The portal hypertension may lead to the formation of varices, when the increased blood pressure causes the dilatation of the veins with thin walls (mainly the blood vessels around the oesophagus or around the anus); in certain conditions these varicose veins may burst, causing blood loss.
Portal hypertension is the increased pressure in the portal vein and its tributaries resulting from increased resistance to the blood flow into the liver, and is usually caused by the scarring process of cirrhosis. The increased pressure causes varices, or dilatations of the veins tributaries to the portal vein. When varices are located in superficial tissues and have thin walls, they may rupture and bleed. The two main locations where bleeding is likely to occur are the lower oesophagus/upper stomach and the perianal region.
Oesophageal varices are likely to bleed most heavily, and this bleeding is sometimes associated with the onset of hepatic encephalopathy or coma. Because of their location at the lower end of the oesophagus and/or the upper portion of the stomach, bleeding from these varices is often difficult to control.
If discovered before bursting, or after successful emergency treatment, varices can be treated long term with beta blockers, which induce a reduction in the portal vein blood pressure.
If varices burst, they can be obliterated using endoscopically placed rubber bands or injections with a drug that turns the varices into sclerotic tissue. If the bleeding is heavy, a rubber baloon may be placed at the lower end of the esophagus or the upper portion of the stomach, and is then inflated, in order to stop the bleeding by pressure.
If treatment via endoscopy fails to stop the bleeding, a TIPS (Transjugular Intrahepatic Portosystemic Shunt) can be created by inserting a short metal mesh tube through a neck vein into the liver, redirecting part of the blood flow from the portal vein to another vein in the liver. Another possibility is to surgically redirect some of the blood flow from the portal vein around the liver.
Some physicians consider the occurence of bleeding oesophagial varices as a condition more serious than a heart attack. It is vital that the patient is taken without delay to a hospital at the first signs of bleeding. The symptoms are vomiting up blood and/or passsing of dark, almost liquid, bowel motions (melena).
[ Fig: Esophageal varices ]
Symptoms
Black, tarry stools
Bloody stools
Decreased urine output
Excessive thirst
Light-headedness
Paleness
Symptoms of chronic liver disease (such as cirrhosis)
Vomiting
Vomiting blood
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.
Nonsurgical Treatment of Variceal Bleeding
These include : -
the endoscopic modalities variceal ligation
and cyanoacrylate injection
the transjugular intrahepatic protosystemic shunt (TIPS)
drug therapy with glypressin, somatostatin, or octreotide.
Bleeding from varices is a medical emergency and treatment should be immediate. If the bleeding is not controlled quickly, a person may go into shock or die. In severe cases, a person may need to be placed temporarily on a ventilator to prevent the lungs from filling with blood. Aside from the urgent need to stop the bleeding, treatment is also aimed at preventing future bleeding. The following procedures help treat bleeding varices by reducing the pressure in these veins.
Banding : - A procedure performed by a gastroenterologist in which small rubber bands are placed directly over the blood vessels (varices). This will stop the bleeding and eradicate the varices.
Sclerotherapy : - A procedure in which a gastroenterologist directly injects the varices with a blood-clotting solution instead of banding them.
Transjugular Intrahepatic Portosystemic Shunt (TIPS) : - A radiological procedure in which a stent (a tubular device) is placed in the middle of the liver. The stent connects the hepatic vein with the portal vein. This procedure is done by placing a catheter through a vein in the neck. It is performed to relieve the high blood pressure that has built up in the liver.
Distal Splenorenal Shunt (DSRS) : - A surgical procedure that connects the splenic vein to the left kidney vein in order to reduce pressure in the varices and control bleeding.
Liver transplant : - A liver transplant may be done in cases of end-stage liver disease.
Devascularization : - A surgical procedure that removes the bleeding varices. This procedure is done when a TIPS or a surgical shunt is not possible or unsuccessful in controlling the bleeding
Possible Complications
Esophageal stricture after surgery or endoscopic therapy
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