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Esophageal Varices: Causes, Symptoms & Treatment

Esophageal varices are abnormally enlarged veins in the esophagus, most commonly caused by liver cirrhosis, and can lead to life-threatening bleeding.

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Things worth knowing about "Esophageal Varices"

Esophageal varices are abnormally enlarged veins in the esophagus, most commonly caused by liver cirrhosis, and can lead to life-threatening bleeding.

What Are Esophageal Varices?

Esophageal varices are dilated, tortuous veins located in the wall of the esophagus (the tube connecting the throat to the stomach). They develop when blood pressure in the portal vein – the large vessel carrying blood from the intestines to the liver – becomes persistently elevated, a condition known as portal hypertension. Because the walls of these enlarged veins are thin and fragile, they are prone to rupturing, which can result in severe, life-threatening bleeding.

Causes

The most common underlying cause of esophageal varices is liver cirrhosis, a condition in which healthy liver tissue is progressively replaced by scar tissue. Other causes include:

Chronic hepatitis B or C infection
Alcohol-related liver disease
Non-alcoholic fatty liver disease (NAFLD/NASH)
Portal vein thrombosis (blood clot in the portal vein)
Budd-Chiari syndrome (obstruction of the hepatic veins)
Right-sided heart failure causing backflow into the liver

As pressure builds in the portal system, blood is rerouted through smaller collateral vessels in the esophagus. These veins become engorged and structurally weakened over time.

Symptoms

Esophageal varices often cause no symptoms until they bleed. A variceal bleed is the most dangerous complication and may present with:

Vomiting of bright red blood (hematemesis)
Black, tarry stools (melena) from digested blood
Sudden drop in blood pressure and dizziness
Rapid heart rate (tachycardia)
Pallor, weakness, and loss of consciousness in cases of severe blood loss

An acute bleed from esophageal varices is a medical emergency requiring immediate hospital treatment.

Diagnosis

The primary diagnostic tool is esophagogastroduodenoscopy (EGD), also known as an upper endoscopy. A flexible camera-equipped tube is inserted through the mouth to directly visualize, grade, and if necessary treat the varices in real time.

Additional investigations may include:

Abdominal ultrasound and Doppler imaging of the liver and portal vein
CT or MRI angiography to assess vascular anatomy
Blood tests to evaluate liver function (e.g., albumin, bilirubin, coagulation parameters)
Measurement of the hepatic venous pressure gradient (HVPG) to quantify portal pressure

Treatment

Acute Management of Bleeding

Active variceal bleeding requires immediate intensive care. Treatment options include:

Endoscopic band ligation (EBL): Small rubber bands are placed around the varices to cut off blood flow – this is the preferred first-line method.
Sclerotherapy: Injection of a sclerosing agent directly into the varix to seal it.
Vasoactive medications: Drugs such as terlipressin or somatostatin analogues (e.g., octreotide) reduce portal blood pressure.
Balloon tamponade (e.g., Sengstaken-Blakemore tube): A temporary bridging measure for uncontrolled bleeding.
Prophylactic antibiotics to prevent bacterial infections, which are common in this setting.

Long-term Management and Prevention

To reduce the risk of recurrent bleeding, the following strategies are used:

Non-selective beta-blockers (e.g., propranolol, carvedilol): Lower portal pressure and are used for both primary and secondary prophylaxis.
Regular endoscopic surveillance and elective ligation of varices.
TIPS (transjugular intrahepatic portosystemic shunt): A radiological procedure that creates a channel between the portal vein and a hepatic vein to reduce portal pressure.
Treatment of the underlying liver disease (e.g., alcohol cessation, antiviral therapy for hepatitis).
Liver transplantation for end-stage cirrhosis as a definitive option.

References

de Franchis R et al. - Baveno VII - Renewing consensus in portal hypertension. Journal of Hepatology, 2022.
European Association for the Study of the Liver (EASL) - Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. Journal of Hepatology, 2018.
Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J - Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management. Hepatology, 2017.

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