What is variceal bleeding?

One of the most significant complications of cirrhosis is variceal bleeding. It can occur if the pressure in the portal vein becomes elevated (portal hypertension). As mentioned in Question 34, blood enters the liver from the portal vein. When the liver is scarred, the blood flow through the liver can become restricted. Blood is a liquid and always tries to find the path of least resistance. This pathway may be around the liver rather than through the liver. In fact, one of the natural alternative routes circumventing the liver is through the vessels in the esophagus and stomach. These vessels typically carry a small amount of blood at low pressure. When the pressure in these vessels increases, they can rupture, causing a massive hemorrhage, vomiting of blood, and loss of consciousness.

Variceal bleeding is treated with intravenous medications, with endoscopy, and later with pills called betablockers. More than 50% of patients awaiting liver transplantation have a variceal bleed before transplantation. Frequently, this bleeding is the initial event that prompts the primary gastroenterologist to refer the patient to a transplant center. Variceal bleeding is a dramatic event that continues to have a mortality rate of as much as 30% despite advances in therapy.

When patients are diagnosed with cirrhosis, endoscopic evaluation of the esophagus is necessary to assess for the presence of varices. During an endoscopy, the gastroenterologist administers intravenous sedation. The patient’s throat is sprayed with a numbing medication to prevent gagging. An endoscope is then passed through the mouth and into the esophagus, stomach, and duodenum (first part of the small intestine). An endoscope is a long tube with a 1/4-inch caliber. On the end of the tube are a bright light and a tiny camera. The camera transmits video images to a television screen. Using this system the gastroenterologist can examine the inside of the esophagus and stomach to determine whether varices are present and, if so, whether they are large or small. If the patient has large varices, then beta-blockers can be started to significantly reduce the risk of variceal bleeding.