What are varices?
Varices are swollen blood vessels (similar to varicose veins) which develop in the lining of the digestive tract, particularly in the lower oesophagus (gullet), stomach or rectum. This information sheet is about the management of oesophageal varices, and the prevention of bleeding.
Oesophageal varices tend to be close to the surface of the lining of the oesophagus. They are at risk of bleeding, which is why it is important to diagnose and treat them.
What causes varices?
The blood from your intestines is filtered through your liver, which processes and stores nutrients, breaks down waste products and toxins, and makes proteins and enzymes which are vital to our health. Blood is carried to the liver by the portal vein. Varices develop when the body tries to redirect the flow of blood in response to increased pressure in the portal vein (portal hypertension).
Over time, collateral vessels develop in an attempt to bypass the liver – these are called varices.
The most common cause of oesophageal varices is cirrhosis of the liver. Cirrhosis is a chronic (long-term) condition which results in scarring to the liver, making it more resistant to the blood passing through it and increasing the pressure in the portal vein. Cirrhosis may be caused by excessive alcohol intake, viruses (such as Hepatitis C) and fatty liver disease (increasingly due to obesity).
Varices can also develop over time due to problems unrelated to the liver, such as clots or blockages in the portal vein, or in blood vessels returning blood from the liver to the heart.
How common are varices?
It is unusual for varices to develop in patients who do not have an existing health condition such as those described above. Approximately half of patients who have cirrhosis will develop varices over time. Of those, about a quarter will experience variceal rupture, which can result in acute bleeding. Fortunately, there are treatments which can prevent and reduce the risk of bleeding.
How are varices diagnosed?
Varices can be detected during investigations such as ultrasound or CT scans. However, the best way to check for varices is a gastroscopy; an endoscopic investigation where a thin, flexible camera is passed down through the oesophagus into the stomach. During gastroscopy treatments can be performed to prevent bleeding or stop it if it occurs.
If varices are diagnosed during a gastroscopy, the Endoscopist will make sure that your GP is aware and that the cause is investigated, if not known already. This may mean having blood tests or an ultrasound scan or referral to a specialist doctor (a consultant Gastroenterologist or Hepatologist).
Why is screening and surveillance important?
It is recommended that all patients who are diagnosed with cirrhosis have a gastroscopy to check for varices. This is called screening. If no varices are found and your liver disease is stable (compensated cirrhosis), you will normally be advised to have a gastroscopy every two to three years, to check that no varices have developed. This is called surveillance.
If your liver disease is not stable (decompensated cirrhosis) or you have tiny varices then you should have a surveillance gastroscopy every year to check for the development or progression of varices. Treating the cause of liver disease can help to prevent varices from developing; this may include avoiding alcohol or losing weight.
If varices are detected, the Endoscopist will note their size, appearance and location, and assess the risk of bleeding. This will help to determine what treatment is required. You will need to have a surveillance gastroscopy at regular intervals, depending on the bleeding risk of your varices.
Beta-blockers may reduce the bleeding risk in more than half of cases for medium or larger varices. However they can cause side-effects and are not suitable for everyone. For varices that are considered to be at high risk of bleeding, preventative treatments such as variceal band ligation can be helpful.
What is variceal band ligation?
This is a treatment which is performed during gastroscopy. Small rubber bands are placed around varices in the oesophagus and left in place. The bands cut off the blood supply to the varices, which drop off, passing harmlessly through your system. The area heals over the next few days.
Avoiding hot drinks and sticking to a soft diet for 24 hours after treatment helps to prevent complications such as pain, although a little discomfort is expected at first. Simple pain medication can help. Banding can result in complications such as bleeding or scarring, and it is not recommended for the treatment of smaller varices. However, a programme of banding (where the treatment is repeated until varices are gone) can dramatically reduce the risk of bleeding for medium or large varices that are considered a high risk.
In the next 24 hours: DO NOT
- Drive any vehicles.
- Operate any machinery or gas or electrical appliances as your reactions may be slower.
- Drink any alcohol.
- Take any sleepy medications.
- Make any important decisions or sign any legal paperwork for 24 hours.
After procedure side-effects
The effects of the sedation can last for up to 24 hours; although you may feel perfectly recovered, your judgement and reactions may be impaired during this time. It is essential you have someone to take you home and stay with you for the remainder of the day and overnight. It is recommended that you rest quietly for the remainder of the day.
If you start developing severe pain, which will not settle after the first 24 hours, on your chest, neck, abdomen, or if you start vomiting blood or passing black stools, please contact the endoscopy department for further advice.
After repeated procedures for banding, it is normal that you may experience some difficulties swallowing. This is normal and expected, as long as you continue to be able to ingest your food safely. Ensure you chew properly any solid food and if the symptoms persists for long, contact the endoscopy department for further advice.
What happens if my varices bleed?
Variceal bleeding is a medical emergency and can be life-threatening; you should seek medical attention urgently in the Emergency Department if you vomit blood, or pass black, tarry stool (melaena), or blood per rectum.
Variceal band ligation is the ‘gold standard’ of treatment for bleeding varices.
Other endoscopic treatments such as gluing, or compressing the varices with a stent or an inflatable balloon (Sengstaken tube) may also be necessary to stop bleeding. An operation called a TIPSS (Transjugular Intrahepatic Portosystemic Shunt) may be considered in extreme cases. Supportive treatment such as blood transfusion may also be necessary.
Blood Donation
Following this procedure, you must not donate blood for 4-6 months. The reason for this is that your ability to donate blood in the future is dependent upon your diagnosis and the possibility that you might need to undergo further investigations or complete treatments (British Society of Gastroenterology Guidance; updated February 2020).
Air travel
If you had your varices banded you should not undertake any air travel for 2 weeks after your procedure.
Sleep Apnoea
Please bring your CPAP machine with you for your appointment as due the possible side effects of the sedative injection it might be necessary for it to be used to ensure your safety.
Medication
Please do not stop taking any prescribed medication prior to the procedure, unless you have been advised by the doctor, including blood pressure tablets.
For any medication queries please telephone 07815178199 Monday – Saturday between 10:30-11:30am and 14:30-15:30pm only.
Outside of these hours, this telephone is for Emergency calls only
Having a procedure with a training Endoscopist
Endoscopy Training at Luton and Dunstable Hospital
Luton and Dunstable Hospital contributes to the training of Endoscopists and as a result has several trainees working in Endoscopy; this leaflet is provided to inform you about how this may affect your Endoscopy procedure, and support your decision as to whether you are happy to have a trainee perform the procedure.
Although the idea of a trainee may be unnerving it is often a very positive experience. All our Endoscopy trainees are in a structured training programme within the national guidelines.
Will they be supervised?
Under no circumstances are trainee Endoscopists unsupervised. Depending on the experience of the trainee, an experienced Consultant will be present, and supervising your Endoscopy procedure throughout or will be immediately available in the endoscopy department. If at any time you or the trainee has any difficulties the trainer can intervene. All the Endoscopy trainers at Luton and Dunstable Hospital are accredited Endoscopy trainers and we regularly monitor their training skills.
Is it safe?
We carefully monitor our complication rates for Endoscopy and there is no difference in safety with a trainee Endoscopist.
Will it be more uncomfortable?
We carefully monitor patient comfort and have not found any suggestion it will be more uncomfortable.
Will it take longer?
While learning a trainee may be slower than an independent Endoscopist, however, our trainers are experienced in monitoring the length of a procedure and will take over if procedure seems prolonged. On a training list we allow a longer time for the whole Endoscopy experience, and patients often find this makes for a more relaxed atmosphere.
What should I do if I don’t want a trainee?
If you wish to let us know you are not happy to have a supervised trainee perform your procedure please inform us at least one week in advance of the procedure, so we can ensure you are not booked on a training list. The Endoscopy Booking Office can be contacted on 01582 497273.