Esophageal varices

Last updated: January 20, 2023

Summarytoggle arrow icon

Esophageal varices are dilated collateral veins resulting from increased blood flow due to portal hypertension, often caused by cirrhosis. Nonbleeding varices are typically asymptomatic. Screening for varices with esophagogastroduodenoscopy (EGD) is recommended at the time of cirrhosis diagnosis. Management of nonbleeding esophageal varices focuses on the prevention of bleeding and involves regular surveillance and, in some cases, primary prophylaxis of bleeding using nonselective beta blockers or eradication of varices using endoscopic variceal ligation (EVL).

Acute variceal hemorrhage is a potentially life-threatening condition. Patients present with clinical features of gastrointestinal bleeding, e.g., sudden hematemesis and melena, and, in some cases, hypovolemic shock. In addition to stabilizing the patient, management involves administration of vasoactive medication and antibiotic prophylaxis in combination with endoscopic treatment. If the hemorrhage persists, balloon tamponade of the bleeding and/or an emergent transjugular intrahepatic portosystemic shunt (TIPS) may be necessary. Secondary prophylaxis of variceal bleeding involves nonselective beta blockers, EVL, and/or TIPS placement.

  • Affects ∼ 50% of patients with cirrhosis [1][2]
  • Variceal hemorrhage is the most common lethal complication in patients with cirrhosis. [3]

Epidemiological data refers to the US, unless otherwise specified.

Several classification methods exist for esophageal varices.

  • Bleeding (i.e., esophageal variceal hemorrhage) vs. non-bleeding
  • Degree of extension into the stomach
  • Size on endoscopy: [4]
    • Small esophageal varices: < 5 mm
    • Medium/large esophageal varices: ≥ 5 mm [4][5]

Consider also a diagnosis of Mallory-Weiss syndrome if bleeding occurs following retching or vomiting.

Esophagogastroduodenoscopy (EGD)

Diagnosis and surveillance of esophageal varices requires esophagogastroduodenoscopy (EGD), with the goal of establishing: [1]

  • Presence of varices
  • Size of varices
  • Stigmata of recent or impending bleeding (i.e., high-risk endoscopic findings): [3][6]
    • Red wale marks: longitudinal red streaks on the surface of a varix
    • Cherry-red spots
    • Hematocystic spots: raised spots that appear as blisters

Additional studies

Approach [1][2][5]

Risk stratification [4]

Monitoring of low-risk varices [1][5]

EGD surveillance is indicated every 1–3 years for patients with low-risk features for esophageal variceal bleeding to screen for the development of high-risk varices.

EGD monitoring for the development of high-risk esophageal varices in patients with compensated cirrhosis [1]
Clinical features Frequency
Small esophageal varices [5] Ongoing liver injury Annual
No ongoing liver injury Every 2 years
No varices Ongoing liver injury
No ongoing liver injury Every 3 years

Patients with esophageal varices have a 10–15% annual risk of variceal hemorrhage; the risk increases with the severity of liver disease, size of varices, and presence of variceal wall thinning. [1][5]

Prevention of first episode of variceal bleeding [1][4][5]

Pharmacological prophylaxis (off-label) [2]

Reduce the dose or discontinue beta blockers if ascites or hepatorenal syndrome develop or systolic blood pressure is < 90 mm Hg. [4]

In patients without varices, there is no evidence to support the use of beta blockers to prevent the development of gastroesophageal varices; however, beta blockers may be used for other indications in patients with clinically significant portal hypertension. [1]

Endoscopic variceal ligation (EVL) [1][5]

  • Repeat every 1–8 weeks until varices are eradicated.
  • Obtain surveillance EGD within 1–6 months of eradication and every 6–12 months thereafter. [1][5]

Combination therapy with EVL and pharmacotherapy is not recommended for primary prophylaxis of esophageal variceal hemorrhage.

Approach [1][4][5]

Esophageal variceal hemorrhage is a medical emergency.

Airway management [8][9]

Anticipate difficult airway management in patients with ongoing bleeding and consider using a video laryngoscope for the first attempt.

Pharmacological treatment

Vasoactive medication and antibiotic prophylaxis are indicated for all patients. [1][4]

Esophageal variceal bleeding is a consequence of portal hypertension, and therefore treatment focuses on reducing portal hypertension rather than the correction of coagulation abnormalities. [4]

Endoscopic treatment [1][5]

EGD should be performed as soon as possible in unstable patients and within 12 hours in all other patients.

Other interventional treatments

Balloon tamponade [1][10]

  • Definition: orogastric tubes with esophageal and gastric balloons that tamponade bleeding when inflated
    • Sengstaken-Blakemore tube: orogastric tube with an esophageal balloon, gastric balloon, and gastric aspiration port
    • Minnesota tube: modification of Sengstaken-Blakemore tube with an additional aspiration port above the esophageal balloon and larger gastric balloon
  • Indication: bridge to definitive treatment if [10]
    • Endoscopy is unavailable and vasoactive medications are ineffective
    • Endoscopic treatment is unsuccessful
  • Complications


  • Consider if pharmacological and endoscopic treatment are unsuccessful. [5]
  • Consider early TIPS (within 72 hours of EVL) in patients at high risk of rebleeding.

Prevention of recurrent variceal bleeding [1][5]

The combination of EVL and nonselective beta blockers for the prevention of recurrent esophageal variceal hemorrhage is more effective than either therapy alone.

  • Six-week mortality rate after a variceal bleeding event is ∼ 20%. [2][5]
  • Risk of rebleeding within 1 year if left untreated is ∼ 60%. [2][5]
  1. Hwang JH, Shergill AK, Acosta RD, et al. The role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc. 2014; 80 (2): p.221-227. doi: 10.1016/j.gie.2013.07.023 . | Open in Read by QxMD
  2. Garcia-Tsao G, Bosch J. Management of Varices and Variceal Hemorrhage in Cirrhosis. N Engl J Med. 2010; 362 (9): p.823-832. doi: 10.1056/nejmra0901512 . | Open in Read by QxMD
  3. de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VII – Renewing consensus in portal hypertension. J Hepatol. 2022; 76 (4): p.959-974. doi: 10.1016/j.jhep.2021.12.022 . | Open in Read by QxMD
  4. Garcia‐Tsao G, Abraldes JG, Berzigotti A, et al.. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2016; 65 (1): p.310-335. doi: 10.1002/hep.28906 . | Open in Read by QxMD
  5. Li T, Ke W, Sun P, et al. Carvedilol for portal hypertension in cirrhosis: systematic review with meta-analysis. BMJ Open. 2016; 6 (5): p.e010902. doi: 10.1136/bmjopen-2015-010902 . | Open in Read by QxMD
  6. Mosier JM, Sakles JC, Law JA, Brown CA, Brindley PG. Tracheal Intubation in the Critically Ill. Where We Came from and Where We Should Go. Am J Respir Crit Care Med. 2020; 201 (7): p.775-788. doi: 10.1164/rccm.201908-1636ci . | Open in Read by QxMD
  7. Russotto V, Myatra SN, Laffey JG, et al. Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries. JAMA. 2021; 325 (12): p.1164. doi: 10.1001/jama.2021.1727 . | Open in Read by QxMD
  8. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  9. Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021; 116 (5): p.899-917. doi: 10.14309/ajg.0000000000001245 . | Open in Read by QxMD
  10. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46 (3): p.922-938. doi: 10.1002/hep.21907 . | Open in Read by QxMD
  11. Khan NM, Shapiro AB. The White Nipple Sign: Please Do Not Disturb. Case Rep Gastroenterol. 2011; 5 (2): p.386-390. doi: 10.1159/000330292 . | Open in Read by QxMD

3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer