Oesophageal varicies

What are oesophageal varices?

Oesophageal varices are swollen, enlarged veins in the lining of your oesophagus (food pipe), the tube that connects your mouth to your stomach. They happen when high blood pressure in the vein that carries blood to your liver, usually caused by liver disease, forces blood into smaller veins that are not designed to cope with it.

What are the symptoms of oesophageal varices?

Oesophageal varices themselves are deep inside your chest and usually cause no symptoms at all until they bleed. Before that point, a doctor might instead notice other signs of liver disease, such as:

• jaundice, a yellowing of your skin and eyes
• ascites, a build-up of fluid in your abdomen
• swollen legs and feet
• upper abdominal pain
• itching with no visible rash
• confusion or disorientation.

If a varix ruptures, signs of internal bleeding include:

• vomiting blood, which may look like fresh red blood or dark "coffee grounds"
• black, tarry stools, or fresh red blood if the bleed is fast
• a pale complexion
• feeling tired, weak or lightheaded.

Get emergency medical help immediately if you also have a fast heart rate, fast breathing, cold clammy skin, sweating, confusion or you lose consciousness. These can be signs of severe blood loss.

What causes oesophageal varices, and who is at risk?

Oesophageal varices are caused by portal hypertension, which is high blood pressure in the portal vein and the smaller veins that branch off it. This vein carries blood from your intestines through your liver. When something blocks or slows this flow, the pressure forces blood into thinner-walled veins nearby, including those in your oesophagus, which then swell.

The most common cause of portal hypertension is cirrhosis (scarring) of the liver, most often due to:

• alcohol-related liver disease
• non-alcoholic fatty liver disease
• long-term hepatitis B or C infection
• autoimmune hepatitis.

Less common causes of portal hypertension include a blood clot in the portal venous system, an enlarged spleen, certain heart conditions, and liver granulomas, which can be caused by a parasite infection called schistosomiasis.

Around half of people already have portal hypertension and oesophageal varices by the time cirrhosis is diagnosed, and up to 90% will develop them within the next 10 years. Up to 50% of people with varices will experience bleeding at some point, and this risk rises as portal hypertension gets worse and varices grow larger. Continuing to drink alcohol, if this is the cause of your liver disease, also increases the risk of bleeding.

Are there different types of oesophageal varices?

Doctors grade oesophageal varices by size during an endoscopy:

• small varices: minimally raised, straight veins
• medium varices: enlarged and tortuous (twisting), taking up less than a third of the width of the oesophagus
• large varices: taking up more than a third of the width of the oesophagus.

Doctors also look for "red wale marks", which are red streaks on the surface of a varix. Larger varices and those with red wale marks carry a higher risk of bleeding. Varices can also develop elsewhere, such as in the stomach, but oesophageal varices tend to enlarge more, bleed more often, and bleed more heavily than varices elsewhere.

How are oesophageal varices diagnosed?

Because varices usually cause no symptoms, most are found through screening in people already known to have cirrhosis, rather than because of symptoms. A doctor will review your history and examine you for other signs of liver disease.

You will usually have blood tests to check your liver function and blood clotting, and you may have a CT scan, an MRA (magnetic resonance angiogram) or a Doppler ultrasound to look at blood flow in your blood vessels.

An upper endoscopy is the main test used to confirm and grade varices directly. A thin, flexible tube with a small camera is passed down through your mouth into your oesophagus and stomach, allowing the doctor to see the varices and treat them at the same time if needed.

How are oesophageal varices treated?

Non-surgical treatment

Treatment aims to control any active bleeding, prevent future bleeding, and reduce portal hypertension where possible. Options include:

• beta-blockers, a type of blood pressure medicine that can reduce the risk of variceal bleeding by up to 50%
• variceal band ligation, an endoscopic procedure where tiny elastic bands are placed around a varix to cut off its blood flow
• medicines given into a vein during active bleeding, to reduce pressure in the portal system and tighten the blood vessels
• antibiotics, to prevent or treat infection during a bleeding episode
• a transjugular intrahepatic portosystemic shunt (TIPS), a non-surgical procedure in which an interventional radiologist creates a new channel between the portal vein and a nearby vein to reduce pressure, using image guidance rather than an operation.

During an active bleed, you may also need supportive care in hospital, such as IV fluids or a blood transfusion. Treating the underlying liver disease, for example by stopping alcohol, losing weight, or treating hepatitis C, can also help.

Surgical treatment

Surgery is generally reserved for cases where the treatments above have not controlled bleeding. Options include:

• a distal splenorenal shunt, a surgical procedure that redirects blood flow away from the portal vein and into a different vein, to permanently reduce pressure
• liver transplantation, for people with advanced liver disease where other treatments have not worked.

When should I see a doctor?

See a doctor for regular check-ups if you have been diagnosed with cirrhosis or another cause of chronic liver disease, so you can be screened for varices before they cause problems.

Get emergency medical help immediately if you vomit blood, pass black or tarry stools, or suddenly feel faint, dizzy or very weak. These can be signs of bleeding from a varix, which is a medical emergency.