Esophageal varices/Bleeding in the digestive tract

Bleeding in the digestive tract

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Varices

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Normally, blood from your intestine, spleen and pancreas enters your liver through a large blood vessel called the portal vein. But if scar tissue blocks circulation through your liver, the blood backs up, leading to increased pressure within the portal vein (portal hypertension)

This forces blood into smaller veins in your esophagus, stomach and occasionally your rectum. The excess blood causes these fragile, thin-walled veins to balloon outward and sometimes to rupture and bleed. Once varices develop, they continue to grow larger.

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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.

Cirrhosis: A leading cause of esophageal varices Esophageal varices are usually a complication of cirrhosis. This serious liver disorder, which is irreversible scarring of liver tissue, often results from alcoholic liver disease or hepatitis B or C infection. Another liver disorder, primary biliary cirrhosis, which destroys the small ducts that carry bile, can also cause scarring of liver tissue and lead to esophageal varices.

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

About one-third of people with esophageal varices will develop bleeding. The signs and symptoms of esophageal bleeding range from mild to severe and include:

Vomiting blood
Black, tarry or bloody stools
Decreased urination from unusually low blood pressure
Excessive thirst
Lightheadedness
Shock, in severe cases
When to see a doctor
See your doctor if you develop signs and symptoms of liver disease, such as:

Weight loss
Small, red spider veins under your skin or easy bruising
Weakness
Fatigue
Yellowing of your skin and eyes and dark, cola-colored urine
The buildup of fluid in your abdominal cavity (ascites)
Itching of your hands and feet and eventually of your entire body
Swelling of your legs and feet from retained fluid (edema)
Mental confusion, such as forgetfulness or trouble concentrating (encephalopathy) .


When it's an emergency

If you've been diagnosed with esophageal varices and experience bloody vomit or stools, call 911 or your local emergency services right away. These may indicate that esophageal varices have ruptured — a life-threatening condition that requires immediate medical care.

Complications

Varices do not cause symptoms until they leak or rupture, leading to extensive bleeding. Signs of bleeding from varices can include vomiting blood, dark-colored or black stools, and lightheadedness. If bleeding is severe, the person may lose consciousness.


Bleeding varices require emergency medical treatment. If not treated quickly, a large amount of blood can be lost and there is a significant risk of dying. If one or more of these symptoms develop, the person needs to seek emergency care.


The most serious complication of esophageal varices is bleeding. Once you have had a bleeding episode, you're at greatly increased risk of another, especially immediately following the first episode. The risk of bleeding is related to the location, size, and appearance of the varix, presence of red wale markings, variceal pressure, prior history of variceal bleeding, as well as the severity of hepatic dysfunction (classified by Child-Pugh class.)

Recurrent bleeding is common in people with esophageal varices — up to 70 percent will bleed again within one year of the first episode of bleeding without treatment. The likelihood of death increases with each episode. You're at greater risk of repeat bleeding if you are older, have liver failure or kidney failure, or drink alcohol.

Other complications of bleeding esophageal varices include:

Hypovolemic shock. This occurs when your body loses some, often at least one-fifth, of its blood volume. Symptoms include low blood pressure, a rapid pulse, weakness, sweating, anxiety, mental confusion and possibly unconsciousness.

Encephalopathy. A damaged liver is less effective at removing toxins from your body — normally one of the liver's key tasks. The buildup of toxins can damage your brain, leading to changes in your mental state, behavior and personality (hepatic encephalopathy). Signs and symptoms include forgetfulness, confusion and mood changes, and in the most severe cases, delirium and coma.

Infection. Aspiration pneumonia, which occurs when you inadvertently inhale vomit or other substances into your lungs, can be a life-threatening complication of bleeding varices or of certain treatments to control them.

If you have cirrhosis or other serious liver disease, your doctor may screen you for esophageal varices, sometimes as often as every year or two.

These tests are usually used to look for varices:
Endoscopy. For this test, your doctor inserts a thin, flexible, lighted tube (endoscope) through your mouth and into your esophagus. If any dilated veins are found, they're graded according to their size and checked for red streaks, which usually indicate a significant risk of bleeding. An esophageal endoscopy takes about 20 to 30 minutes, and the risks are generally minor. The most common side effect is a sore throat from swallowing the endoscope.

Imaging tests. Both computerized tomography (CT) scans and magnetic resonance imaging (MRI) may be used to diagnose esophageal varices. Unlike an endoscopy, these noninvasive tests also allow your doctor to examine your liver and circulation in the portal vein. But imaging tests aren't as effective at finding varices as endoscopy is, and they're not as useful for determining which varices are likely to bleed. For that reason, they're most often used in addition to endoscopy or when endoscopy can't be performed.


Treatment and Drugs
The primary aim in treating esophageal varices is to prevent bleeding. To help achieve this goal, doctors usually prescribe high blood pressure drugs (beta blockers) to reduce pressure in the portal vein once your initial episode of bleeding has resolved.


Beta blockers, which are traditionally used to treat high blood pressure, are the most commonly recommended medication to prevent bleeding from varices. Beta blockers decrease pressure inside of the varices, which can reduce the risk of bleeding by 45 to 50 percent .


Side effects of beta blockers — The most common side effects of beta blockers are fatigue and dizziness. They can also cause insomnia, a decreased ability to exercise, a slow heart rate, impotence, and cold hands and feet. The beta blockers used for cirrhosis can worsen symptoms of asthma, other lung diseases, or blood vessel disease (such as peripheral vascular disease). As a result, they normally are not prescribed for people with these conditions. Side effects should be discussed with a healthcare provider before stopping the medication..


Other drugs may be used for people who don't respond to beta blockers or who have severe side effects. Sometimes the varices may be injected directly with a solution that causes them to shrink. Or they may be tied with elastic bands before they have a chance to bleed.

Treating bleeding

. Bleeding varices are life-threatening, and immediate treatment is essential. To stop bleeding, you're likely to have one of the following procedures:

Variceal ligation. This is the preferred treatment for bleeding esophageal varices. During the procedure, your doctor uses an endoscope to snare the varices with an elastic band, which essentially "strangles" the veins. Variceal ligation usually causes fewer serious complications than do other treatments. It's also less likely to lead to episodes of repeat bleeding.
Endoscopic injection therapy. In this procedure, the bleeding varices are injected with a solution that shrinks them. Bleeding is usually controlled after one or two treatments, but complications can occur, including perforation of the esophagus and scarring of the esophagus that can lead to trouble swallowing (dysphagia).

Medications. A drug called octreotide (Sandostatin, Sandostatin LAR) is often used in combination with endoscopic therapy to treat bleeding from esophageal varices. Octreotide works by reducing pressure in the varices. The drug is usually continued for five days after a bleeding episode.

Balloon tamponade. This procedure is sometimes used to stop severe bleeding while waiting for a more permanent procedure. A tube is inserted through your nose and into your stomach and then inflated. The pressure against your veins can temporarily stop bleeding.


Shunt. In this procedure, called transjugular intrahepatic portosystemic shunt (TIPS), a small tube called a shunt is placed between the portal vein and the hepatic vein, which carries blood from your liver back to your heart. The tube is kept open with a metal stent. By providing an artificial path for blood through the liver, the shunt often can control bleeding from esophageal varices. But TIPS can cause a number of serious complications, including liver failure and encephalopathy, which may develop when toxins that would normally be filtered by the liver are passed through the shunt directly into the bloodstream. TIPS is mainly used when all other treatments have failed or as a temporary measure in people awaiting a liver transplant.


Other Causes Of Bleeding;

Bleeding in the digestive tract

What causes bleeding in the digestive tract?
Stomach acid can cause inflammation that may lead to bleeding at the lower end of the esophagus. This condition, usually associated with the symptom of heartburn, is called esophagitis or inflammation of the esophagus. Sometimes a muscle between the esophagus and stomach fails to close properly and allows the return of food and stomach juices into the esophagus, which can lead to esophagitis. In another, unrelated condition, enlarged veins (varices) at the lower end of the esophagus may rupture and bleed massively. Cirrhosis of the liver is the most common cause of esophageal varices. Esophageal bleeding can be caused by a tear in the lining of the esophagus (Mallory-Weiss syndrome). Mallory-Weiss syndrome usually results from vomiting but may also be caused by increased pressure in the abdomen from coughing, hiatal hernia, or childbirth. Esophageal cancer can cause bleeding.

The stomach is a frequent site of bleeding. Infections with Helicobacter pylori (H. pylori), alcohol, aspirin, aspirin-containing medicines, and various other medicines (NSAIDs) (particularly those used for arthritis) can cause stomach ulcers or inflammation (gastritis). The stomach is often the site of ulcer disease. Acute or chronic ulcers may enlarge and erode through a blood vessel, causing bleeding. Also, patients suffering from burns, shock, head injuries, or cancer,or those who have undergone extensive surgery may develop stress ulcers. Bleeding can also occur from benign tumors or cancer of the stomach, although these disorders usually do not cause massive bleeding.

A common source of bleeding from the upper digestive tract is ulcers in the duodenum (the upper small intestine). Duodenal ulcers are most commonly caused by infection with H. pylori bacteria or drugs such as aspirin or NSAIDs.

In the lower digestive tract, the large intestine and rectum are frequent sites of bleeding. Hemorrhoids are the most common cause of visible blood in the digestive tract, especially blood that appears bright red. Hemorrhoids are enlarged veins in the anal area that can rupture and produce bright red blood, which can show up in the toilet or on toilet paper. If red blood is seen, however, it is essential to exclude other causes of bleeding since the anal area may also be the site of cuts (fissures), inflammation, or cancer.

Benign growths or polyps of the colon are very common and are thought to be forerunners of cancer. These growths can cause either bright red blood or occult bleeding. Colorectal cancer is the third most frequent of all cancers in the United States and often causes occult bleeding at some time, but not necessarily visible bleeding.

Inflammation from various causes can produce extensive bleeding from the colon. Different intestinal infections can cause inflammation and bloody diarrhea. Ulcerative colitis can produce inflammation and extensive surface bleeding from tiny ulcerations. Crohn's disease of the large intestine can also produce bleeding.

Diverticular disease caused by diverticula--outpouchings of the colon wall--can result in massive bleeding. Finally, as one gets older, abnormalities may develop in the blood vessels of the large intestine, which may result in recurrent bleeding.

Patients taking blood thinning medications (warfarin) may have bleeding from the GI tract, especially if they take drugs like aspirin.

What are the common causes of bleeding in the digestive tract?

Esophagus

inflammation (esophagitis)
enlarged veins (varices)
tear (Mallory-Weiss syndrome)
cancer
Stomach

ulcers
inflammation (gastritis)
cancer
Small intestine

duodenal ulcer
inflammation (irritable bowel disease)
Large intestine and rectum

hemorrhoids
infections
inflammation (ulcerative colitis)
colorectal polyps
colorectal cancer
diverticular disease


How is bleeding in the digestive tract recognized?
The signs of bleeding in the digestive tract depend upon the site and severity of bleeding. If blood is coming from the rectum or the lower colon, bright red blood will coat or mix with the stool. The stool may be mixed with darker blood if the bleeding is higher up in the colon or at the far end of the small intestine. When there is bleeding in the esophagus, stomach, or duodenum, the stool is usually black or tarry. Vomited material may be bright red or have a coffee-grounds appearance when one is bleeding from those sites. If bleeding is occult, the patient might not notice any changes in stool color.

If sudden massive bleeding occurs, a person may feel weak, dizzy, faint, short of breath, or have crampy abdominal pain or diarrhea. Shock may occur, with a rapid pulse, drop in blood pressure, and difficulty in producing urine. The patient may become very pale. If bleeding is slow and occurs over a long period of time, a gradual onset of fatigue, lethargy, shortness of breath, and pallor from the anemia will result. Anemia is a condition in which the blood's iron-rich substance, hemoglobin, is diminished.

How is bleeding in the digestive tract diagnosed?
The site of the bleeding must be located. A complete history and physical examination are essential. Symptoms such as changes in bowel habits, stool color (to black or red) and consistency, and the presence of pain or tenderness may tell the doctor which area of the GI tract is affected. Because the intake of iron, bismuth (Pepto Bismol), or foods such as beets can give the stool the same appearance as bleeding from the digestive tract, a doctor must test the stool for blood before offering a diagnosis. A blood count will indicate whether the patient is anemic and also will give an idea of the extent of the bleeding and how chronic it may be.

Endoscopy
Endoscopy is a common diagnostic technique that allows direct viewing of the bleeding site. Because the endoscope can detect lesions and confirm the presence or absence of bleeding, doctors often choose this method to diagnose patients with acute bleeding. In many cases, the doctor can use the endoscope to treat the cause of bleeding as well.

The endoscope is a flexible instrument that can be inserted through the mouth or rectum. The instrument allows the doctor to see into the esophagus, stomach, duodenum (esophago-duodenoscopy), colon (colonoscopy), and rectum (sigmoidoscopy); to collect small samples of tissue (biopsies); to take photographs; and to stop the bleeding.

Small bowel endoscopy, or enteroscopy, is a procedure using a long endoscope. This endoscope may be used to localize unidentified sources of bleeding in the small intestine.

Other Procedures
Several other methods are available to locate the source of bleeding. Barium x rays, in general, are less accurate than endoscopy in locating bleeding sites. Some drawbacks of barium x rays are that they may interfere with other diagnostic techniques if used for detecting acute bleeding, they expose the patient to x rays, and they do not offer the capabilities of biopsy or treatment.

Angiography is a technique that uses dye to highlight blood vessels. This procedure is most useful in situations when the patient is acutely bleeding such that dye leaks out of the blood vessel and identifies the site of bleeding. In selected situations, angiography allows injection of medicine into arteries that may stop the bleeding.

Radionuclide scanning is a noninvasive screening technique used for locating sites of acute bleeding, especially in the lower GI tract. This technique involves injection of small amounts of radioactive material. Then, a special camera produces pictures of organs, allowing the doctor to detect a bleeding site.

In addition, barium x rays, angiography, and radionuclide scans can be used to locate sources of chronic occult bleeding. These techniques are especially useful when the small intestine is suspected as the site of bleeding since the small intestine may not be seen easily with endoscopy.

How is bleeding in the digestive tract treated?
Endoscopy is the primary diagnostic and therapeutic procedure for most causes of GI bleeding.

Active bleeding from the upper GI tract can often be controlled by injecting chemicals directly into a bleeding site with a needle introduced through the endoscope. A physician can also cauterize, or heat treat, a bleeding site and surrounding tissue with a heater probe or electrocoagulation device passed through the endoscope. Laser therapy is useful in certain specialized situations.

Once bleeding is controlled, medicines are often prescribed to prevent recurrence of bleeding. Medicines are useful primarily for H. pylori, esophagitis, ulcer, infections, and irritable bowel disease. Medical treatment of ulcers, including the elimination of H. pylori, to ensure healing and maintenance therapy to prevent ulcer recurrence can also lessen the chance of recurrent bleeding.

Removal of polyps with an endoscope can control bleeding from colon polyps. Removal of hemorrhoids by banding or various heat or electrical devices is effective in patients who suffer hemorrhoidal bleeding on a recurrent basis. Endoscopic injection or cautery can be used to treat bleeding sites throughout the lower intestinal tract.

Endoscopic techniques do not always control bleeding. Sometimes angiography may be used. However, surgery is often needed to control active, severe, or recurrent bleeding when endoscopy is not successful.

How do you recognize blood in the stool and vomit?

bright red blood coating the stool
dark blood mixed with the stool
black or tarry stool
bright red blood in vomit
coffee-grounds appearance of vomit
What are the symptoms of acute bleeding?

any of bleeding symptoms above
weakness
shortness of breath
dizziness
crampy abdominal pain
faintness
diarrhea
What are the symptoms of chronic bleeding?

any of bleeding symptoms above
weakness
fatigue
shortness of breath
lethargy
faintness
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http://www.mamashealth.com/stomach/bleeding.asp

Sources/Excerpts http://www.cnn.com/HEALTH/library/esophageal-varices/DS00820.html
http://www.uptodate.com/patients/content/topic.do?topicKey=~l.22S8wqWBcwQG
http://www.uptodate.com/patients/content/topic.do?topicKey=~l.22S8wqWBcwQG
http://www.mombu.com/medicine/heart/t-portal-hypertension-and-bleeding-of-oesophageal-varices-sclerosing-cholangitis-endoscopy-cholangitis-stomach-heart-2382216.html