Varices are abnormally swollen or enlarged veins, similar in concept to the more common varicose veins seen in the legs. However, the term “varices” often refers to esophageal varices: dilated veins located in the lining of the lower part of the esophagus, the tube connecting the throat to the stomach.
Unlike the varicose veins in the legs, esophageal varices carry a severe risk of rupture and life-threatening internal bleeding. Their presence is a direct consequence of a serious underlying medical issue.
How Varices Form
Esophageal varices are a direct result of a condition called portal hypertension, which is an elevated blood pressure within the portal venous system. This system collects blood from the digestive organs and directs it through the liver before returning it to the heart.
The most frequent cause of portal hypertension is advanced liver disease, specifically cirrhosis, where scar tissue blocks the normal flow of blood through the liver. This obstruction causes blood to back up and increase the pressure inside the portal vein.
When the resistance to blood flow through the liver becomes too high, the body attempts to reroute the blood through smaller, alternative vessels known as collateral circulation. These detour vessels connect the high-pressure portal system to the lower-pressure systemic veins, bypassing the obstructed liver.
These collateral vessels form in several areas, but the ones in the lower esophagus are particularly vulnerable because their walls are thin and not designed to handle the high volume and pressure of the diverted blood. As the pressure continues to rise, these vessels balloon outward, becoming the dilated and tortuous veins known as esophageal varices.
Recognizing the Symptoms and Diagnosis
Esophageal varices often do not cause any noticeable symptoms until a major complication occurs. Patients with known liver disease, however, may exhibit signs like jaundice, fluid accumulation in the abdomen (ascites), or easy bruising, which indicate the underlying cause.
The most serious and often first sign of varices is a rupture and subsequent bleed, which is a medical emergency. This acute bleeding can manifest as vomiting large amounts of bright red blood, known as hematemesis. Another sign is the passage of dark, tarry stools, or melena, which indicates blood that has been partially digested.
Because varices are often silent until they bleed, screening is performed for all patients diagnosed with cirrhosis to identify them proactively. The primary diagnostic tool is an upper endoscopy, or esophagogastroduodenoscopy (EGD). During this procedure, a doctor guides a thin, flexible tube equipped with a camera down the throat to visually examine the lining of the esophagus.
The doctor assesses the varices for size, which is a major factor in determining the risk of bleeding. They also look for specific visual markers, such as red streaks or spots on the surface of the varices, which indicate a high risk of imminent rupture. Based on these findings, a management plan can be initiated to prevent the first bleed.
Medical Interventions and Management
The medical management of varices focuses on two main goals: preventing the first bleed (primary prophylaxis) and treating active bleeding episodes (acute management).
Primary Prophylaxis
For preventative management in patients with high-risk varices, a class of medication called non-selective beta-blockers, such as propranolol or nadolol, is commonly prescribed. These medicines work by lowering the blood pressure in the portal vein, reducing the tension on the variceal walls and decreasing the likelihood of rupture.
Endoscopic variceal ligation (EVL), or banding, is another effective preventative strategy for medium-to-large varices. This procedure is performed during a screening endoscopy, where a small elastic band is placed around the enlarged vein, effectively strangling it. Over time, the banded varix clots, shrinks, and is replaced by scar tissue, eliminating the risk of bleeding from that site.
Acute Management
In the event of an acute, life-threatening bleed, immediate treatment is necessary to stop the hemorrhage. IV medications like octreotide are administered to slow blood flow into the portal vein and reduce the bleeding pressure. Concurrently, an emergency endoscopy is performed to directly treat the bleeding source.
EVL is the preferred first-line treatment for an active bleed, as it quickly stops the hemorrhage with a lower rate of complications. Another option is Endoscopic Injection Sclerotherapy, which involves injecting a chemical solution into the varix to cause it to clot and harden.
If endoscopic methods fail to control severe or recurrent bleeding, a more advanced interventional procedure called Transjugular Intrahepatic Portosystemic Shunt (TIPS) may be performed. TIPS involves creating a channel within the liver to divert blood flow from the portal vein into one of the main hepatic veins, dramatically reducing the portal pressure. TIPS is typically reserved for severe cases due to its complexity and potential for complications, like hepatic encephalopathy.