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Presents with upper gastrointestinal bleeding in a patient with indirect signs of cirrhosis.

Esophageal varices are venous collaterals that arise from the portal vein due to portal hypertension. Bleeding occurs due to rupture due to the overpressure and because there is no counterpressure from the surrounding tissue. They protrude into the lumen of the esophagus. The varices are usually located in the distal 5 centimeters of the esophagus. They cause hematemesis and/or melena.

Diagnosis is made by esophagoscopy, where esophageal varices can be visualized directly. In 20% of bleeding in a patient with cirrhosis, the cause is not esophageal varices, but among others Mallory Weiss, ulcer, etc.

When esophageal varices are diagnosed, one third of patients will bleed within two years. Signs of a high risk of rupture are large varices and the presence of red spots in the varicose wall, as an expression of thinness of the wall.

Without therapy, the mortality of a first hemorrhage is 20 to 50%, depending on the remaining liver function. If a recurrence of bleeding occurs, this is in 40% of cases within six weeks with a mortality of 40%. If correct treatment is instituted, the mortality at that time is reduced to less than 10%.

Given the high risk of rupture of esophageal varices, preventive measures should be taken in the presence of large varices. This therapy consists of non-selective beta-blockers (propranolol type) or carvedilol (+ alpha-receptor blocker). Carvedilol is not indicated in hypotension and renal insufficiency. The selective beta-blocker reduces the splanchnic inflow, which reduces portal hypertension.

If there is a contraindication for beta-blockers, ligatures should be placed as a preventive measure.

If esophageal varices bleeding is suspected, the patient should be transferred to a specialized hospital quickly. General measures for upper gastrointestinal bleeding should be initiated, such as protecting the airway against aspiration pneumonia and treating hypovolemic shock with blood transfusions. Fluid overload maintains the bleeding and blood transfusions are only indicated from a hemoglobin < 7g/dl.

If upper gastrointestinal bleeding due to esophageal varices is suspected, somatostatin or terlipressin should be administered immediately. These products reduce portal pressure by vasoconstriction of the splanchnic arterioles.

If esophageal varices are found, they should be treated with rubber band ligatures. To accelerate gastric emptying and thus prevent aspiration pneumonia, erythromycin IV can be administered half an hour before endoscopy. High intestinal bleeding in a cirrhotic patient is associated with a high risk of bacterial infection. Therefore, antibiotics should be started systematically.

When someone has bled, secondary prevention must absolutely be instituted. That is the combination of the non-selective fatty blocker together with eradication of the varicose veins by rubber band ligatures.

In some circumstances, a transjugular intrahepatic portosystemic shunt (TIPS) must be created. In this case, a dilatable endoprosthesis is introduced via the jugular vein into one of the hepatic veins. The endoprosthesis is advanced to the portal vein, creating an intrahepatic shunt. This is the most efficient way to reduce portal hypertension. TIPS placement is indicated in case of esophageal varices in the following circumstances:

- in a patient with advanced cirrhosis (Child C);

- when drug and endoscopic therapy fails;

- in secondary prevention after repeated bleeding.

Creation of an intrahepatic shunt provokes hepatic encephalopathy in at least 20% of patients.

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