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One consequence of chronic liver disease can be portal hypertension.
This is an increase in the blood pressure in the portal vein, which carries
the blood from the bowel and spleen to the liver. The pressure in the
portal vein may rise because there is a blockage, such as a blood clot,
or because the resistance in the liver is increased because of scarring,
or cirrhosis. As a result, the pressure in the portal vein rises - this
is known as portal hypertension.
As the blood tries to find another way back to the heart, new blood vessels
open up. Among these vessels are those that run along the wall under the
lining of the upper part of the stomach and the lower end of the oesophagus
(gullet). These veins protrude into the gullet and the stomach and can
bleed. This bleeding may be a gentle ooze in which case anaemia is the
commonest symptom. Sometimes there can be a major bleed and the person
has a haemorrhage and either vomits blood or passes blood through the
bowels. This blood may appear to be black, since it is often changed as
it passes through the body.
There are many causes of cirrhosis, alcohol being the most common. Others
include viral hepatitis, autoimmune liver disease, primary biliary cirrhosis,
primary sclerosing cholangitis and some metabolic diseases. Please see
our other leaflets on these specific conditions.
Portal hypertension may also arise as a result of a parasitic disease,
which is common in the Middle East and parts of South America. Other conditions
including clotting disorders and pancreatic disease can lead to portal
hypertension.
Portal hypertension and its consequence of bleeding varices are usually
seen in people with moderately advanced liver disease. There may be other
features such as ascities (fluid in the stomach) and encephalopathy (disturbance
of brain function as a result of disordered liver function).
Detection of varices
The dilated veins in the gullet are known as varices. Unless they bleed
they do not produce any complications or symptoms. The only way they
can be detected is by a process called endoscopy. During endoscopy a
small flexible tube is put into the gullet and the endoscopist can see
not only where the varices are present but also their size.
Prevention of bleeding
Not everyone with cirrhosis has varices and not everyone with varices
will bleed. In general, small varices rarely bleed and bigger ones may
bleed. Small varices however, may well develop into large varices over
time.
For those people who have varices and are likely to bleed, treatment
with drugs can sometimes reduce the risk of bleeding and reduce the
severity of any bleed should it occur. The drug most commonly used is
Propranolol. As with all drugs, not everyone is suitable and some people
have side-effects. Alternative methods may sometimes be used for those
who are at risk of bleeding.
Treatment
Propranolol is used both for the prevention of bleeding and also in
those people who have bled. It may be used in the prevention of re-bleeding.
Treatment of bleeding varices
If you vomit blood or pass blood with your stools this is a medical
emergency and you should go to hospital immediately. You should tell
the doctors and nurses that you have liver disease and bleeding, since
early treatment will reduce the consequences.
Initial treatment is to replace the fluid and then to identify and correct
the cause of bleeding. Not everyone who has varices and who bleeds will
be bleeding from varices. They may be bleeding from another area in
the digestive tract.
A number of treatment options are available for the treatment and prevention
of bleeding.
Drugs
Several drugs are useful in the treatment of the variceal bleed. These
drugs, such as Glypressin or Octreotide, are given by injection.
Endoscopic techniques
There are two treatments that can be given at endoscopy to treat and
prevent bleeding :-
- Injection sclerotherapy
This is injection of a sclerosant (special chemical) material in the
veins of the gullet. Usually after sedation the endoscope is passed
into the gullet. A fine flexible needle is passed through this endoscope
and used to inject sclerosant material into the oesophageal veins or
alongside the veins. These injections cause clotting (thrombosis in
the veins) and will also stimulate some scarring to reduce the risk
of varices recurring.
- Banding
With banding techniques the oesophageal varix (single varicose vein)
is sucked into a ring at the end of the endoscope. A small band is placed
around the base of the varix that has been sucked into the ring. After
1 or 2 days this will result in thrombosis (blood clot) of the varix,
which will control the bleeding.
These two techniques are complementary and the endoscopist will use
one or the other depending on the clinical situation. Both techniques
have advantages and disadvantages and complications. You should discuss
these with the endoscopist.
Sengstaken tube
Sometimes it is just not possible to get immediate control of the bleeding
with either drugs or endoscopic techniques. In this case, a tube known
as a Sengstaken tube or Lintern tube is passed through the mouth and
into the stomach. The balloon is inflated and applies compression to
the varices. This will achieve temporary control of the bleeding and
allow time for other measures to work.
Shunts
Shunting operations involve joining two veins. Shunts may either be
done surgically or by the radiologist. In a surgical shunt, the blood
that would normally go into the portal vein is diverted into another
vein. There are several types of shunts available. This process involves
a major operation.
TIPSS
TIPSS stands for Transjugular Intrahepatic Portal Systemic Shunt. This
technique is usually done by a radiologist but other clinicians also
carry this out.
In this procedure a metal tube is passed across the liver to allow the
blood in the portal vein to go straight into the hepatic vein and so
bypass the high resistance of the liver. This procedure is usually done
in the Radiology Department and may take several hours.
Both types of shunt procedure are very effective in lowering portal
pressure but they do have complications.
One of these complications is encephalopathy whereby the person may
get a little bit drowsy, confused or in rare cases even comatosed. This
is because the blood usually clears toxins from the bowel and if these
toxins bypass the liver they can affect the electrical activity of the
brain.
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