapse.