Esophageal Varices

Risk factors

• Cirrhosis of any etiology (alcoholic, viral hepatitis B/C, MASH/NASH, autoimmune, hemochromatosis, Wilson, primary biliary cholangitis)
• Non-cirrhotic portal hypertension (portal vein thrombosis, schistosomiasis, congenital hepatic fibrosis)
• Hepatic vein thrombosis (Budd-Chiari)
• Predictors of bleeding: large varices, red wale signs on EGD, decompensated cirrhosis (Child-Pugh B/C), HVPG >12 mmHg

Pathophysiology

Increased intrahepatic resistance (fibrosis, regeneration nodules, vasoconstriction) plus splanchnic vasodilation raises portal pressure. When the hepatic venous pressure gradient (HVPG) exceeds 10 mmHg, portosystemic collaterals develop. Variceal rupture occurs when wall tension (Laplace's law: pressure × radius / wall thickness) exceeds tissue tolerance — typically HVPG >12 mmHg.

Clinical presentation

Differential diagnosis

• Peptic ulcer bleed — Most common cause of UGIB overall; epigastric pain, NSAID/H. pylori; visible vessel or active bleed on EGD
• Mallory-Weiss tear — Hematemesis after retching/vomiting; linear mucosal tear at GEJ
• Erosive esophagitis/gastritis — Diffuse erosions; usually less severe bleeding
• Dieulafoy lesion — Recurrent massive bleeding from small submucosal vessel; often proximal stomach
• Aortoenteric fistula — Prior aortic graft; herald bleed followed by massive hemorrhage; CT angiography
• Gastric varices — Often fundic; isolated or with esophageal varices; cyanoacrylate glue rather than banding
• Portal hypertensive gastropathy — Snake-skin mosaic pattern; chronic anemia more than acute bleed

Diagnostic workup

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]

Treatment

Complications

• Hemorrhagic shock and death
• Spontaneous bacterial peritonitis (SBP) — high risk; prophylactic ceftriaxone reduces incidence
• 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