Esophageal Varices Guide: Signs of Bleeding Esophageal Varices

Esophageal varices are enlarged or dilated veins in the esophagus. They mainly occur in people who have liver cirrhosis. Symptoms typically do not occur until they begin to bleed. Bleeding can be severe and life threatening. The main treatment is esophageal varices banding. This is an endoscopic procedure to tie off the veins to prevent them from bleeding.

This article explains esophageal varices, including the symptoms, causes, and treatment.

Esophageal varices are veins in the esophagus that have widened and enlarged. This dilation is due to portal hypertension, which is high blood pressure in the portal vein. The portal vein carries blood from the intestines and digestive organs to the liver. The liver then filters the blood to store and metabolize vitamins, minerals, and nutrients. It also gets rid of toxins and processes medications.

When there is too much pressure in the portal vein, blood backs up in the system. Collateral vessels begin to form alternate routes to relieve this pressure. Esophageal varices are collateral vessels that form in the esophagus or top of the stomach.

While esophageal varices relieve pressure in the portal system, they carry the risk of rupture.

Gastric varices are another type of varices that can cause internal bleeding. Esophageal varices are different than gastric varices. Similar to esophageal varices, gastric varices are due to portal hypertension. However, gastric varices may not involve liver cirrhosis. Gastric varices extend into the upper area of the stomach and are less common than esophageal varices. This article focuses on esophageal varices.

Esophageal varices are dangerous because they can enlarge and rupture. When they burst, they can cause severe bleeding or hemorrhage. Bleeding esophageal varices are often fatal.

Doctors grade esophageal varices based on their size:

• Small: These varices are 5 millimeters (mm) or less and have a 5% rate of bleeding in the first year. They generally do not need treatment. Doctors monitor them instead.
• Medium/large: These varices measure more than 5 mm. They require treatment because their rate of bleeding in the first year is 15%.

Up to 12% of small varices per year will progress to large varices.

There generally are no symptoms of esophageal varices until bleeding occurs. When the bleeding starts, it is usually sudden and painless. Symptoms may include:

• abdominal discomfort
• appetite loss
• black, tarry stools
• bright red blood in the stool or rectal bleeding
• low blood pressure, which may cause dizziness or fainting
• rapid heart rate
• vomiting blood 

Bleeding esophageal varices is an emergency. Seek immediate medical care for symptoms of bleeding from esophageal varices.

Liver cirrhosis is the most common cause of portal hypertension and the development of esophageal varices. Cirrhosis is permanent scarring of the liver, which blocks blood flow through the liver. In the United States, the most common causes of liver cirrhosis include:

• alcohol use disorder
• chronic hepatitis
• nonalcoholic fatty liver disease  

Other possible causes of esophageal varices include:

• alpha-1 antitrypsin deficiency, which causes liver disease
• Budd-Chiari syndrome, which is narrowing of the hepatic vein that carries blood from the liver to the heart
• constrictive pericarditis, which causes scarring and thickening of the sac around the heart as well as a backup of blood in the veins
• right sided heart failure, which causes a backup of blood in the veins
• enlarged spleen
• obstruction of the portal vein, such as a blood clot
• schistosomiasis, which is a parasitic infection
• Wilson disease, which causes excess copper and damage in organs including the liver

Current recommendations for people with cirrhosis include screening for esophageal varices. Doctors do this with esophagogastroduodenoscopy (EGD), also known as upper endoscopy. It can find varices that are at high risk of bleeding before they rupture. An EGD can also diagnose actively bleeding esophageal varices. 

Lab tests will also be part of the diagnostic process including:

• bleeding times
• blood chemistry panel
• complete blood count
• hepatitis testing 
• kidney function tests
• liver function tests

Other diagnostic procedures and imaging exams a doctor may order include:

• abdominal ultrasound or Doppler ultrasound
• CT or MRI angiography
• hepatic vein and portal vein pressure testing

The goal is to find esophageal varices before they rupture and treat them if necessary.

When doctors find esophageal varices before they bleed, the size will determine what treatment is necessary.

Regular monitoring is all that is recommended for small esophageal varices.

For medium or large varices, esophageal varices banding is the main treatment. This procedure involves tying off the vein to prevent it from bursting. Doctors use an endoscope to place esophageal bands for varices. They can also perform this procedure during a screening endoscopy.

Bleeding esophageal varices is a life threatening emergency. Endoscopic banding is the main treatment for bleeding esophageal varices.

Doctors also use the drug octreotide (Sandostatin) along with banding to treat the bleeding. It reduces blood flow in the digestive system to slow bleeding.

The rate of infection is high with bleeding esophageal varices, so IV antibiotics are part of treatment protocols. They are administered through a vein.

Additional treatment options are available for esophageal varices that are resistant to endoscopic banding treatment. These include:

• Endoscopic injection of a sclerosing agent: This irritant substance causes a reaction that damages and destroys the bleeding vessel.
• Endoscopic stent placements: This procedure puts pressure on the area to stop bleeding. This off-label procedure may be used in emergency situations.
• Transjugular intrahepatic portosystemic shunt (TIPS): TIPS uses interventional radiology to reduce portal hypertension when endoscopic therapy is unsuccessful or not feasible. A doctor places a stent between the intrahepatic portal vein branch and the hepatic vein.

The main risk factor for developing esophageal varices is the presence of liver cirrhosis. Signs and symptoms of cirrhosis include:

• easy bleeding and bruising
• fatigue
• yellow skin and eyes
• itchy skin
• edema, which is swelling in the ankles, feet, or legs
• unintentional weight loss
• nausea

At the time of diagnosis, about 30% of people with cirrhosis will already have esophageal varices. At 10 years after diagnosis, this number increases to 90%. 

In the United States, the other main risk factor for cirrhosis, and consequently developing esophageal varices, is chronic hepatitis B or C.

Since liver cirrhosis is the main cause, preventing esophageal varices focuses on treating liver disease.

A screening endoscopy will reveal if a person with cirrhosis has developed esophageal varices.

For people who have not developed esophageal varices, prevention means treating the underlying cause of liver disease. 

The goal is to prevent decompensation, which is the acute decline in liver function in people with cirrhosis. Symptoms of decompensated cirrhosis include:

• jaundice
• abdominal swelling
• brain problems

Nearly all people with decompensated cirrhosis will have esophageal varices.

For people who already have varices at the time of screening, the goal is to prevent bleeding.

For small varices, doctors may recommend a beta-blocker. These medications may slow the formation of varices, but they are not proven to decrease the overall risk of mortality from varices. Follow-up endoscopy will be necessary to monitor the size.

For medium or large varices, endoscopic banding is recommended to prevent bleeding varices. 

The main complication of esophageal varices is bleeding, which can be fatal. The highest risk of death is in the first few days after the bleed.

About half of all people with esophageal varices will have variceal bleeding. The risk of recurrent variceal bleeding is 50–75% within 1–2 years. 

About 20% of people die within 6 weeks of variceal bleeding. Better treatments have improved this number from the past when more than 50% of cases were fatal.

People with advanced cirrhosis have a higher risk of death than those who still have remaining liver function.

Esophageal varices are mainly a complication of liver cirrhosis. Bleeding is often the first sign of them.

Doctors can use endoscopy to screen for esophageal varices in people with cirrhosis. If they find varices that are at high risk of bursting, they can treat them during the screening endoscopy.

When esophageal varices rupture, it is a life threatening emergency. The mortality rate is high, even with treatment.