Overview
For patients with cirrhosis, the blood flow through the liver is limited due to the scarring of the liver. As a result, blood flow is diverted away from the liver. One of these paths is blood vessels around the stomach and the esophagus. Occasionally varices can break open and cause internal bleeding. Nadolol (corgard®) and propranolol (inderal®) are beta-blockers that lower blood pressure in vessels, and are used to prevent and decrease the risk of bleeding from varices. Other options to prevent or stop bleeding include sclerotherapy, band ligation, surgical shunt, or TIPS.
Sclerotherapy eliminates veins by injecting them with a solution that causes the blood to clot. Sclerotherapy can be used through an endoscope to eliminate esophageal or gastric varices. Band ligation can also be done through an endoscope and stops bleeding by placing a rubber band across the bleeding vessel (see figure below). Compared to sclerotherapy, band ligation is more successful in controlling bleeding, reduces the chance of re-bleeding, and has fewer complication.
For the refractory cases of bleeding, surgical shunt or TIPS are alternative procedures. Surgical shunt is a procedure that connects two veins together to pass blood around the liver. Both procedures are successful because they allow blood to be shunted away from the liver and bleeding varices. Unfortunately, mental status and neurologic symptoms can worsen after surgical shunts and TIPS in some patients, so the procedure might not be an option for those patients already showing signs of encephalopathy.
Symptoms of Variceal Bleeding
- Vomiting blood
- Black stool
- Tarry stool
- Blood in stool
- Low blood pressure
Causes
Bleeding varices are a life-threatening complication of increased blood pressure in the portal vein caused by liver disease (portal hypertension). The portal vein carries blood from the intestine to the liver. Increased pressure causes the veins to balloon outward. The vessels may break open (rupture). Any cause of chronic liver disease can cause bleeding varices.
Treatment
Treatment options include : -
- pharmacologic therapy (e.g., vasopressin),
- temporary balloon tamponade of varices,
- endoscopic sclerotherapy,
- variceal ligation,
- transjugular intrahepatic portacaval shunt (TIPS) surgery
- portal-systemic shunt surgery.
Possible Complications
- Esophageal stricture after surgery or endoscopic therapy
- Hypovolemic shock
- Infection (pneumonia, bloodstream infection, peritonitis)
- Return of bleeding after treatment
- Worsening encephalopathy (confusion)
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