Overview
Oesophageal Varices
1. Clinical Overview
Summary
Oesophageal Varices are dilated submucosal veins in the lower oesophagus (And sometimes extending to the stomach as Gastric Varices) that develop as a consequence of Portal Hypertension, most commonly due to Cirrhosis. They represent a critical manifestation of decompensated liver disease, with a major risk of life-threatening haemorrhage. Approximately 50% of patients with cirrhosis have varices at diagnosis, and the annual risk of first variceal bleed is ~5-15% depending on variceal size and liver function. Variceal bleeding carries a mortality of 15-20% at 6 weeks despite modern management. Management involves Primary Prophylaxis (Non-selective Beta-Blockers ± Endoscopic Band Ligation) to prevent first bleed, Acute Management (Resuscitation, Vasoactive drugs, Emergency OGD with Band Ligation/Sclerotherapy, Antibiotics), and Secondary Prophylaxis (NSBB + Band Ligation) to prevent rebleeding. TIPSS (Transjugular Intrahepatic Portosystemic Shunt) is used for refractory cases. [1,2,3]
Clinical Pearls
"Big Varices + Bad Liver = High Bleed Risk": Large varices in Child-Pugh B/C cirrhosis have the highest bleeding risk.
"Terlipressin + Band Ligation + Antibiotics": The triple therapy for acute variceal bleed.
"Never Forget Antibiotics": Antibiotic prophylaxis in acute variceal bleed reduces infections and mortality.
"If They Bleed, They Need a Scope": OGD within 12 hours for haemostasis (Band ligation).
2. Epidemiology
Demographics
| Factor | Notes |
|---|---|
| Prevalence | ~50% of cirrhotics have varices at diagnosis. |
| Annual Bleed Risk (Untreated) | Small varices: ~5%. Large varices: ~15%. |
| Mortality | Acute variceal bleed: ~15-20% at 6 weeks. |
Risk Factors for Varices
| Factor | Notes |
|---|---|
| Cirrhosis | Any cause: Alcohol, Viral hepatitis (HBV, HCV), NAFLD, PBC, PSC. |
| Portal Vein Thrombosis | Non-cirrhotic portal hypertension. |
| Hepatic Vein Occlusion (Budd-Chiari) | |
| Schistosomiasis | Endemic areas. Presinusoidal portal hypertension. |
Risk Factors for Bleeding
| Factor | Notes |
|---|---|
| Variceal Size | Large (>5mm) > Medium > Small. |
| Red Wale Signs | On endoscopy. Cherry-red spots. Indicate high pressure. |
| Severity of Liver Disease | Child-Pugh B/C. Higher bleed risk. |
| Portal Pressure | HVPG (Hepatic Venous Pressure Gradient) >12 mmHg = Varices possible. >20 mmHg = High bleed risk. |
3. Pathophysiology
Portal Hypertension
- Definition: Portal venous pressure >5 mmHg (Normal less than 5 mmHg). Clinically significant if HVPG >10 mmHg.
- Cause in Cirrhosis: Increased intrahepatic resistance (Fibrosis, Nodules, Sinusoidal compression) + Increased splanchnic blood flow.
- HVPG >10 mmHg: Varices may develop.
- HVPG >12 mmHg: Risk of variceal bleeding.
Varix Formation
- Increased Portal Pressure: Blood seeks alternative routes.
- Porto-Systemic Collaterals: Develop at sites of communication between portal and systemic venous systems.
- Oesophageal Varices: At the gastro-oesophageal junction (Left gastric vein → Oesophageal veins → Azygos vein).
- Gastric Varices: May extend from oesophagus or be isolated (Fundal varices from short gastric veins/Splenic vein).
Variceal Rupture
- Wall tension increases with variceal size, Pressure, and Thin wall.
- Laplace's Law: Tension = Pressure × Radius / Wall Thickness.
- Large, Thin-walled varices under high pressure are at highest risk.
4. Classification
Oesophageal Varices (Size)
| Size | Description |
|---|---|
| Small | less than 5mm, Minimally raised, Straightened by insufflation. |
| Medium | 5-10mm, Tortuous, Occupy less than 1/3 lumen. |
| Large | >10mm, Tortuous, Occupy >1/3 lumen, May have confluence. |
Gastric Varices (Sarin Classification)
| Type | Description |
|---|---|
| GOV1 | Gastro-oesophageal varices extending along lesser curve. (Most common). |
| GOV2 | Gastro-oesophageal varices extending into fundus. |
| IGV1 | Isolated Gastric Varices in fundus. (Often due to splenic vein thrombosis). |
| IGV2 | Isolated Gastric Varices in body/Antrum. |
Endoscopic Red Signs (High-Risk Features)
| Sign | Description |
|---|---|
| Red Wale Marks | Longitudinal red streaks on varices. |
| Cherry-Red Spots | Flat red spots. |
| Haematocystic Spots | Raised red blebs ("Blood blisters"). |
| Diffuse Erythema |
5. Clinical Presentation
Asymptomatic Varices
Acute Variceal Bleeding
| Feature | Notes |
|---|---|
| Haematemesis | Large volume, Fresh blood (Bright red) or "Coffee-grounds" (Older blood). |
| Melaena | Black tarry stools. Digested blood. |
| Haematochezia | Fresh rectal bleeding (If massive, rapid transit). |
| Hypovolaemic Shock | Tachycardia, Hypotension, Pallor, Dizziness, Collapse. |
| Hepatic Encephalopathy | May be precipitated or worsened by bleed (Protein load, Hypovolaemia). |
Other Features of Decompensated Cirrhosis
| Feature | Notes |
|---|---|
| Ascites | Fluid in abdomen. |
| Jaundice | Yellow skin/eyes. |
| Coagulopathy | Easy bruising. Prolonged bleeding. |
| Stigmata of Chronic Liver Disease | Spider naevi, Palmar erythema, Gynaecomastia, Caput medusae. |
Many patients have varices detected on screening OGD (For known cirrhosis).
Common presentation.
No symptoms until bleeding.
Common presentation.
6. Investigations
Laboratory
| Test | Notes |
|---|---|
| FBC | Anaemia (Blood loss), Thrombocytopenia (Hypersplenism). |
| Coagulation | PT/INR prolonged (Liver synthetic failure). |
| LFTs | Bilirubin, Albumin, AST/ALT. |
| U&Es | Urea elevated (GI bleed – Protein digestion). Creatinine (Hepatorenal syndrome). |
| Group and Save / Crossmatch | Essential before OGD/Transfusion. |
Endoscopy (OGD)
| Notes |
|---|
| Gold Standard for diagnosis and treatment of varices. |
| Screening OGD at diagnosis of cirrhosis. |
| Emergency OGD within 12 hours for acute variceal bleed. |
| Assess size, Red signs, Active bleeding. |
| Band Ligation (EVL) = First-line endoscopic treatment. |
Imaging
| Modality | Notes |
|---|---|
| CT Abdomen with Contrast | Assess portal vein patency, Liver, Spleen, Collaterals. |
| Doppler USS Liver | Portal vein flow, Direction, Thrombosis. |
HVPG (Hepatic Venous Pressure Gradient)
- Measured invasively.
- Clinical correlation: >10 mmHg = Varices. >12 mmHg = Bleed risk. >20 mmHg = High mortality.
- Used in research/Specialist settings. Not routine.
7. Management
Management Algorithm
PATIENT WITH CIRRHOSIS
↓
SCREENING OGD
(All cirrhotics at diagnosis)
┌────────────────┴────────────────┐
NO/SMALL VARICES MEDIUM/LARGE VARICES
↓ ↓
Repeat OGD in 2-3 years **PRIMARY PROPHYLAXIS**
(Or 1 year if ongoing ┌──────────────────────────────────
liver injury) │ NSBB (Non-selective Beta-Blocker)
│ - Propranolol or Carvedilol
│ - Target HR 55-60 bpm (or 25% ↓)
│ OR
│ Endoscopic Variceal Ligation (EVL)
│ (Band Ligation)
│ - Every 2-4 weeks until varices
│ obliterated
└──────────────────────────────────
↓
ACUTE VARICEAL BLEED
(Haematemesis, Shock, Known cirrhosis)
┌──────────────────────────────────────────────────────────┐
│ **RESUSCITATION** │
│ - ABCDE approach │
│ - Large bore IV access x2 │
│ - IV Fluids (Crystalloid – Avoid over-resuscitation) │
│ - Crossmatch (Aim Hb 7-8 g/dL) │
│ - Correct Coagulopathy (FFP, Platelets if severe) │
│ - Airway protection (Intubation if massive bleed/ │
│ Encephalopathy) │
│ │
│ **VASOACTIVE DRUGS (Start Before OGD)** │
│ - **Terlipressin** 2mg IV stat then 1-2mg 4-6 hourly │
│ (Up to 5 days) │
│ OR Octreotide 50mcg bolus then 50mcg/hr infusion │
│ │
│ **ANTIBIOTICS (Prophylaxis – Reduce Mortality)** │
│ - Ceftriaxone 1g IV OD (Or Quinolone if low-risk) │
│ - Duration: 5-7 days │
│ │
│ **PPI** (Reduce ulcer rebleeding, Not specifically │
│ for varices but often co-prescribed) │
└──────────────────────────────────────────────────────────┘
↓
EMERGENCY OGD (Within 12 Hours)
┌──────────────────────────────────────────────────────────┐
│ - **Endoscopic Variceal Ligation (Band Ligation)** │
│ = First-line for oesophageal varices │
│ - Sclerotherapy = Alternative (Higher complications) │
│ - Gastric varices → Consider Glue injection │
│ (Cyanoacrylate) or TIPSS │
└──────────────────────────────────────────────────────────┘
↓
REFRACTORY BLEEDING (Endoscopy Fails x2)
┌──────────────────────────────────────────────────────────┐
│ - **Balloon Tamponade (Sengstaken-Blakemore Tube)** │
│ = Temporising measure (Max 24 hours) │
│ - **TIPSS** (Transjugular Intrahepatic Portosystemic │
│ Shunt) = Definitive. Reduces portal pressure. │
│ - Consider early TIPSS for high-risk patients │
│ (Child C or B with active bleeding) │
└──────────────────────────────────────────────────────────┘
↓
SECONDARY PROPHYLAXIS (After Bleed Controlled)
┌──────────────────────────────────────────────────────────┐
│ - **NSBB + Repeat EVL** (Combined = Best) │
│ - EVL every 2-4 weeks until varices obliterated │
│ - Surveillance OGD 3-6 monthly then 6-12 monthly │
│ - Consider TIPSS if rebleeds despite above │
│ - Liver Transplant assessment if appropriate │
└──────────────────────────────────────────────────────────┘
Medications
| Drug | Mechanism | Use |
|---|---|---|
| Propranolol | NSBB. Reduces portal pressure (↓ Cardiac output, Splanchnic vasoconstriction). | Primary/Secondary prophylaxis. |
| Carvedilol | NSBB + Alpha-1 blocker. May be more effective. | Primary prophylaxis. |
| Terlipressin | Vasopressin analogue. Splanchnic vasoconstriction. | Acute bleed. |
| Octreotide | Somatostatin analogue. Reduces portal flow. | Acute bleed. |
| Ceftriaxone | Antibiotic prophylaxis. Reduces infection and mortality. | Acute bleed. |
8. Complications
| Complication | Notes |
|---|---|
| Haemorrhagic Shock | From massive bleeding. |
| Aspiration | Blood aspirated into lungs. |
| Hepatic Encephalopathy | Triggered by bleed (Protein load, Hypovolaemia). |
| Hepatorenal Syndrome | Renal failure in context of liver failure and haemodynamic stress. |
| Infection / SBP | High risk. Antibiotics essential. |
| Rebleeding | ~60% rebleed without secondary prophylaxis. |
| Death | ~15-20% at 6 weeks from index bleed. |
9. Prognosis and Outcomes
| Factor | Notes |
|---|---|
| 6-Week Mortality (Acute Bleed) | ~15-20%. Improved with modern management. |
| Rebleed Risk (Without Prophylaxis) | ~60% at 1 year. |
| With Secondary Prophylaxis (NSBB + EVL) | Rebleed reduced to ~20-30%. |
| TIPSS | Effective at reducing rebleeding but risk of encephalopathy. |
| Liver Transplant | Only definitive cure for underlying cirrhosis. |
10. Evidence and Guidelines
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Variceal Bleeding | Baveno VII (2021) | Primary prophylaxis (NSBB or EVL). Acute bleed (Terlipressin + EVL + Antibiotics). Secondary prophylaxis (NSBB + EVL). Early TIPSS for high-risk. |
| GI Bleeding | NICE NG141 | OGD within 24h (12h for varices). Band ligation. Antibiotics. |
Baveno VII Key Points
- Primary Prophylaxis: NSBB (Carvedilol or Propranolol) OR EVL for medium/large varices.
- Acute Bleed: Resuscitation, Vasoactive drugs (Terlipressin), Antibiotics, OGD within 12 hours with EVL.
- Early TIPSS: Consider in Child-Pugh C (Score 10-13) or Child-Pugh B with active bleeding at OGD.
11. Patient and Layperson Explanation
What are Oesophageal Varices?
Oesophageal varices are swollen veins in the lower part of your food pipe (Oesophagus). They develop because of high pressure in the blood vessels around your liver, Usually due to liver scarring (Cirrhosis).
Why are they dangerous?
These veins can burst and bleed. Bleeding from varices is a medical emergency and can be life-threatening.
What are the symptoms of bleeding?
- Vomiting blood (May be bright red or look like coffee grounds).
- Black tarry stools.
- Feeling faint, Dizzy, Or unwell.
If you have these symptoms, call 999 immediately.
How are they treated?
- Prevention: Medications (Beta-blockers) can reduce the pressure and prevent bleeding.
- Endoscopy: A camera test can tie off the varices (Band ligation) to stop or prevent bleeding.
- Emergency Treatment: If bleeding occurs, You will need fluids, Blood transfusion, Medication to slow bleeding, And an urgent endoscopy.
Can they be cured?
Treating the underlying liver disease is key. In some cases, A liver transplant may be needed.
12. References
Primary Sources
- de Franchis R, et al. Baveno VII – Renewing consensus in portal hypertension. J Hepatol. 2022;76(4):959-974. PMID: 35120733.
- Garcia-Tsao G, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-938. PMID: 17879356.
- National Institute for Health and Care Excellence. Acute upper gastrointestinal bleeding in over 16s (NG141). 2016.
13. Examination Focus
Common Exam Questions
- Primary Prophylaxis: "What is the first-line primary prophylaxis for medium/large oesophageal varices?"
- Answer: Non-Selective Beta-Blocker (Propranolol or Carvedilol) OR Endoscopic Variceal Ligation (EVL).
- Acute Management Triad: "What is the immediate management of acute variceal bleed?"
- Answer: Resuscitation + Vasoactive Drug (Terlipressin) + Antibiotics (Ceftriaxone) + OGD with EVL within 12 hours.
- HVPG Threshold: "At what HVPG do varices develop and bleed?"
- Answer: >10 mmHg = Varices develop. >12 mmHg = Bleed risk.
- Refractory Bleed: "What is the rescue procedure for refractory variceal bleeding?"
- Answer: TIPSS (Transjugular Intrahepatic Portosystemic Shunt).
Viva Points
- Baveno VII: Current guideline. Know primary/Secondary prophylaxis, Acute management.
- Antibiotics Reduce Mortality: Essential in acute bleed.
- Carvedilol May Be Superior: To propranolol for primary prophylaxis (Baveno VII).
- Early TIPSS: For high-risk (Child C or B + Active bleeding).
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.