Dilated submucosal esophageal veins from portal hypertension; high-risk source of upper GI bleeding.
Also known as: esophageal varices, variceal hemorrhage, variceal bleeding, gastroesophageal varices
Overview
Dilated submucosal veins of the distal esophagus, formed as portosystemic collaterals in response to portal hypertension. Variceal hemorrhage is a life-threatening complication of cirrhosis.
Epidemiology
Develop in ~50% of cirrhotic patients; prevalence rises with severity of liver disease (Child-Pugh class). First-bleed risk 10-15%/yr in patients with medium/large varices without prophylaxis. Six-week mortality after variceal bleed 15-25%.
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CT abdomen if suspect alternative source or portal vein thrombosis
MRE or vibration-controlled transient elastography (FibroScan) for non-invasive staging of fibrosis
Other studies
Variceal screening EGD in newly diagnosed cirrhosis (Baveno VII allows deferral if liver stiffness <20 kPa and platelets >150,000)
Surveillance EGD every 1-3 yr based on size and presence/absence of decompensation
Diagnostic algorithm
flowchart TD
A[Suspected variceal bleed<br/>known/likely cirrhosis] --> B[Resuscitate<br/>2 large-bore IVs<br/>Restrictive Hgb ~7]
B --> C[Octreotide IV<br/>+ Ceftriaxone 1g]
C --> D[EGD within 12h]
D --> E[Endoscopic<br/>band ligation]
E --> F{Hemostasis<br/>achieved?}
F -->|Yes, high-risk<br/>Child-Pugh C<14<br/>or B with active bleed| G[Early TIPS<br/>within 72h]
F -->|Yes, lower risk| H[Secondary prophylaxis:<br/>NSBB + serial EVL]
F -->|No| I[Rescue TIPS<br/>± balloon tamponade<br/>as bridge]
Acute variceal hemorrhage management — Baveno VII / AASLD pathway.
Vasoactive agent — octreotide 50 mcg IV bolus then 50 mcg/h × 3-5 days (or terlipressin where available) — START BEFORE EGD if suspected
Prophylactic IV antibiotic — ceftriaxone 1 g daily × up to 7 days (reduces SBP, rebleeding, and mortality)
Endoscopic variceal band ligation (EVL) within 12 h — preferred over sclerotherapy
Cyanoacrylate injection for gastric varices
Correct coagulopathy judiciously — overcorrection has not shown benefit; platelets if <50,000
Airway protection (intubation) for active hematemesis or altered mental status
Primary prophylaxis (no prior bleed, medium/large varices)
Non-selective beta-blocker — propranolol, nadolol, or carvedilol — titrate to HR 55-60 or maximum tolerated dose
OR endoscopic variceal band ligation every 2-4 weeks until eradication
Carvedilol preferred in compensated cirrhosis per Baveno VII
Secondary prophylaxis (after first bleed)
Combination non-selective beta-blocker + serial EVL (every 2-4 weeks until obliteration, then surveillance every 3-6 months)
Lifelong therapy
TIPS for failure of combined therapy
Second-line / adjunct
TIPS (transjugular intrahepatic portosystemic shunt) — rescue therapy after failed endoscopic control; early/preemptive TIPS within 72 h reduces mortality in high-risk patients (Child-Pugh C <14, or B with active bleeding)
Balloon tamponade (Sengstaken-Blakemore, Minnesota, or Linton tubes) — temporizing bridge to definitive therapy; maximum 24 h
Self-expanding covered metal esophageal stent — alternative to balloon tamponade
Hepatic encephalopathy precipitated by GI bleed (lactulose, rifaximin)
Aspiration pneumonia
Hepatorenal syndrome
Rebleeding (60-70% within 1 yr without secondary prophylaxis)
PANCE pearls
Start octreotide and ceftriaxone BEFORE endoscopy whenever variceal bleed is suspected — both reduce mortality.
Restrictive transfusion strategy (Hgb target ~7) reduces rebleeding and mortality vs liberal strategy (Villanueva, NEJM 2013).
Early TIPS (within 72 h) in high-risk patients (Child-Pugh C <14 or B with active bleeding on endoscopy) reduces mortality (García-Pagán, NEJM 2010).
Beta-blocker contraindications relative in advanced cirrhosis: refractory ascites, SBP, hypotension (SBP <90), or AKI — discontinue if these develop.
Carvedilol lowers portal pressure more than propranolol and is preferred in compensated cirrhosis (Baveno VII).
Variceal screening can be deferred in compensated cirrhosis with liver stiffness <20 kPa AND platelets >150,000 (Baveno VI/VII criteria).
References
Baveno VII 2022 — de Franchis R et al. Baveno VII — Renewing consensus in portal hypertension. J Hepatol 2022;76:959-974
AASLD 2017 — Garcia-Tsao G et al. Portal Hypertensive Bleeding in Cirrhosis: Risk Stratification, Diagnosis, and Management. Hepatology 2017;65:310-335
Restrictive Transfusion — Villanueva C et al. Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. NEJM 2013;368:11-21
Early TIPS — García-Pagán JC et al. Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding. NEJM 2010;362:2370-2379
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