med vytorin

By Jeyashree Sundaram, MBA

Varices are large swollen veins in the esophagus or stomach. High pressure in the portal veins or portal hypertension is a primary cause for this condition, and it is found in 50% of liver cirrhosis patients.

Gastric varices can typically be differentiated into cardiac or fundic depending on their location. The submucosal veins of the stomach balloon up (dilate) due to gastric varices. When the pressure is more in the portal veins than that in the inferior vena cava, secondary conditions develop resulting in inflated and sinuous submucosal vessels in the stomach. This leads to a fatal condition when there is profuse internal bleeding because of portal pressure that is higher than 12 mm Hg.

Varices are highly correlated to liver cirrhosis and correspondingly to portal hypertension.

Symptoms of Bleeding Varices

Initially, gastric varices do not show symptoms, but they are highly sensitive and tend to burst at the slightest pressure, resulting in heavy internal bleeding. The most common symptoms of bleeding varices are stools that appear tarry or bloody, vomiting blood, hypotension, high heart rate, dizziness, and shock.

Symptoms Related to Liver Disease

Cirrhosis or chronic liver disease is the most common factor of portal hypertension. The following are a few indications to varices that can be seen in patients with cirrhosis:

• General weakness and feeling of constant tiredness
• Lack of appetite leading to weight loss
• Easy bruising and excessive bleeding
• Muscle cramps and muscle wasting
• Testicular atrophy (in men)
• Abdominal swelling
• Nausea and vomiting
• Jaundice
• Dark colored urine
• Spider angiomas (growth of new blood vessels showing spider-like patterns)
• Cholestatic conditions (obstruction of bile and related complications)
• Encephalopathy (changes in behavior due to loss of memory and loss of intellectual function)
• Dupuytren contracture (curvature of the fingers toward the palm due to muscular problems)
• Altered features of the hands and nails such as palmar erythema and leukonychia
• Asterixis (shaking of the hand like that of the flapping wings of a bird).

Symptoms Related to Portal Vein Hypertension

The increased pressure in the portal veins leads the blood to be forced away from the liver. This blood gets diverted into smaller vessels that are thin walled and cannot manage the increase in flow, which causes them to swell and rupture. Patients of portal hypertension may also present with the following serious complexities.

• Swollen abdomen may be a symptom of accumulation of fluid in the abdomen. Here the anterior walls of the abdomen are dilated, which is indicated by raised venal patterns just below the skin.
• Melena or hematemesis is the vomiting of blood and/or excretion of dark colored feces, indicating the presence of dried blood.
• Fever and stomach pain are the symptoms of bacterial peritonitis, an infection of ascitic fluid found in patients with chronic cirrhosis.
• Abnormal behavior indicates the presence of a neuropsychiatric syndrome. This condition happens when there is severe metabolic stress caused by bleeding in the GI tract, infection, or irregularities in the electrolytes.
• Hematochezia is the condition where the patient is found with blood in the stool.
• Caput medusa is a condition where the gastric veins develop from the navel in the form of a palm tree.
• Anal hemorrhoids is the painless bleeding during bowel movements.
• Ascites is an abnormal collection of fluid (above 25 ml) inside the peritoneal cavity, mostly seen in liver disease patients.
• Paraumbilical hernia is the condition, where a small pouch is formed near the navel. Weak abdominal muscles allow the contents of the intestine and even the bowel to fill up in the pouch.

Other related symptoms are symptoms of increased blood circulation, presenting as an irregular and bounding pulse, very warm hands and legs, decreased tension in the arteries, and a distinct sound of blood flow around the pericardium.
Other vital signs of portal hypertension that could lead to varices are as follows.

• Sallow skin is an indicator of internal bleeding that is active.
• Bluish coloration of the tongue, lips, and other external parts indicating reduced oxidation in blood, which is known as cyanosis.
• Labored breathing, also called dyspnea, is one in which the patient finds difficulty in breathing. The patient with tachypnea has an increased above-normal rate of respiration. The cause could be pathological or physiological metabolic stress.
• Telangiectasis is the spiderlike veins that are actually abnormally inflated blood vessels, most commonly visible in the extremities.
• Fetor hepaticus means bad breath almost like a fecal smell occurring in portal vein hypertension of any cause (cirrhosis).

The size of the liver is an important indication of related disease. Constant audible venous noises as a result of fast and unstable flow in the collateral veins and hemorrhoids denotes bleeding and black stools.

Bleeding varices are a medical emergency, but they can be restrained by the use of beta blockers and banding. Antibiotic treatment should also be given to reduce recurrence and complications.

Further Reading

• All Gastric Varices Content
• Gastric Varices
• Treatment of Gastric Varices
• Sarin Classification of Gastric Varices