What are Oesophageal Varices?

Varices resemble varicose veins, but they appear inside the oesophagus (the tube that passes from the mouth into the stomach) and occasionally they occur in the stomach. A ‘varix’ is a part of a vein that has become enlarged and has thin walls.  Varices develop when most of the normal liver tissue has been replaced by scar tissue. Because the scar tissue pushes upon the veins in the liver, blood cannot flow normally through the veins.  Pressure inside the liver veins begins to build up and this pressure is then transmitted into other veins located outside the liver.  This occurs most frequently in the vessels in the oesophagus and stomach, which form part of the portal circulation.  This increased pressure is called portal hypertension. These smaller portal veins become engorged and dilated, forming oesophageal varices. 

Oesophageal varices have thin walls and often rupture, causing bleeding (haemorrhage).  Lifting heavy objects, straining, sneezing, coughing and vomiting can cause the varices to tear, so can poorly chewed food and irritation from stomach acid.

	This image found at this Website

Signs and Symptoms

Often the first sign of a person having oesophageal varices is bleeding - when the varices burst. In mild bleeding there may be black tarry bowel motion (stool) varying to bright red stools. When bleeding is severe it is common to vomit bloody fluid.

What Happens in Intensive Care?

Patients are usually transferred from the emergency department to intensive care if bleeding is severe and the patient is unstable. When the patient arrives in the intensive care unit they will be placed on a bedside monitor to closely observe their vital signs and oxygen may given via an oxygen mask.   An indwelling urinary catheter will be used to monitor urine output and invasive monitoring using an arterial line and central line will be considered.  In some cases the patient may require full assistance using an endotracheal tube (breathing tube) and ventilator (the breathing machine).   Frequent blood tests will be done and blood products replaced as required.  Medications such as terlipressin or vasopressin may be given to help reduce pressure in the liver.

A priority in the treatment plan will be to identify where the bleeding is coming from and stop it. Several techniques may be used, with endoscopy being the most common. Endoscopy is a procedure where a tube is passed into the oesophagus to identify the source of bleeding. The tube has a camera at the tip that shows the inside of the oesophagus and bleeding points can be seen. Once bleeding varices are identified, a drug is injected into them, making the vessels constrict, preventing further bleeding. The site can also be cauterised (burnt) to stop bleeding, or they could be banded. Banding is a process where tiny rubber bands are wrapped around the varices, effectively strangulating the vessel and thereby preventing further bleeding.

If bleeding becomes uncontrollable a balloon tamponade device may be inserted. The balloon tamponade tube is passed into the oesophagus and stomach. The smaller balloon sits in the stomach while the larger balloon sits in the oesophagus. The stomach balloon is inflated and the tube is connected to a weight applying extra pressure to the varices. The balloon usually remains inflated for 24-48hours to ensure bleeding has stopped. During this time the patient remains in intensive care where they are closely monitored.
		This is an example of a balloon tamponade tube

The patient will require a breathing tube and assistance with breathing whilst the balloon tamponade device is in. Sedation is also given to aid comfort, and reduce agitation. Once the 24-48hrs period has passed and bleeding has been stabilized the balloons are deflated, and endoscopy is attempted as described above.

Whilst the patient is in Intensive Care ongoing monitoring of vital signs using a bedside monitor will continue and a tube into the bladder will be placed to drain away urine. Invasive monitoring using an arterial line and central line will be considered. Medications such as terlipressin or vasopressin may be given to help reduce pressure in the liver. Frequent blood tests will be done and blood products replaced as required.

Further surgery may be needed to reduce portal hypertension. This procedure called transjugular intrahepatic portosystemic shunt (TIPPS). A metal opening device is placed in the liver connecting the hepatic and portal veins this allows blood to flow through a different path. This image found at the following website

How long will the patient remain in Intensive Care?

The time spent in Intensive Care will vary from patient to patient and can vary from a few days to weeks. How well the patient does depends on a number of factors including severity of liver disease and amount of bleeding.

Date Published

Oesphageal Varices Version 1 (Author: Suzy Dimovski CNC) First published online August 2006

 

The information contained on this page is general in nature and therefore cannot reflect individual patient variation.  In addition it reflects Australian intensive care practice which may differ from other countries. It is meant as a back up to specific information which will be discussed with you by the Doctors and Nurses caring for your loved one.  ICCMU attests to the accuracy of the information contained here BUT takes no responsibility for how it may apply to an individual patient.  Please refer to the full disclaimer.