Esophageal Varices

Esophageal varices are enlarged, swollen veins in the lower part of the esophagus that develop as a result of increased pressure in the portal vein system (portal hypertension). These abnormally dilated veins are most commonly associated with advanced liver disease and cirrhosis. While esophageal varices may not cause symptoms initially, they represent a serious medical condition because they can rupture and cause life-threatening bleeding that requires immediate emergency treatment.

Medical Disclaimer: This information is for educational purposes only and should not replace professional medical advice. Esophageal varices can cause life-threatening bleeding. If you have liver disease and experience vomiting blood or black stools, seek emergency medical attention immediately.

Overview

Esophageal varices are abnormally enlarged veins that develop in the lower third of the esophagus when blood flow through the liver is blocked or restricted. Under normal circumstances, blood from the digestive organs flows through the portal vein to the liver for processing. When the liver becomes scarred or damaged (as in cirrhosis), this normal flow is impeded, causing increased pressure in the portal vein system.

This increased pressure, known as portal hypertension, forces blood to find alternative pathways back to the heart. The esophageal veins, which normally carry only small amounts of blood, become engorged as they serve as collateral circulation. These enlarged veins have thin walls and are prone to rupture, especially when portal pressure exceeds 10-12 mmHg.

Esophageal varices are present in approximately 50% of patients with cirrhosis at the time of diagnosis, and the prevalence increases to 85-90% in patients with advanced cirrhosis. The annual incidence of variceal bleeding is 5-15% in patients with known varices, with a mortality rate of 10-20% per episode. The condition affects men more frequently than women, reflecting the higher prevalence of liver disease in males.

Symptoms

Esophageal varices often develop silently without causing symptoms until they rupture and bleed. The symptoms experienced depend on whether the varices are stable or actively bleeding.

Asymptomatic Phase

  • No specific symptoms from the varices themselves
  • Symptoms may be related to underlying liver disease
  • Possible mild discomfort when swallowing
  • Occasional sensation of fullness in the chest

Symptoms of Variceal Bleeding (Medical Emergency)

  • Vomiting bright red blood (hematemesis)
  • Vomiting dark, coffee-ground material
  • Passing black, tarry stools (melena)
  • Passing bright red blood rectally (rare)
  • Dizziness - from blood loss and low blood pressure
  • Lightheadedness or fainting
  • Rapid, weak pulse (tachycardia)
  • Cold, clammy skin
  • Profuse sweating

Symptoms of Blood Loss

  • Weakness and fatigue
  • Shortness of breath
  • Pale skin and mucous membranes
  • Confusion or altered mental status
  • Decreased urine output
  • Thirst
  • Restlessness or anxiety

Associated Symptoms from Underlying Liver Disease

  • Nausea - common in patients with liver disease
  • Abdominal pain or discomfort
  • Abdominal swelling (ascites)
  • Yellowing of skin and eyes (jaundice)
  • Easy bruising and bleeding
  • Swelling in legs and feet
  • Mental confusion (hepatic encephalopathy)

Signs of Shock (Life-Threatening)

  • Severe drop in blood pressure
  • Rapid heart rate (over 100 beats per minute)
  • Weak or absent pulse
  • Rapid, shallow breathing
  • Loss of consciousness
  • Extremely pale or blue skin color
  • No urine production

Causes

Esophageal varices develop as a direct consequence of portal hypertension, which occurs when blood flow through the liver is obstructed. Understanding the underlying causes helps identify at-risk patients and implement preventive strategies.

Primary Cause: Portal Hypertension

Portal hypertension is defined as an increase in pressure within the portal vein system. Normal portal pressure is 3-5 mmHg, but when it exceeds 10-12 mmHg, collateral circulation develops, leading to varices formation.

Liver-Related Causes (Most Common)

Cirrhosis

  • Alcoholic liver disease: Chronic alcohol abuse leading to liver scarring
  • Viral hepatitis: Chronic hepatitis B, C, and D infections
  • Non-alcoholic fatty liver disease (NAFLD): Associated with obesity and diabetes
  • Autoimmune hepatitis: Immune system attacking liver cells
  • Primary biliary cholangitis: Destruction of bile ducts
  • Primary sclerosing cholangitis: Inflammation and scarring of bile ducts

Other Liver Conditions

  • Wilson's disease: Copper accumulation in the liver
  • Hemochromatosis: Iron overload disorder
  • Alpha-1 antitrypsin deficiency: Genetic enzyme deficiency
  • Congenital hepatic fibrosis: Genetic condition affecting liver structure

Vascular Causes

  • Portal vein thrombosis: Blood clots blocking the portal vein
  • Hepatic vein thrombosis (Budd-Chiari syndrome): Blockage of liver drainage
  • Splenic vein thrombosis: Clots in the splenic vein
  • Arteriovenous malformations: Abnormal connections between arteries and veins

Systemic Conditions

  • Heart failure: Backup of blood causing increased portal pressure
  • Schistosomiasis: Parasitic infection affecting liver blood flow
  • Sarcoidosis: Inflammatory disease affecting multiple organs
  • Myeloproliferative disorders: Blood disorders affecting circulation

Drug and Toxin-Related Causes

  • Chronic medication use: Methotrexate, amiodarone
  • Herbal supplements: Certain traditional medicines
  • Industrial toxins: Vinyl chloride, arsenic exposure
  • Vitamin A toxicity: Excessive vitamin A intake

Risk Factors

Several factors increase the risk of developing esophageal varices and experiencing variceal bleeding. Understanding these risk factors helps in early detection and prevention strategies.

Primary Risk Factors

  • Cirrhosis: Present in 85-90% of patients with esophageal varices
  • Chronic liver disease: Any condition causing progressive liver damage
  • Portal hypertension: Elevated pressure in the portal vein system
  • History of variceal bleeding: 60-70% rebleeding risk within one year

Demographic Risk Factors

  • Age: More common in adults over 40 years
  • Gender: Men affected more frequently than women
  • Family history: Genetic predisposition to liver disease
  • Ethnicity: Higher prevalence in certain populations with genetic liver diseases

Lifestyle Risk Factors

  • Chronic alcohol abuse: Leading cause of cirrhosis in developed countries
  • Obesity: Risk factor for non-alcoholic fatty liver disease
  • Diabetes mellitus: Associated with NAFLD and liver fibrosis
  • Intravenous drug use: Risk for hepatitis B and C transmission

Medical Risk Factors

  • Viral hepatitis infections: Chronic hepatitis B, C, or D
  • Autoimmune conditions: Autoimmune hepatitis, primary biliary cholangitis
  • Metabolic disorders: Wilson's disease, hemochromatosis
  • Blood disorders: Thrombotic conditions, myeloproliferative diseases

Risk Factors for Variceal Bleeding

  • Large varix size: Larger varices have higher bleeding risk
  • High portal pressure: Pressure gradient >12 mmHg
  • Red whale markings: Endoscopic signs of high-risk varices
  • Severe liver dysfunction: Child-Pugh class C cirrhosis
  • Active alcohol use: Continued drinking in patients with liver disease
  • Medications: NSAIDs, anticoagulants, aspirin
  • Infections: Bacterial infections increasing portal pressure

Protective Factors

  • Early detection and treatment of liver disease
  • Alcohol cessation in patients with alcoholic liver disease
  • Antiviral treatment for viral hepatitis
  • Regular endoscopic surveillance
  • Prophylactic medical therapy (beta-blockers)

Diagnosis

Diagnosis of esophageal varices requires a combination of clinical assessment, laboratory studies, and imaging. Early detection through screening programs is crucial for patients with known liver disease.

Clinical Assessment

Medical History

  • History of liver disease or cirrhosis
  • Alcohol consumption patterns
  • Previous episodes of bleeding
  • Current medications, especially those affecting bleeding
  • Family history of liver disease
  • Symptoms of portal hypertension

Physical Examination

  • Signs of chronic liver disease: Jaundice, spider angiomata, palmar erythema
  • Portal hypertension signs: Splenomegaly, ascites, caput medusae
  • Bleeding assessment: Pallor, tachycardia, hypotension
  • Abdominal examination: Hepatomegaly, fluid wave

Laboratory Studies

Complete Blood Count

  • Hemoglobin and hematocrit levels
  • Platelet count (often decreased in portal hypertension)
  • White blood cell count

Liver Function Tests

  • Bilirubin levels (total and direct)
  • Albumin and total protein
  • Liver enzymes (ALT, AST, alkaline phosphatase)
  • Prothrombin time and INR

Additional Laboratory Tests

  • Creatinine and electrolytes
  • Blood type and crossmatch (if bleeding suspected)
  • Viral hepatitis serologies
  • Alpha-fetoprotein (screening for liver cancer)

Imaging Studies

Ultrasound

  • Assessment of liver texture and size
  • Detection of ascites
  • Measurement of portal vein diameter
  • Evaluation of spleen size

CT or MRI

  • Detailed liver assessment
  • Detection of portal vein thrombosis
  • Evaluation of collateral circulation
  • Assessment for liver tumors

Endoscopic Evaluation

Upper Endoscopy (EGD)

  • Gold standard: Direct visualization of varices
  • Grading system: Small, medium, or large varices
  • Risk assessment: Red whale markings, cherry red spots
  • Active bleeding detection: Immediate identification of bleeding source

Specialized Studies

Hepatic Venous Pressure Gradient (HVPG)

  • Direct measurement of portal pressure
  • Normal: <5 mmHg
  • Portal hypertension: >5 mmHg
  • High bleeding risk: >12 mmHg

Screening Recommendations

  • All cirrhotic patients: Upper endoscopy at diagnosis
  • No varices found: Repeat endoscopy every 2-3 years
  • Small varices: Repeat endoscopy every 1-2 years
  • Large varices: Treatment and follow-up as indicated

Treatment Options

Treatment of esophageal varices focuses on preventing initial bleeding in patients with known varices and managing acute bleeding episodes. The approach varies depending on whether the patient is experiencing active bleeding or requires prophylactic treatment.

Emergency Treatment for Acute Variceal Bleeding

Initial Resuscitation

  • Airway protection: Intubation if altered mental status
  • IV access: Two large-bore IV lines
  • Fluid resuscitation: Crystalloids and blood products
  • Blood transfusion: Target hemoglobin 7-9 g/dL
  • Coagulopathy correction: Fresh frozen plasma, platelets

Pharmacological Treatment

  • Vasoactive drugs:
    • Octreotide: 50 mcg bolus, then 50 mcg/hour infusion
    • Terlipressin: 2 mg IV every 4 hours (where available)
    • Somatostatin: 250 mcg bolus, then 250 mcg/hour
  • Antibiotics: Prophylactic antibiotics to prevent infection
  • Proton pump inhibitors: High-dose IV PPI therapy

Endoscopic Treatment

Endoscopic Variceal Ligation (EVL)

  • First-line treatment: For acute variceal bleeding
  • Technique: Placement of rubber bands around varices
  • Success rate: 85-95% for controlling acute bleeding
  • Complications: Rebleeding, esophageal ulceration, stricture

Endoscopic Sclerotherapy

  • Alternative method: When ligation is not feasible
  • Technique: Injection of sclerosing agent into varices
  • Agents: Ethanolamine, sodium morrhuate
  • Higher complication rate: Compared to ligation

Rescue Therapies

Balloon Tamponade

  • Temporary measure: For refractory bleeding
  • Types: Sengstaken-Blakemore, Minnesota tube
  • Duration: Maximum 24 hours
  • Complications: Aspiration, esophageal rupture

Self-Expanding Metal Stents

  • Newer alternative to balloon tamponade
  • Less risk of complications
  • Can be left in place for up to 2 weeks
  • Allows for oral intake

Surgical and Interventional Procedures

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

  • Indication: Refractory or recurrent bleeding
  • Procedure: Creating shunt between portal and systemic circulation
  • Success rate: >95% for controlling bleeding
  • Complications: Hepatic encephalopathy, shunt dysfunction

Surgical Shunts

  • Distal splenorenal shunt: Selective decompression
  • Portocaval shunt: Direct portal-systemic connection
  • Indications: Failed TIPS, good surgical candidates
  • Mortality: Higher operative risk than TIPS

Primary Prevention (Preventing First Bleeding)

Medical Therapy

  • Non-selective beta-blockers:
    • Propranolol: 40-80 mg twice daily
    • Nadolol: 40-80 mg daily
    • Target: 25% reduction in heart rate
  • Carvedilol: Alpha and beta-blocker, 6.25-12.5 mg daily

Endoscopic Prophylaxis

  • Indication: Large varices or high-risk features
  • Method: Prophylactic variceal ligation
  • Schedule: Every 2-4 weeks until obliteration
  • Alternative: To beta-blockers in intolerant patients

Secondary Prevention (Preventing Rebleeding)

  • Combination therapy: Beta-blockers plus endoscopic ligation
  • Schedule: Ligation every 1-4 weeks until obliteration
  • Long-term beta-blockers: Continued indefinitely
  • TIPS: For failed medical/endoscopic therapy

Liver Transplantation

  • Definitive treatment: For end-stage liver disease
  • Timing: Before development of contraindications
  • Evaluation: Comprehensive transplant assessment
  • Bridge therapies: TIPS, endoscopic treatment while waiting

Prevention

Prevention of esophageal varices focuses on preventing the development of portal hypertension and liver disease, as well as preventing bleeding in patients with established varices.

Primary Prevention (Preventing Liver Disease)

  • Alcohol moderation: Avoid excessive alcohol consumption
  • Hepatitis vaccination: Hepatitis A and B vaccines for at-risk individuals
  • Safe practices: Avoid sharing needles, practice safe sex
  • Weight management: Maintain healthy BMI to prevent NAFLD
  • Diabetes control: Proper management of blood sugar levels
  • Medication safety: Avoid hepatotoxic medications when possible

Secondary Prevention (Preventing Varices Development)

  • Early liver disease treatment: Antiviral therapy for hepatitis
  • Alcohol cessation: Complete abstinence in alcoholic liver disease
  • Regular monitoring: Surveillance for portal hypertension development
  • Nutritional support: Proper nutrition to support liver function
  • Treat underlying conditions: Wilson's disease, hemochromatosis

Tertiary Prevention (Preventing Bleeding in Known Varices)

Medical Prevention

  • Beta-blocker therapy: For patients with medium to large varices
  • Regular endoscopic surveillance: Monitor variceal progression
  • Avoid NSAIDs: Increase bleeding risk
  • Treat infections promptly: Prevent increases in portal pressure

Endoscopic Prevention

  • Prophylactic variceal ligation for high-risk varices
  • Regular follow-up endoscopy
  • Treatment of recurrent varices

Lifestyle Modifications

  • Complete alcohol cessation: Essential for all patients with liver disease
  • Dietary modifications: Low-sodium diet if ascites present
  • Exercise program: Moderate activity as tolerated
  • Smoking cessation: Reduces overall cardiovascular risk
  • Stress management: Techniques to reduce psychological stress

High-Risk Patient Management

  • Specialized hepatology care
  • Multidisciplinary team approach
  • Patient education about warning signs
  • Emergency action plans
  • Regular laboratory monitoring

When to See a Doctor

Call 911 immediately for:

  • Vomiting bright red blood or coffee-ground material
  • Passing black, tarry stools
  • Signs of shock: rapid pulse, dizziness, fainting
  • Severe abdominal pain with bleeding
  • Confusion or loss of consciousness
  • Difficulty breathing with signs of bleeding

Seek urgent medical attention for:

  • New onset nausea and vomiting in patients with liver disease
  • Increasing abdominal swelling or pain
  • Yellowing of skin or eyes (jaundice)
  • Mental confusion or personality changes
  • Persistent fatigue or weakness
  • Easy bruising or bleeding from minor injuries

Schedule routine appointments for:

  • Known liver disease requiring monitoring
  • Family history of liver disease
  • Regular surveillance endoscopy if varices are known
  • Medication management and dose adjustments
  • Alcohol counseling and support services

Related Conditions

References

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  2. Tripathi D, Stanley AJ, Hayes PC, et al. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015;64(11):1680-1704.
  3. de Franchis R, Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop. J Hepatol. 2015;63(3):743-752.
  4. Simonetto DA, Liu M, Kamath PS. Portal hypertension and related complications: diagnosis and management. Mayo Clin Proc. 2019;94(4):714-726.
  5. Rosch J, Hanafee WN, Snow H. Transjugular portal venography and radiologic portacaval shunt: an experimental study. Radiology. 1969;92(5):1112-1114.