Esophageal Varices

What are esophageal varices?

Esophageal varices are enlarged veins in the lining of your esophagus, the swallowing tube that connects your mouth to your stomach. Varices are serious because they have weakened walls that can leak or break and bleed. Internal bleeding from a ruptured vein can be sudden, severe and life-threatening.

Esophageal varices occur in people with portal hypertension, which is high blood pressure in the portal vein that runs through your liver and the other veins that branch off from it. Abnormal pressure causes the thin esophageal veins to swell and enlarge. This most often occurs in people with liver disease.

How serious are esophageal varices?

Bleeding is the most serious risk of esophageal varices. Not everyone will experience bleeding, but up to 50% will. The risk increases as portal hypertension increases. When portal hypertension results from chronic liver disease — which is most of the time — it worsens as your liver condition worsens.

People with advanced liver disease (cirrhosis) have other concerns besides esophageal varices. But bleeding varices are the most common cause of hospitalization and death in people with cirrhosis. An episode of variceal bleeding has a mortality rate of around 20%, and bleeding often recurs (comes back).

How common are esophageal varices?

In people diagnosed with cirrhosis of the liver, 30% already have portal hypertension and esophageal varices at the time of diagnosis. Up to 90% will develop them over the next 10 years. In general, more severe cirrhosis leads to increasing pressure and larger varices, which are more likely to rupture.

What are the signs and symptoms of esophageal varices?

Esophageal varices aren’t visible from the outside like varicose veins in your leg might be. They’re deep inside your chest cavity, usually close to the bottom, where your esophagus meets your stomach. You’re not likely to feel them when you swallow. They usually don’t cause symptoms at all until they bleed.

A healthcare provider might suspect that you have esophageal varices if they see other signs suggesting portal hypertension or chronic liver disease. These might include:

• Jaundice, a yellowing of your skin and eyes.
• Ascites, a buildup of fluid in your abdomen.
• Edema, swollen legs and feet.
• Upper abdominal pain (your liver or spleen might be sore).
• Itching (pruritus), with no visible rash.
• Confusion or disorientation (hepatic encephalopathy).

If one of your varices ruptures, you probably won’t feel anything at the time. But look out for signs of gastrointestinal bleeding or blood loss. These might include:

• Vomiting blood. A slow blood leak may show up as dried, coagulated blood, which looks like coffee grounds. A ruptured vein will produce fresh, red blood in your vomit.
• Blood in your poop. If you swallow blood and it passes through your digestive system, it will usually be black by the time it comes out in your poop, making it look like tar (melena). However, a rapid bleed may show up as fresh, red blood.
• Pale complexion, as though the blood has drained out of your face.
• Feeling tired, weak and lightheaded. These may be signs of low blood pressure.

Seek emergency medical care if you develop symptoms of severe blood loss and hypovolemic shock. These might include:

• Fast heart rate.
• Fast breathing.
• Cold, clammy skin.
• Sweating.
• Anxiety and confusion.
• Loss of consciousness.

What causes esophageal varices?

Esophageal varices are a direct consequence of portal hypertension, which is high blood pressure in your portal venous system. This includes the portal vein that runs through your liver and the smaller veins that branch off from it, sending blood back to your heart and into general circulation in your body.

Your body compensates for portal hypertension by redirecting blood flow into smaller veins that aren’t designed to handle the greater volume. The smallest of these, with the thinnest walls, become enlarged. These veins are in the mucous lining of your gastrointestinal tract: your esophagus, stomach and anus.

Are esophageal varices different from other gastrointestinal varices?

Because they’re so delicate and close to the surface of the organ, esophageal varices tend to enlarge more, rupture more often and bleed more heavily. Varices in your stomach or anus may also rupture and bleed. But this happens less often, and when it does, the bleeding is less often severe.

Gastric varices (in your stomach) usually produce small, slow bleeds that stop spontaneously. They cause bruising and tissue damage to your stomach lining (portal hypertensive gastropathy). Varices in your anus might resemble hemorrhoids, but you probably wouldn’t notice them unless they rupture.

What causes esophageal varices to rupture and bleed?

Pressure gradually increases until a rupture occurs. There doesn’t seem to be any precipitating event, but rupture usually occurs when blood pressure in the vein has risen by 50% to 100%. Varices that bleed are usually larger than 5 millimeters. Smaller varices reach this size at an average rate of 8% each year.

What causes portal hypertension?

The most common cause is cirrhosis of the liver. “Cirrhosis” means scarring. This is the result of long-term, chronic liver damage. Constant inflammation (hepatitis) in your liver tissues eventually turns them into scar tissue, which blocks the flow of blood through the portal vein. This is a gradual process that usually takes decades.

Cirrhosis is the end-stage of any chronic liver disease, including:

• Alcohol-induced hepatitis.
• Nonalcoholic steatohepatitis.
• Chronic viral hepatitis.
• Autoimmune hepatitis.

Other causes of portal hypertension include:

• Granulomas of the liver. Granulomas are collections of inflammatory cells that accompany various infections and inflammatory diseases. They can obstruct your portal vein as benign tumors, and they’re sometimes followed by scarring. A parasite infection called schistosomiasis, which affects 230 million people worldwide, is the most common cause of liver granulomas.
• Blood clots. Thrombosis in your portal venous system can obstruct blood flow into your liver, through your liver or out of your liver. Many things can cause this, including inherited diseases. A blood clot in one of the veins coming out of your liver is known as Budd-Chiari syndrome.
• Enlarged spleen. This may be a symptom of liver disease or an acute infection. A swollen spleen may create new blood vessels that feed into the portal venous system.
• Heart conditions. Right-sided heart failure or constrictive pericarditis may create pressure and backflow in your portal venous system.

How do you know if you have esophageal varices?

You probably won’t know until a healthcare provider checks you. If you’ve already been diagnosed with cirrhosis, your healthcare provider will probably recommend regular screening for varices. But people don’t always know that they have liver disease, even when it’s advanced.

How are esophageal varices diagnosed?

A healthcare provider will evaluate your symptoms and health history, including any current or chronic conditions. An initial physical exam may show signs of bleeding, blood loss or liver disease. They’ll follow up with blood tests and imaging tests to look for evidence of portal hypertension and varices.

What tests can show esophageal varices?

If you don’t have signs of active bleeding, your provider might begin with noninvasive imaging tests, such as a CT scan, magnetic resonance angiogram (MRA) or Doppler ultrasound, to look at your blood vessels and blood flow. If they find evidence of varices, they might want to follow up with an endoscopy.

What is an upper endoscopy?

An upper endoscopy (also called an EGD test) is an examination of your upper gastrointestinal tract. That includes your esophagus, stomach and the top of your small intestine (duodenum). A gastroenterologist, a specialist in gastrointestinal diseases and endoscopic procedures, performs it.

The endoscope is a long, thin tube with a tiny camera on the end. It passes down your esophagus, into your stomach and duodenum. The camera projects to a monitor, showing your endoscopist what’s inside. If they find issues, they can treat them with instruments passed through the endoscope.

Can esophageal varices be treated?

Healthcare providers have several ways of treating varices to prevent and control bleeding. Most treatment is aimed at damage control. Varices usually don’t reduce and go away, unless portal hypertension does. This may be possible in some cases, depending on the condition causing it.

What is the treatment for esophageal varices?

The goals of treatment are to:

1. Control active bleeding.
2. Prevent future bleeding.
3. Reduce portal hypertension or prevent it from worsening, if possible.

Controlling variceal bleeding

Bleeding from esophageal varices is an emergency that requires immediate treatment. Supportive care in the hospital may include:

• IV fluids.
• Blood transfusion.
• Mechanical ventilation.
• Antibiotics to prevent infections.

When your condition is stable, you’ll have an emergency upper endoscopy to diagnose and treat the bleeding. Treatment during endoscopy will include:

• IV medications to reduce blood pressure and tighten veins in your portal venous system. Commonly used medications include octreotide, vasopressin and somatostatin.
• Variceal band ligation: An endoscopist will wrap tiny elastic bands around bleeding varices to cut off their blood flow. They may also treat larger varices at risk of future bleeding.

Follow-up treatment after variceal band ligation includes:

• Proton pump inhibitors, medications to promote healing of small wounds in your gastrointestinal tract.
• Regular screening for additional bleeding, and additional variceal band ligation if necessary.
• Additional procedures to redirect portal blood flow if band ligation fails.

Preventing variceal bleeding

If you’ve already been treated for bleeding, or if your varices aren’t bleeding yet but are at risk, your healthcare provider will offer you preventive treatment. Prevention generally includes:

• Beta-blockers: These medications, which are commonly prescribed to treat high blood pressure, can reduce the risk of variceal bleeding by up to 50%. But they may not be appropriate for everyone. Your healthcare provider will outline the risks and benefits of your condition.
• Variceal band ligation: You may have band ligation as a preventive procedure if beta-blockers aren’t appropriate for you.

Treating portal hypertension

If the above treatments don’t reduce your risk of variceal bleeding, or if you’re having other complications from portal hypertension, your provider might recommend alternative procedures to reduce portal hypertension in the portal vein itself.

Procedures include:

• Transjugular intrahepatic portal-systemic shunt (TIPS): In this nonsurgical procedure, an interventional radiologist uses X-ray imaging to guide a slim catheter through a vein in your neck into your liver. They send a guidewire with a needle on the end through the catheter to the portal vein in your liver. The needle creates a new connection between your portal vein and one of your hepatic veins, the veins that drain blood from your liver. This diverts some of the blood flow in your portal vein and reduces pressure. After withdrawing the needle and guidewire, they send a stent through the catheter and place it to keep the new channel open. This procedure can be very effective, but can also cause complications if the stent is too large and redirects too much of your portal blood flow. The redirected blood doesn’t get filtered as it normally would, so toxins in this blood flow will go back into your circulation. These toxins can build up and cause mild cognitive impairment (hepatic encephalopathy). The shunt can also close up again over time, especially if the stent is too small. This would require another procedure to fix.
• Distal splenorenal shunt (DSRS): This surgical shunt procedure has strong long-term results, but you have to be in good condition to safely undergo it and recovery. The procedure redirects portal system blood flow by disconnecting your splenic vein from your liver and attaching it to your left kidney vein instead. This selectively and permanently reduces pressure.

Treating the cause

Portal hypertension may improve by treating the cause in some cases. If the cause is a blood clot or an infection that can be cured, curing these might cure portal hypertension. Liver damage can improve up to a point, depending on how far advanced it is. This also depends on what’s injuring your liver.

Possible ways to reduce liver damage include:

• Quitting alcohol. If alcohol use is the cause of your cirrhosis, quitting will significantly improve your condition. Your healthcare provider can offer resources to help you quit. Even if alcohol isn’t the main cause of your condition, it’s always a factor in your liver health. Avoiding it can prevent unnecessary stress on your liver.
• Losing weight. Metabolic factors related to having obesity are among the leading causes of liver disease. If you have fatty liver disease, losing fat can change these metabolic factors, reduce fat storage in your liver and prevent further damage. Even if these aren’t the cause of your condition, they affect your liver health.
• Testing and treatment for hepatitis C. Chronic hepatitis C is another leading cause of cirrhosis. Some people don’t know they have it, and some people don’t know that it’s treatable. Testing and treatment can cure you of the virus and prevent further liver damage. (Remember, liver disease can have more than one cause.)

Can esophageal varices be cured?

Varices sometimes reduce with treatment, especially if portal hypertension can be reduced. But they rarely go away completely. Once you’ve been diagnosed with esophageal varices, your healthcare provider will want to keep a close eye on your condition. Even with treatment, new bleeding is always a risk.

What is the life expectancy of someone with esophageal varices?

Your outlook depends on:

• Whether you have variceal bleeding.
• How advanced your liver disease is.

Only about 50% of people with esophageal varices have bleeding. But most people who have esophageal varices have other factors affecting their life expectancy. When liver disease advances to liver failure, it’s eventually fatal without a liver transplant. Other conditions also apply.

The state of your liver disease partly determines your risk of bleeding. And if you do have bleeding, the state of your liver disease greatly influences how well you’ll recover. Mortality from a single episode of bleeding ranges from 10% in early liver disease to more than 70% in the advanced stages.

In overall statistics:

• The risk of mortality from your first episode of variceal bleeding is 20%.
• In 40% of cases, bleeding resolves spontaneously without treatment.
• In 90% of cases, treatment with band ligation controls the bleeding.
• However, the risk of new bleeding is 60%, regardless of treatment.
• The risk of mortality from your second episode of bleeding is 30%.
• The one-year survival rate for people with cirrhosis and bleeding is 50%.

A note from Cleveland Clinic

Esophageal varices are among the most serious complications of portal hypertension and cirrhosis. But liver disease takes time to advance to this stage. If you catch it earlier, you can use the advantage of time to make lifestyle changes that may improve the course of your disease, preventing varices.