Esophageal Varices are abnormally dilated veins in the lower part of the esophagus that develop as a result of portal hypertension, commonly due to liver cirrhosis. These varices pose a high risk of massive upper gastrointestinal (GI) bleeding, which can be life-threatening.
When esophageal varices rupture, they can cause severe hematemesis (vomiting of blood), shock, and potentially death if not managed promptly.
Causes and Pathophysiology
- Portal Hypertension: The most common cause of esophageal varices is liver cirrhosis (often due to chronic alcohol use, hepatitis B or C, or fatty liver disease).
Portal hypertension occurs when the liver becomes scarred and obstructs blood flow, leading to increased pressure in the portal venous system.
- Collateral Circulation Formation: To relieve this increased pressure, the body forms collateral blood vessels (varices) in the esophagus and stomach. These varices are thin-walled and prone to rupture.
- Rupture and Hemorrhage: When pressure becomes too high or if the varices are mechanically disrupted (e.g., vomiting, coughing), they can rupture, leading to severe bleeding.
Signs and Symptoms of Esophageal Variceal Bleeding
EMS providers should be alert for the following symptoms in patients with a known history of liver disease or portal hypertension:
- Profuse Hematemesis: Patients often present with large volumes of bright red blood in vomit, which is the hallmark sign of a ruptured varix.
- Melena or Hematochezia: Blood may pass through the GI tract and present as black, tarry stools (melena) or bright red rectal bleeding (hematochezia), depending on the speed and severity of the bleed.
- Hypovolemic Shock: Tachycardia and hypotension are common signs. Cool, clammy skin, altered mental status, and pallor indicate worsening shock.
- Signs of Liver Disease:
- Jaundice (e.g., yellowing of the skin and eyes)
- Ascites (e.g., swollen abdomen due to fluid accumulation)
- Spider Angiomata (e.g., visible, web-like blood vessels on the skin)
- Hepatic Encephalopathy (e.g., confusion, altered consciousness)
Prehospital Assessment
- Scene Size-Up and Initial Impression: Evaluate the scene for large amounts of blood, which can indicate massive hemorrhage.
Assess for a patient history of liver disease, alcoholism, or known cirrhosis.
- Airway & Breathing: Monitor for airway obstruction due to blood in the mouth or pharynx.
Be prepared to suction the airway frequently to prevent aspiration.
Assess respiratory status and provide high-flow oxygen if needed.
- Circulatory Assessment: Check for signs of shock (e.g., tachycardia, hypotension).
Establish large-bore IV access (18 gauge or larger) for potential fluid and medication administration.
Monitor mental status and skin condition (pallor, coolness).
- Focused History & Physical Exam: Ask about the patient’s history of liver disease, alcohol use, hepatitis, or prior variceal bleeding.
Inquire about recent triggers (e.g., vomiting, straining, recent alcohol binge) that may have precipitated bleeding.
Prehospital Treatment and Management
Managing esophageal varices in the prehospital setting is challenging and requires prompt, aggressive intervention to control bleeding and prevent shock.
1. Airway Management
- Suctioning: Keep a suction device readily available for continuous use to clear the airway of blood.
- Airway Positioning: Consider placing the patient in the left lateral recumbent position if unconscious to reduce the risk of aspiration.
- Definitive Airway: If the patient is at risk of losing their airway (e.g., massive hematemesis or altered mental status), consider early endotracheal intubation, if within your scope and if protocols allow.
2. Hemodynamic Support
- IV Fluid Resuscitation: Establish two large-bore IVs and begin fluid resuscitation with isotonic crystalloids (e.g., normal saline) if the patient shows signs of hypovolemic shock.
Avoid aggressive fluid overload, as it can increase portal hypertension and worsen bleeding.
- Blood Products: If available (e.g., in critical care transport), consider initiating blood transfusion early in patients with significant bleeding or hemorrhagic shock.
3. Medications
- Vasoactive Agents (for ALS Providers): If within your scope and protocol, consider octreotide or vasopressin, which can reduce portal pressure and control variceal bleeding (requires medical control consultation).
- Anti-Emetics: Administer antiemetics (e.g., ondansetron) to prevent retching and reduce the risk of worsening the variceal tear.
4. Rapid Transport and Early Notification
- Transport Priority: All patients with suspected variceal bleeding should be considered critical and require rapid transport to the nearest facility with endoscopic capabilities and surgical backup.
- Early Notification: Notify the receiving hospital as early as possible about the suspected diagnosis, so the facility can mobilize appropriate resources.
Differentiating from Other GI Bleeds
- Peptic Ulcer Disease: Often presents with coffee-ground emesis and less profuse bleeding.
- Mallory-Weiss Syndrome: Similar to varices but generally involves small, non-life-threatening mucosal tears with moderate bleeding.
- Gastric Cancer or Erosive Gastritis: May have chronic, low-volume bleeding rather than acute hemorrhage.
Who Discovered Esophageal Varices?
Esophageal Varices themselves are not attributed to a specific individual. They were gradually recognized as a consequence of portal hypertension in patients with liver disease, a concept that evolved over centuries of clinical observation.
The condition was first described in detail in the early 20th century, as the understanding of cirrhosis and portal hypertension advanced.
The development of endoscopy in the mid-20th century allowed for more precise diagnosis and management of this life-threatening condition.
Key Considerations for EMS Providers
- Early Recognition: Suspect esophageal varices in any patient with massive hematemesis and a history of liver disease or alcohol abuse.
- Airway Safety: Suctioning and airway management are critical to prevent aspiration.
- Shock Management: Focus on maintaining perfusion with controlled fluid resuscitation.
- Definitive Treatment is Hospital-Based: EMS management is primarily supportive, with rapid transport to a facility that can perform endoscopy and possible surgical interventions.
Further Reading:
Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education
Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins
Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson
Meseeha, M., & Attia, M. (2023) Esophageal Varices. StatPearls. Treasure Island, Florida: StatPearls. Accessed September 28, 2024
Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education
Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell
