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Variceal Bleeding

What is Variceal Bleeding?

Varices are dilated submucosal veins, most commonly detected in the distal oesophagus or proximal stomach. These varices can bleed. Varices are associated with portal hypertension of any cause including presinusoidal (portal vein thrombosis), sinusoidal (cirrhosis) and postsinusoidal (Budd Chiari syndrome) causes, the commonest being cirrhosis. Despite advances in therapy over the last decade, variceal haemorrhage is associated with a mortality of at least 20% at 6 weeks.

Symptoms

  • Hematemesis (vomiting with blood present)
  • Blood in the stool
  • Melena (black coloured stool)

Causes

Varices are the major complication of portal hypertension caused by either liver cirrhosis in most cases or non-cirrhotic portal hypertension. Liver cirrhosis refers to scarring of the liver which results in liver failure. Portal hypertension refers to increased blood pressure in the portal vein which is the main blood vessel supplying the liver. This is a significant complication of liver cirrhosis which generally signals irreversible damage. Blood flow through the liver meets increasing resistance leading to elevated pressures in the portal vein. This results in an enlarged spleen (splenomegaly), swollen veins around and in the stomach and oesophagus (varices) and the accumulation of fluid in the abdominal cavity (ascites). Most of the symptoms and signs of liver cirrhosis are a result of the development of portal hypertension.

Prevention

The risk of variceal bleeding can be reduced by

  • Non-selective beta blocker medication (e.g. propranolol) to reduce the risk of variceal bleeding.
  • Endoscopic band ligation of oesophageal varices.

Diagnosis

Endoscopy

Treatment

  • Intravenous antibiotics
  • Intravenous terlipressin/octreotide/somatostatin
  • Non-selective beta blocker medication (e.g. propranolol) to reduce the risk of variceal bleeding.
  • Endoscopic band ligation of oesophageal varices to treat bleeding acutely or as a prophylactic measure for future bleeding.
  • Endoscopic sclerotherapy of gastric varices to treat acute bleeding.

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure that involves the insertion of a stent (tube) through the liver.This procedure will connect the portal veins to adjacent blood vessels that lead back to the heart. Subsequently, it relieves portal hypertension and can help stop the bleeding.