Overview
Esophageal varices

Esophageal varices are enlarged veins in the esophagus, the tube that connects the throat and stomach. Esophageal varices most often happen in people with serious liver diseases.

Esophageal varices develop when regular blood flow to the liver is blocked by a clot or scar tissue in the liver. To go around the blockages, blood flows into smaller blood vessels that aren’t designed to carry large volumes of blood. The vessels can leak blood or even burst, causing life-threatening bleeding.

A few medicines and medical procedures are available to help prevent or stop bleeding from esophageal varices.

Symptoms

Esophageal varices usually don’t cause symptoms unless they bleed. Symptoms of bleeding esophageal varices include:

• Vomiting large amounts of blood.
• Black, tarry or bloody stools.
• Lightheadedness due to blood loss.
• Loss of consciousness in severe cases.

Your doctor might suspect esophageal varices if you have signs of liver disease or been diagnosed with liver cirrhosis, including:

• Yellow coloration of the skin and eyes, known as jaundice.
• Easy bleeding or bruising.
• Fluid buildup in the abdomen, called ascites (uh-SY-teez).

When to see a doctor

Make an appointment with your health care provider if you have symptoms that worry you. If you’ve been diagnosed with liver disease, ask your provider about your risk of esophageal varices and what you can do to reduce your risk. Also ask whether to get a procedure to check for esophageal varices.

If you’ve been diagnosed with esophageal varices, your provider will likely tell you to watch for signs of bleeding. Bleeding esophageal varices are an emergency. Call Us or your local emergency services right away if you have black or bloody stools, or bloody vomit.

Causes

Esophageal varices sometimes form when blood flow to your liver is blocked. This is most often caused by scar tissue in the liver due to liver disease, also known as cirrhosis of the liver. The blood flow begins to back up. This increases pressure within the large vein, known as the portal vein, that carries blood to your liver. This condition is called portal hypertension.

Portal hypertension forces the blood to seek other pathways through smaller veins, such as those in the lowest part of the esophagus. These thin-walled veins balloon with the added blood. Sometimes they rupture and bleed.

Causes of esophageal varices include:

• Severe liver scarring, called cirrhosis. Several liver diseases — including hepatitis infection, alcoholic liver disease, fatty liver disease and a bile duct disorder called primary biliary cholangitis — can result in cirrhosis.
• Blood clot, also called thrombosis. A blood clot in the portal vein or in a vein that feeds into the portal vein, known as the splenic vein, can cause esophageal varices.
• Parasitic infection. Schistosomiasis is a parasitic infection found in parts of Africa, South America, the Caribbean, the Middle East and East Asia. The parasite can damage the liver, as well as the lungs, intestine, bladder and other organs.

Risk factors

Although many people with advanced liver disease develop esophageal varices, most won’t have bleeding. Esophageal varices are more likely to bleed if you have:

• High portal vein pressure. The risk of bleeding increases as the pressure in the portal vein increases.
• Large varices. The larger the esophageal varices, the more likely they are to bleed.
• Red marks on the varices. Some esophageal varices show long, red streaks or red spots. Your health care provider can see them through a thin, flexible tube, called an endoscope, passed down your throat. These marks suggest a high risk of bleeding.
• Severe cirrhosis or liver failure. Most often, the more severe your liver disease, the more likely esophageal varices are to bleed.
• Continued alcohol use. Your risk of variceal bleeding is far greater if you continue to drink than if you stop, especially if your disease is alcohol related.

If you’ve had bleeding from esophageal varices before, you’re more likely to have varices that bleed again.

Complications

The most serious complication of esophageal varices is bleeding. Once you’ve had a bleeding episode, your risk of another bleeding episode greatly increases. If you lose enough blood, you can go into shock, which can lead to death.

Prevention

Currently, no treatment can prevent the development of esophageal varices in people with cirrhosis. While beta blocker drugs are effective in preventing bleeding in many people who have esophageal varices, they don’t prevent esophageal varices from forming.

If you’ve been diagnosed with liver disease, ask your health care provider about strategies to avoid liver disease complications. To keep your liver healthy:

• Don’t drink alcohol. People with liver disease are often advised to stop drinking alcohol, since the liver processes alcohol. Drinking alcohol may stress an already vulnerable liver.
• Eat a healthy diet. Choose a diet that’s full of fruits and vegetables. Select whole grains and lean sources of protein. Reduce the amount of fatty and fried foods you eat.
• Maintain a healthy weight. An excess amount of body fat can damage your liver. Obesity is associated with a greater risk of complications of cirrhosis. Lose weight if you are obese or overweight.
• Use chemicals sparingly and carefully. Follow the directions on household chemicals, such as cleaning supplies and insect sprays. If you work around chemicals, follow all safety precautions. Your liver removes toxins from your body, so give it a break by limiting the amount of toxins it processes.
• Reduce your risk of hepatitis. Sharing needles and having unprotected sex can increase your risk of hepatitis B and C. Protect yourself by abstaining from sex or using a condom if you choose to have sex. Get tested for exposure to hepatitis A, B and C, since infection can make your liver disease worse. Also ask your health care provider whether to be vaccinated for hepatitis A and hepatitis B.

Gastrointestinal (GI) Bleeding

Gastrointestinal (GI) bleeding is a symptom of many digestive system disorders, including reflux, ulcers and cancer. It can occur in any part of the digestive system (GI tract), which runs from the mouth to the anus. Bleeding can be mild and ongoing or come on suddenly and be life-threatening.

Overview

What is a GI bleed?

Gastrointestinal bleeding is when there is blood loss from any of the several organs included in your digestive system. It can occur from any part of the GI tract that runs from your mouth to your anus.

Upper GI bleeds stem from issues with your:

• Esophagus.
• Stomach.
• Duodenum (first part of your small intestine).

Small Bowel bleeds stem from issues with your:

• Jejunum (middle part of your small intestine).
• Ileum (the last section of your small intestine).

Lower GI bleeds stem from issues with your:

• Colon.
• Rectum.
• Anus.

What are the types of GI bleeds?

• Acute: Sudden, severe bleeding that’s a sign of a medical emergency.
• Chronic: Bleeding that comes and goes over a long time.
• Occult: Bleeding is not visible as it is microscopic, but you can see signs of GI blood loss (such as low blood counts) on laboratory testing.
• Overt: Visible signs of a GI bleed, including abnormal colors or substances in your feces (poop). You may also vomit blood.
• Obscure: When standard endoscopy testing does not reveal a source of GI bleeding.

Symptoms and Causes

What causes an upper GI bleed?

Issues affecting the upper GI area that can cause bleeding include:

• Crohn’s disease.
• Esophageal cancer.
• Esophageal varices.
• Esophagitis.
• Gastritis.
• Gastrointestinal stromal tumor (GIST).
• GERD (Chronic Acid Reflux).
• Liver cancer.
• Pancreatic cancer.
• Peptic ulcers.
• Stomach cancer.

What causes a lower GI bleed?

Issues affecting the lower GI area that can cause bleeding include:

• Anal cancer.
• Anal fissures.
• Colon polyps.
• Colorectal cancer.
• Crohn’s disease.
• Diverticulitis and diverticulosis.
• Gastrointestinal stromal tumor (GIST).
• Hemorrhoids.
• Rectal ulcers.
• Ulcerative colitis.

What are the symptoms of a GI bleed?

GI bleed symptoms depend on the source and how severe it is.

You may experience:

• Abdominal cramping.
• Dark-colored poop or regular-colored poop with blood in it.
• Pale appearance.
• Shortness of breath (dyspnea).
• Tiredness
• Vomit with blood in it or a substance that looks like coffee grounds.
• Weakness and fatigue.

Are the symptoms of acute bleeding different?

Acute GI bleed symptoms come on suddenly and are often severe. It’s important to seek immediate medical care if you notice:

• Dizziness or faintness (syncope).
• Difficulty urinating.
• Rapid pulse, which can make you feel anxious or like your heart is fluttering.
• Shock, which occurs when there isn’t enough blood flow to your organs.

Diagnosis and Tests

How is GI bleeding diagnosed?

Healthcare providers perform a thorough assessment that starts with you describing your symptoms. To identify the source of the bleed and how severe it is, you will need to undergo testing.

What types of testing might I need?

Initial steps may include:

• Blood tests check for signs of GI bleeds, such as anemia, using a sample of your blood.
• Fecal occult blood test (FOBT) is a lab test that checks for signs of blood in a poop sample.
• CT scan is a sophisticated imaging study that uses technology to produce 3D, enhanced views of your intestines.
• GI X-rays take images of your upper or lower digestive tract to check for signs of a bleed or other conditions. The tests use a barium contrast solution that makes it easier to see the digestive tract on the X-ray.
• Upper endoscopy is a procedure to examine symptoms of an upper GI bleed. It uses a long tube with a camera and light at the tip (endoscope).
• Balloon enteroscopyis like an endoscopy. It uses long tubes and a camera. Tiny balloons at the endoscope tip inflate to help providers examine hard-to-reach small bowel.
• Colonoscopy or sigmoidoscopy is a procedure to examine signs of a lower GI bleed. The test uses endoscopes that are passed through the anus.

Are there other tests I may need?

More tests may be necessary if:

• Your healthcare provider cannot pinpoint the source of the bleed.
• You’re showing signs of an acute bleed.

These tests may include:

• Angiography is an imaging study that uses dye to make the GI tract’s blood vessels easier to see.
• Capsule endoscopy involves swallowing a pill-sized camera. As it travels along the GI tract, it takes pictures. You eliminate the camera through a bowel movement.
• Radionuclide scan involves receiving a substance with safe levels of radioactive material. The substance highlights red blood cells during an imaging study.

Management and Treatment

What medical therapies are available for GI bleeds?

Medications can treat some bleeds, including ones due to ulcers, hemorrhoids or GERD. These medications:

• Reduce levels of stomach acid.
• Help your blood clot.
• Relieve swelling.

Will I need a procedure?

In many cases, healthcare providers deliver GI bleed treatments during an endoscopy or colonoscopy. Tiny instruments at the tip of the endoscope or colonoscope make it possible to:

• Remove abnormal growths, such as colon polyps.
• Inject medications that help the body stop bleeding.
• Seal abnormal blood vessels with a tiny clip or band.
• Use low levels of a laser or a hot or cold gas to destroy the tissue causing the bleed.

How is GI bleed treatment different when the bleeding is acute?

For severe bleeds, emergency surgery may be necessary. Care may include laparoscopy. Surgeons make tiny incisions through which they pass a tiny camera and surgical instruments. This technique enables them to quickly access the source of the bleed and deliver treatment.

Prevention

How can I prevent GI bleeding?

Steps you can take to protect yourself against GI bleeding include:

• Taking nonsteroidal anti-inflammatory medicines (NSAIDs) and aspirin only when necessary.
• Limiting alcohol use.
• Quitting tobacco if you regularly use it.
• Getting treatment to keep symptoms of GI conditions, like diverticulitis, well managed.
• Checking for infections like helicobacter pylori, if one is at risk, which can cause ulcers.

Outlook / Prognosis

What is the outlook for people who have had a GI bleed?

Most people make a full recovery. It can take your intestines a few months to heal. You can lower the risk of future bleeds by making lifestyle changes, such as:

• Avoiding medications that can provoke bleeding if possible.
• Treating causes of ulcers, like helicobacter pylori infections.
• Reducing stress, which may involve relaxation techniques, like deep breathing.
• Maintaining an active lifestyle and balanced diet, so you achieve a healthy weight.

Living With

Will I need to follow special care instructions?

Even if treatment is successful, GI bleeds can come back. Other actions you can take to protect your health include:

• Going to all follow-up appointments. These visits enable your healthcare provider to assess treatment progress. Testing can detect the early signs of new bleeds.
• Staying on medications. If medication side effects make you sick, talk with your healthcare provider. They may reduce the dose or prescribe a gentler option.
• Maintaining lifestyle changes. Even if you no longer have GI bleed symptoms, a healthy lifestyle can help you continue feeling your best.

A note from Cleveland Clinic

GI bleeding is a symptom of many medical issues and can occur anywhere along the digestive tract. Healthcare providers often use endoscopy or colonoscopy to diagnose and treat bleeds. Bleeds can come back even after successful treatment. This is why it’s important to follow care instructions, even if you’re not experiencing symptoms.