By Jeyashree Sundaram (MBA)
The esophagus connects the pharynx and the stomach via a long tube. The inflammation in the veins of the esophagus is termed as esophageal varices. As the enlarged veins are very close to the inner lining of the esophagus, they are highly prone to rupture and cause profuse bleeding. The bleeding cannot be spontaneously terminated and requires treatment. Several drugs and treatments are available to aid in stopping the bleeding from the veins.
The blockage of the bleeding is the primitive goal in the treatment of esophageal varices. The recurrence of bleeding is more common after the treatment. The regular follow-ups are required to check for recurrent bleeding and appropriate treatment is given to prevent more esophageal varices from developing.
Treatment at the initial stage is successful in 80% to 90% of cases with esophageal varices and the rest are difficult to recover due to association with other complexities like hepatorenal syndrome, liver failure, and hepatic infections.
Treatments involving lowering the high portal blood pressure can decrease the occurrence of esophageal varices. Such treatments are called preventive treatments. The major objective of this treatment is to stop the varices from breaking and leaking blood.
The below mentioned are the common preventive treatments for esophageal varices:
Reduction of pressure in portal vein by drugs
The high blood pressure in portal veins is brought down by beta blockers and it reduces the probability of bleeding. Some of the beta blockers that are used to treat portal hypertension are nadolol and propranolol.
The endoscopic band ligation approach is carried out for the patients with esophageal varices. Through endoscopy, a small elastic band is tied over the enlarged veins to prevent bleeding. It is an effective and safe, and there is less recurrence of bleeding after the procedure.
Treatment for occurrence of bleeding
As bleeding is a very serious and aggressive condition in esophageal varices, it is extremely important to treat the varices and block the bleeding veins effectively by either single or combination of treatment procedures. Such treatments are discussed below:
After the bleeding episode, usually pharmacologic drugs like octreotide are administered along with endoscopy to the patients to slow down the blood flow from the inner organs to the portal veins. It is generally given for five consecutive days after the hemorrhage. Also, vasoconstrictor drugs are provided immediately after the detection of bleeding in esophageal varices. Terlipressin is a synthetic vasopressin infused intravenously in case of acute variceal hemorrhage.
Reinstating the blood is essential to maintain the standard volume of blood in an individual since there would be heavy loss in blood due to variceal. Blood transfusion is done for a patients with high hemorrhage. Prophylatic antibiotics are used to prevent bacterial infection that occurs during bleeding and early rebleeding.
Endoscopic therapy is the main treatment for managing the esophageal varices and liver cirrhosis. It can be used as both primary and secondary prophylactic therapies. Endoscopic variceal ligation is executed until the varices are cleared, and this technique reduces the effect in the inner wall of the esophagus. However, these treatments will not reduce the blood flow in portal veins.
Endoscopic injection sclerotherapy is another therapy used to treat varices by developing a blood clot. This technique suffers the drawback of exhibiting harmful and dangerous complications.
Blood flow averting
The flow of blood is redirected bypassing the portal veins. This can be achieved through a technique called transjugular intrahepatic portosystemic shunt (TIPS) that places a stent connecting the liver and the heart. This reduces the pressure in portal veins as the blood is carried to the heart by these stents. In turn, bleeding in the esophageal varices is terminated.
Although TIPS procedure helps in reducing the portal vein hypertension, it causes some critical adverse effects like liver failure and delirium. These effects are due to the non-filtration of toxins by the stents and are free to flow to other parts of the body through the blood. Hence, TIPS is used as a limited treatment for the sufferer until the donor liver is available for liver transplantation.
In case of rebleeding, the suggested treatments are the administration of beta blockers and elastic band ligation method to prevent further hemorrhage.
Liver transplantation is the best possible method for people with critical liver disease. Although the transplantation procedure is successful over the years, the availability of a donor liver is low and the patients have to wait considerably more for a transplant.
In case of failure of control and rebleeding, rescue therapy with balloon tamponade or TIPS is needed. In this therapy, the hemorrhage is made to cease in the esophagus under endoscopic control, which effectively manages the recurrence of hemorrhage in esophageal varix after treatment.