Information Leaflet
Portal Hypertension and Bleeding of
Oesophageal Varices
One consequence of chronic liver disease can be portal hypertension. This is an
increase in the blood pressure in the portal vein, which carries the blood from the
bowel and spleen to the liver. The pressure in the portal vein may rise because there
is a blockage, such as a blood clot, or because the resistance in the liver is increase
because of scarring, or cirrhosis. As a result, the pressure in the portal vein rises –
this is known as portal hypertension.
As the blood tries to find another way back to the heart, new blood vessels open up.
Among these vessels are those that run along the wall under the lining of the upper
part of the stomach and the lower end of the oesophagus (gullet). These veins
protrude into the gullet and the stomach and can bleed. This bleeding may be a gentle
ooze in which case anaemia is the commonest symptom. Sometimes there can be a
major bleed and the person has a haemorrhage and either vomits blood or passes
blood through the bowels. This blood may appear to be black, since it is often
changed as it passes through the body.
There are many causes of cirrhosis, alcohol being the most common. Others include
viral hepatitis, autoimmune liver disease, primary biliary cirrhosis, primary sclerosing
cholangitis and some metabolic diseases.
Portal hypertension may also arise as a result of a parasitic disease, which is common
in the Middle East and parts of South America. Other conditions including clotting
disorders and pancreatic disease can lead to portal hypertension.
Portal hypertension and its consequence of bleeding varices are usually seen in people
with moderately advanced liver disease . There may be other features such as ascites
(fluid in the stomach) and encephalopathy (disturbance of brain function as a result of
disordered liver function).
Detection of Varices
The dilated veins in the gullet are known as varices. Unless they bleed they do not
produce any complications or symptoms. The only way they can be detected is by a
process called endoscopy. During endoscopy a small flexible tube is put into the
gullet and the endoscopist can see not only where the varices are present but also their
size.
Prevention of bleeding
Not everyone with cirrhosis has varices and not everyone with varices will bleed. In
general, small varices rarely bleed and bigger ones may bleed. Small varices
however, may well develop into large varices over time.
For those people who have varices and are likely to bleed, treatment with drugs can
sometimes reduce the risk of bleeding and reduce the severity of any bleed should it
occur. The drug most commonly used is Propranolol. As with all drugs not everyone
is suitable and some people have side-effects. Alternative methods may sometimes be
used for those who are at risk of bleeding.
Treatment
Propanolol is used both for the prevention of bleeding and also in those people who
have bled. It may be used in the prevention of re-bleeding.
Treatment of Bleeding Varices
If you vomit or pass blood with your stools this is a medical emergency and you
should go to hospital immeadiately. You should tell the doctors and nurses that
you have liver disease and bleeding, since early treatment will reduce the
consequences.
Initial treatment is to replace the fluid and then to identify and correct the casue of
bleeding. Not everyone who has varices and who bleeds will be bleeding from
varices. They may bleed from another area in the digestive tract.
A number of treatment options are available for the treatment and prevention of
bleeding.
Drugs
Several drugs are useful in the treatment of the variceal bleed. These drugs, such a
Glypressin or Octreotide, are given by injection.
Endoscopic Techniques
There are two treatments that can be given at endoscopy to treat and prevent bleeding.
These are
1.
Injection Sclerotherapy
This is injection of a sclerosant (special chemical) material in the veins of the
gullet. Usually after sedation the endoscope is passed into the gullet. A fine
flexible needle is passed through this endoscope and used to inject sclerosant
material into the oesophageal veins or alongside the veins. These injections cause
clotting (thrombosis in the veins) and will also stimulate some scarring to reduce
the risk of varices recurring.
2.
Banding
With banding techniques the oesophageal varix (single varicose vein) is sucked
into a ring at the end of the endoscope. A small band is placed around the base of
the varix that has been sucked into the ring. After 1 or 2 days this will result in
thrombosis (blood clot) of the varix, which will control the bleeding.
These two techniques are complementary and the endoscopist will use one or the
other depending on the clinical situation. Both techniques have advantages and
disadvantages and complications. You should discuss these with the endoscopist.
Sengstaken Tube
Sometimes it is just not possible to get immeadiate control of the bleeding with either
drugs or endoscopic techniques. In this case, a tube known as a Sengstaken Tube or
Lintern Tube is passed through the mouth and into the stomach. The balloon is
inflated and applies compression to the varices. This will achieve temporary control
of the bleeding and allow time for other measures to work.
Shunts
Shunting operations involve joining two veins. Shunts may either be done surgically
or by the radiologist. In a surgical shunt, the blood that would normally go into the
portal vein is diverted into another vein. There are several types of shunts available.
This process involves a major operation.
TIPSS
TIPSS stands for Transjugular Intraheptic Portal Systemic Shunt. This technique is
usually done by a radiologist but other clinicians also carry this out. In this procedure
a metal tube is passed across the liver to allow the blood in the portal vein to go
straight into the hepatic vein and so bypass the high resistance of the liver. This
procedure is usually done in the Radiology Department and may take several hours.
Both types of shunt procedure are very effective in lowering portal pressure but they
do have complications.
One of these complications is encephalopathy whereby the person may get a little bit
drowsy, confused or in rare cases even comatosed. This is because the blood usually
clears toxins from the bowel and if these toxins bypass the liver they can affect the
electrical activity of the brain.
Summary
Oesophageal varices do represent a significant complication of cirrhosis and some
other types of liver damage. Current treatments do allow for early identification of
those people who are risk of variceal bleeding and treatments can greatly reduce the
risk and severity of the bleeds. For those who have bleeding oesophageal varices, this
is a medical emergency but early treatment is usually effective. There are a variety of
approaches to treat bleeding varices and the treatment used will depend on the overall
condition of the individual.