Oesophageal varices: symptoms, bleeding risk and treatment

The oesophagus, or gullet, is the tube that carries food from the throat to the stomach. Cambridge University Hospitals describes oesophageal varices as swollen veins in the gullet, rather like the varicose veins some people have in their legs, formed when blood flow through the liver is restricted.

Liver UK explains the mechanism: scars in a liver with cirrhosis make it hard for blood to pass through normally, which increases the pressure inside the liver's blood vessels (portal hypertension). Blood is redirected to smaller veins in the food pipe and stomach that are not meant to carry that much, so they swell and weaken, putting them at risk of leaking or bursting.

Liver UK says varices do not usually cause any symptoms that you would notice, although some people feel some discomfort when they swallow. It describes a variceal bleed as sometimes slow, causing blood loss and anaemia that makes you feel very tired, but also as capable of bursting, so that you bleed a lot and might vomit blood or have blood in your poo, which looks black and tarry.

• Vomiting blood.

• Black, tarry or bloody poo.

• Signs of shock from heavy blood loss: fast, shallow breathing, an unusually fast heart rate, cold, clammy, pale skin, a weak pulse, dizziness, fainting or weakness.

• Tiredness from slow, hidden bleeding and anaemia.

• The NHS lists symptoms of cirrhosis itself, which may point to the underlying problem: tiredness, loss of appetite, yellow skin and eyes, a swollen tummy, and confusion.

Liver UK says a variceal bleed is an emergency: go to A&E or call an ambulance straight away, and tell the 999 call handler that you may have a variceal bleed. The NHS says to call 999 or go to A&E if you have been diagnosed with cirrhosis and you are vomiting blood, your poo is very dark or black, or you suddenly become confused or have slurred speech. It adds not to drive to A&E, and to bring any medicines you take.

The NHS says to ask for an urgent GP appointment or get help from 111 if you have cirrhosis and your skin or the whites of your eyes look yellow, you have difficulty breathing, or you have a swollen tummy, legs, ankles or feet.

The commonest cause of portal hypertension is cirrhosis. The NHS says cirrhosis is caused by long-term liver damage and you may be more likely to have it if you regularly drink a lot of alcohol, have hepatitis B or C, live with obesity, have type 2 diabetes or non-alcoholic fatty liver disease, have an autoimmune liver condition, or have a genetic condition such as haemochromatosis, Wilson's disease or alpha-1 antitrypsin deficiency.

NICE says bleeding from oesophageal varices is a major complication of cirrhosis. Liver UK says drinking alcohol increases the pressure in the varices and can cause bleeding, so people with varices should avoid alcohol.

Liver UK says everyone with cirrhosis should have checks to see if they are at risk of varices. This may be an endoscopy (gastroscopy), where a thin flexible tube with a camera is passed down the food pipe. Some hospitals first do a blood test for platelet levels and a FibroScan to check the scarring in the liver; if the results show low risk you may not need an endoscopy at first, and the tests are repeated after a year.

If an endoscopy finds no varices, Liver UK says another check is due in 2 to 3 years. If small varices are found, another check in 1 to 2 years, or a medicine to lower the pressure in the veins. For larger varices you should be given medicine to prevent a bleed and may have banding during the endoscopy. If you have cirrhosis and have not been offered screening, speak to your medical team.

Liver UK says the main goal for people with varices is to stop them bursting. It describes beta-blockers, which reduce the pressure in the varices by lowering the blood pressure in the veins around the liver, and banding and clotting treatments, which are used both to prevent bleeding and to treat it.

Cambridge University Hospitals describes variceal banding (ligation) as the preferred method: during a gastroscopy a tube loaded with small rubber bands is attached to the end of the scope, the vein is identified, suction applied and a band positioned. This is repeated until all the veins have been treated. After a couple of days a clot forms in each treated vein, which causes it to shrink, and several treatments may be required.

Injection (sclerotherapy) puts a clotting drug, or in the stomach a glue, into the varices to block them. Liver UK says this is mainly used for varices in the stomach. For variceal bleeding it also lists antibiotics to reduce the risk of serious infection and vasoconstrictors to help control bleeding. TIPS (transjugular intrahepatic portosystemic shunt) is a small tube that helps blood flow through the liver and is used to treat the portal hypertension that causes varices.

Cambridge University Hospitals says the gastroscopy takes between 5 and 15 minutes. You can choose throat spray alone, which numbs the throat for about half an hour so you can leave when you are ready, or intravenous sedation, which makes you relaxed and sleepy but not unconscious, and requires an escort home. Afterwards you may have chest discomfort and a sore throat for the rest of the day, and a soft diet is recommended for the first 24 hours after banding.

The leaflet explains that the treated veins ulcerate over the next few days before healing, which can cause soreness on swallowing, and that you are given medication to help ulcers heal. There is a small risk of bleeding in the few days after the procedure. A narrowing (stricture) of the gullet may form, more likely if the varices are large and repeated treatments have been needed, which can make swallowing difficult but can be treated. Complications are generally fewer with banding than injection.

Liver UK advises taking prescribed medicines exactly as directed, asking about checks if you have cirrhosis, avoiding alcohol, and speaking to your medical team before flying, because there is a possible risk of bleeding from varices on flights, even short ones. It also says to tell your travel insurer that you have varices.

NICE reports that the 6-week mortality from variceal bleeding is 10% to 20%. The NHS says how serious cirrhosis is depends on its cause and how early it is diagnosed and treated, and that many people with cirrhosis feel well and live for many years.

On the NHS, screening and banding are arranged through hepatology or gastroenterology and endoscopy units, and bleeding is treated as an emergency in hospital. Private endoscopy units may offer screening gastroscopy sooner, but the emergency care of a bleed takes place in an NHS hospital.

Whichever route you use, make sure the cirrhosis team knows the result so follow-up endoscopies are scheduled at the right interval.