What are Esophageal Varices?
Oesophageal varices are enlarged or dilated veins that are present in the gullet (oesophagus). These most commonly arise as a result of liver disease but may occur from other causes. In many cases the varices do not cause any problem but they may bleed. Bleeding from oesophageal varices can be a serious event and, therefore, doctors may advise treatment to reduce the risk of bleeding from the varices. There are several different treatments available and your doctor will discuss the best form of treatment with you. Some people do not require any additional treatment, some require treatment with drugs and others require endoscopic intervention. There are two types of endoscopic intervention available:
The method best suited to your needs will depend on a number of factors and is usually decided by the doctor when the varices are assessed during the endoscopy.
1. Band ligation (banding)
In band ligation the endoscopist will, using the endoscope, put a small band around the base of the varix. This will result in the blood inside varix becoming clotted and scarred. Band ligation is the preferred method of treatment of oesophageal varices.
2. Endoscopic sclerotherapy
Endoscopic sclerotherapy is where the varices are injected with a chemical agent which causes the varices to clot and become scarred. A long needle is passed through the endoscope and the doctor injects the varices with the chemical agent. Endoscopic sclerotherapy has largely been replaced by band ligation.
Before the procedure
Treatment of varices may be done either as an inpatient or outpatient procedure. In either case you should have nothing to eat or drink for four hours preceding the investigation.
You need to bring a friend or relative with you to your appointment so they can accompany you home afterwards. If you are taking any medicines or tablets or any form of treatment please ask a doctor or nurse whether you should take the medication or not. If you have diabetes, then please let the doctor or nurse know so that treatment can be arranged appropriately. You should also let the doctor know if you are allergic to anything. Immediately prior to the procedure a small needle (a cannula) will be put in your arm. This cannula will allow the doctor to give you sedation and, if needed, pain relief. Before the procedure starts you will be asked to sign a consent form. It is very important that you ask the doctor or nurse any questions that you may have.
The procedure
The procedure is usually performed in the Endoscopy room. After the doctor has explained the procedure, you will be asked to lie on your left hand side. A small clip will be placed on one of your fingers. This is to measure the amount of oxygen in your blood and your pulse rate. You may be given additional oxygen through a tube placed in your nose. A small plastic mouth piece will be put in between your teeth to protect them during the procedure. Sometimes, you may be given a throat spray to anaesthetise the back of your throat. When you are lying comfortably the doctor will then give you an injection to sedate you. You will be sleepy and relaxed but it is unlikely you will be fully asleep. The doctor will then ask you to swallow so that the endoscope passes into the gullet. The doctor will then assess the varices as well as the rest of the oesophagus, stomach and first part of the small bowel. If treatment is indicated then the doctor will either band or inject the varices.
If the doctor feels that injection of the varices is best, he will inject the varices using a long, flexible needle that is passed through the endoscope. If the doctor has decided that banding ligation is the best treatment, the endoscope will be removed so that an additional attachment can be placed on the end of the endoscope. You will then be asked to swallow the endoscope again and the banding will be done. The procedure usually takes between 15–30 minutes.
What are the risks?
General complications of endoscopy occur rarely; these include perforation of the gullet. This may lead to local complications including an abscess around the gullet.
Additional risks of sclerotherapy and banding :
Bleeding may occur immediately after injection of varices (in about 3–5% of patients) or a few days later. The nurse will carefully monitor your blood pressure and pulse after the procedure. Pain may also occur and this should be treated with painkillers. Paracetamol is usually all that is needed. Sometimes the gullet narrows after sclerotherapy causing difficulty in swallowing. This can usually be treated endoscopically by widening the gullet (dilatation). Sometimes after injection of the varices, ulcers will form. These ulcers themselves may bleed. For this reason you may be asked to take anti–ulcer forming drugs. As with injection sclerotherapy, there are complications with banding. In general, these tend to be similar to those of sclerotherapy mentioned above but occur slightly less commonly.
After the procedure
If you are an inpatient you will be taken back on your bed to the ward. The nurses will monitor your blood pressure and pulse. If you have not had a throat spray you will be able to drink once you are sufficiently awake. If you have had a throat spray you may have to wait for an hour before being able to drink any fluid.
If you have any pain after the procedure please let the nursing team know so they can give you some pain relief.
Please do remember that after sedation you should not drive or operate machinery for at least 24, and preferably, 36 hours. You should have someone with you for the next 12 hours.
Please remember that it often requires several sessions of endoscopic treatment to get rid of the varices. You must be sure that you are aware of the plans for follow–up. This may require a further attendance for endoscopy or outpatient attendance.
General points to remember
• Following the procedure, if you have any problems with persistent abdominal pain or bleeding please contact your docter immediately, informing them that you have had an endoscopy.
• If you are unable to contact or speak to your doctor, you must go immediately to your local Emergency department (A&E).