Oesophageal varices

Who is the leaflet for? What is its aim?

This information leaflet is for people who are having a gastroscopy to screen for varices. The aim of this leaflet is to explain what varices are, why they are important, what the gastroscopy procedure entails, and what treatment will be recommended if you have varices.

What are varices?

Varices are abnormal veins (blood carrying tubes) which sprout because blood is struggling to get through the liver in the normal way. If the liver is scarred and knobbly as occurs in cirrhosis, or the main blood vessel supplying the liver (the portal vein) is blocked, new blood vessels (varices) form to allow blood to flow from one side of the liver to the other. Varices are in many ways similar to bypass roads, bypassing a congested town centre. They are the body’s way of helping blood to flow. However, the varices can become problematic if they grow into hollow structures, such as the gullet or stomach, because they can bleed.

The most common condition that can cause varices is liver cirrhosis – 9 out of 10 people with cirrhosis will develop varices within 10 years. There are some rarer conditions where varices can form in the absence of cirrhosis or blockage to the main portal vein.

Varices can form anywhere, but the most likely site that they can cause problems is in the gullet or stomach.

Why are varices important?

If people develop large varices in the gullet there is a 1 in 3chance that they will bleed at some point in the future. Varices in the stomach have about a 1in 10 chance of bleeding. If your varices bleed, the bleeding can be life threatening. But if we know that you have varices before they bleed, we can treat them to stop them from bleeding and to keep you well.

How do I know if I have varices or not?

The only way to diagnose varices before they bleed is to look at the gullet and stomach via a gastroscopy (see below). Scans including ultrasound, CT and MRI do not tell us if the varices are pushing into the gullet or stomach in a way that puts you at risk of bleeding.

How will I know if my varices are bleeding?

If your varices bleed, you will vomit blood or have black, purple or bloody stool. If you have any of these symptoms you should dial 999.

What is a gastroscopy?

If we think that you are at risk of developing varices, we will refer you for a gastroscopy. A gastroscopy, also called an endoscopy, is a test that involves you swallowing a long slim tube with a camera on the tip. The tube is passed over the tongue to the back of the throat, down the gullet, to the stomach, and then the first part of the bowel. The gastroscopy is the best way to diagnose varices in the gullet and stomach that could bleed in the future.

The gastroscopy takes no more than 10 minutes and is performed as a day case procedure. Many people will manage the test with some throat-numbing spray, but there is the option of sedation with medication. A patient information leaflet about the gastroscopy test itself will accompany your gastroscopy appointment letter.

During the gastroscopy, the doctor performing the procedure will look for varices, and then grade them according to their size. Further treatment depends on the size and site of the varices.

Varices Grading

Grade 1 oesophageal varices (small varices in the gullet): Grade 1 (small) varices in the gullet are unlikely to bleed and for this reason do not require treatment. Your varices will be monitored with an annual gastroscopy, and if they get bigger then we will consider treatment at that stage.

Grade 2 or 3 oesophageal varices (large varices in the gullet), or grade 1 oesophageal varices with “red signs”: Large varices in the gullet have a one in three chance of bleeding, and for this reason we will recommend that you start treatment to reduce the bleeding risk.

Treatment options

There are two methods of treatment. One is a tablet called carvedilol (a beta-blocker), and the other is a procedure called band ligation (“banding”) that is done during the gastroscopy. Both the beta blocker and the banding are equally good at treating varices and reduce the likelihood of bleeding from 1 in 3 to 1 in 10. The choice of treatment will depend on your preference and other medical factors, which we will discuss with you.

Further information about beta-blockers and banding is provided below:

Carvedilol (beta-blockers)

What is carvedilol and how do I take it?

As varices are enlarged blood vessels, if the pressure in the varices is too high, it can cause the walls of the oesophagus to split and bleed. Beta-blockers like carvedilol are used to help prevent bleeding by reducing the blood pressure in these blood vessels.

Carvedilol is a tablet that is taken once or twice a day. We will often start you at a low dose and then increase it gradually according to your heart rate and blood pressure. Please refer to the instructions on your box of medicine and letter from us for your current dose.

Are there any problems with taking carvedilol?

Carvedilol and beta-blockers may not be suitable for everyone. It can worsen asthma and may not be advised in some heart conditions or blood vessel diseases (such as peripheral vascular disease). We will check these with you before you start treatment.

Like all medicines, carvedilol can cause side effects, but not everyone will experience these. The dose we use to treat varices is relatively low when compared to its other uses. If you are not tolerating these side effects, please contact and discuss with us.

Many people will experience mild dizziness, lightheadedness or fatigue in the first few days to weeks of taking carvedilol. If your symptoms are mild, the symptoms are likely to improve over time and it is recommended that you continue taking the medication. If your symptoms are severe, you should stop taking the tablet immediately and seek medical help. Splitting the dose to take twice a day or taking carvedilol at night can reduce these symptoms we may advise you to do this. Carvedilol also slows down the heart rate and lowers the blood pressure, if this is an issue we can adjust the dose accordingly.

These are not all the side effects of carvedilol. For a full list see the leaflet inside your medicines packet.

What if I forget to take it?

If you miss a dose of carvedilol, take it as soon as you remember, unless it’s nearly time for your next dose. In this case, just leave out the missed dose and take your next dose as normal.

Never take 2 doses at the same time. Never take an extra dose to make up for a forgotten one.

If you often forget doses, it may help to set an alarm to remind you. You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.

What if I take too much?

The amount of carvedilol that can lead to an overdose varies from person to person.

Taking too much carvedilol can lower your blood pressure, slow your heart rate, and make it difficult to breathe.

Pregnancy, breastfeeding and fertility

Carvedilol is not usually recommended if you’re pregnant.

If you're trying to get pregnant or you're already pregnant, please discuss with us.

It is OK to take carvedilol while breastfeeding.

There is no information about whether carvedilol passes into breast milk, but it would only be expected to pass through in small amounts. It’s unlikely to cause any side effects in your baby.

If you notice that your baby isn't feeding as well as usual, or seems unusually sleepy, or if you have any other concerns about your baby, then talk to your health visitor, midwife or doctor as soon as possible.

There’s no clear evidence to suggest that taking carvedilol will reduce fertility in either men or women.

Cautions with other medicines

There are some medicines that can affect the way carvedilol works. We will check with you before starting treatment.

Tell us if you’re taking:

• other medicines for high blood pressure – when taken together with carvedilol, they can sometimes lower your blood pressure too much
• other medicines that can lower your blood pressure – these include some antidepressants, nitrates (for chest pain), baclofen (a muscle relaxant), medicines for an enlarged prostate gland like tamsulosin, or levodopa (for Parkinson’s disease)
• medicines for an irregular heartbeat such as amiodarone or flecainide
• medicines for asthma or chronic obstructive pulmonary disease (COPD)
• medicines for diabetes, particularly insulin – carvedilol may make it more difficult to recognise the warning signs of low blood sugar. Speak to your doctor if you have low blood sugar levels without getting any warning signs. You should check your blood sugar after exercise, and follow usual advice about checking it before driving, or operating machinery.
• medicines that treat nose or sinus congestion, or other cold remedies (including those you can buy in the pharmacy)
• medicines for allergies, such as ephedrine, noradrenaline or adrenaline
• non-steroidal anti-inflammatory medicines (NSAIDs), such as ibuprofen, diclofenac and naproxen – these medicines may increase your blood pressure

Mixing carvedilol with herbal remedies and supplements

There's very little information about taking herbal remedies and supplements with carvedilol. However, some herbal products, such as cod liver oil, hawthorn and garlic tablets may cause low blood pressure (hypotension).

Variceal band ligation (banding)

Banding is a procedure that is performed during the gastroscopy and involves placing elastic bands on the varices. Banding works by causing scar tissue to form over the surface of the varices, stopping the blood supply so that they disappear. Banding is also used as a treatment for actively bleeding varices.

If you have agreed to banding, first you will have a normal gastroscopy to decide if banding is still required. The gastroscopy tube will then be removed, a cap with the bands will be placed on the tip of the gastroscopy tube, and you will swallow the tube for a second time to allow the banding to occur. The total procedure usually takes no more than 15 minutes.

Banding is not a one off, and the varices can come and go. You will be required to have a repeat gastroscopy every 2- 4 weeks until the varices have cleared. About half of people will require more than 3 gastroscopies and banding to clear the varices. You will then require further gastroscopies to ensure that the varices do not return.

Most patients prefer to have sedation medication when they have banding. You will not be able to drive for 24 hours after the procedure, and will require someone to accompany you home and stay with you overnight.

It is recommended to have a soft (semi solid) diet for the first 24 hours after a banding procedure. You will be prescribed daily stomach acid reducing medication to take for the period banding is occurring so that any ulcers which form when the bands drop off are protected from the effect of stomach acid.

The usual medication is ‘omeprazole’ but may be a different type.

It is quite common for people to have some mild discomfort in the chest after banding, or to have mild difficulty swallowing that lasts for a few days. If your symptoms are severe or prolonged you should seek medical help. There is also a slight risk of bleeding or perforation (hole in the lining of the gullet) that can make you unwell, but the risk is low. If you vomit blood or have black, purple or bloody stools after banding you should seek medical help.

Gastric varices (varices in the stomach)

The treatment for stomach varices is not as clear cut as for gullet varices. Depending on the size and site of your stomach varices, your doctor may recommend that you take a beta-blocker. Rarely, the doctor may recommend that you have injection treatment during the gastroscopy.

If I am found to have varices, are there any other precautions that I should take?

1. Alcohol consumption increases the pressure in the varices and can cause bleeding – you should avoid alcohol completely.
2. There is a theoretical risk of bleeding from varices when flying (both short trips and long haul) due to changes in pressure during the flight. If you are planning on flying, please discuss with your doctor or nurse. You may be advised not to fly until treatment is established. You will need to inform your travel insurance provider about the presence of varices.

Research

There are a number of large multi-centre trials taking place in the UK currently, which are attempting to help our understanding of how best to treat varices. You may be given a choice to take part in one of the trials by the doctor performing the gastroscopy or by our research nurses.

Further information

Please direct any questions to your regular doctor or nurse, or the hepatology team using the phone numbers listed in the letters we have sent you.