Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Vomiting Blood (Haematemesis) article more useful, or one of our other health articles.
Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
What are oesophageal varices?
Variceal haemorrhage occurs from dilated veins (varices) at the junction between the portal and systemic venous systems. Varices tend to be in the distal oesophagus and/or the proximal stomach but isolated varices may be found in the distal stomach, and the large and small intestine. The majority of patients with variceal bleeding have chronic liver disease.Variceal bleeding is characteristically severe and may be life-threatening. The size of oesphageal varices and their tendency to bleed are directly related to the portal pressure, which is usually directly related to the severity of underlying liver disease. Large oesphageal varices with red spots are at highest risk of rupture .
- The prevalence of oesophageal varices varies between 40% and 95% in people with cirrhosis.
- The annual incidence of oesophageal varices in people with cirrhosis varies from 3% to 22%.
- Oesophageal varices are one of the two most common causes of upper gastrointestinal bleeding (the other being gastric erosions).
- In Western countries, alcoholic and viral cirrhosis are the leading causes of portal hypertension and oesophageal varices.
- The one-year rate of first variceal bleeding is 5% for small varices, and 15% for large varices.
- It is more common in males than in females.
- The mortality rate is 10-20% in the first six weeks after a bleed.
The causes of oesophageal varices are anything that can cause portal hypertension. Some examples are in the table that follows.
Causes of oesophageal varices
Factors that increase the risk of variceal bleeding
These are also the same factors that increase the risk of portal hypertension:
- Decompensation of liver disease.
- Alcohol intake.
- Physical exercise.
- Circadian rhythms.
- Increased intra-abdominal pressure.
- Non-steroidal anti-inflammatory drugs (NSAIDs).
- Bacterial infection (cause of initial, and recurrence of, bleeding).
- Haematemesis (most commonly), melaena.
- Abdominal pain.
- Features of liver disease and specific underlying condition.
- Dysphagia/odynophagia (pain on swallowing; uncommon).
- Confusion secondary to encephalopathy (even coma).
- Peripherally shut down.
- Hypotension and tachycardia (ie shock).
- Reduced urine output.
- Signs of chronic liver disease.
- Reduced Glasgow Coma Scale.
- Signs of sepsis may also commonly be present.
- FBC - haemoglobin may be low; MCV may be high, normal or low; platelets may also be low; WCC may be raised. Thrombocytopenia may suggest portal hypertension and/or large oesophageal varices.
- Clotting including INR.
- Renal function.
- BUN (blood urea nitrogen) may be elevated if there has been a bleed.
- Group and cross-match.
- Hepatic serology.
- CXR - patients may have aspirated or have chest infection.
- Ascitic tap may be needed if bacterial peritonitis is suspected.
- Investigations as indication for the underlying cause of portal hypertension (see the separate Portal Hypertension article).
Various imaging techniques are available to assist in diagnosis, identification of underlying cause and risk factors, and response to treatment. These include:
- Transient elastography for identifying chronic liver disease patients at risk of developing clinically significant portal hypertension.
- Hepatic vein pressure gradient to diagnose clinically significant portal hypertension.
- Video capsule endoscopy screening as an alternative to traditional endoscopy.
- Doppler sonography.
- CT or MRI-angiography.
- Ultrasound of the abdomen may reveal biliary obstruction (eg, cancer).
Other causes of UGIB, as listed in the separate Upper Gastrointestinal Bleeding article.
Variceal bleeding management
See also the separate Upper Gastrointestinal Bleeding article.
Management for acute variceal haemorrhage consists of vasoactive drugs, endoscopic band ligation and antibiotics prophylaxis. Transjugular intrahepatic portosystemic shunt (TIPS) is reserved for those who do not respond or are unlikely to respond to initial standard management .
National Institute for Health and Care Excellence (NICE) guidance
- Terlipressin should be offered to patients with suspected variceal bleeding at presentation. Treatment should be stopped after definitive haemostasis has been achieved, or after five days, unless there is another indication for its use.
- Prophylactic antibiotic therapy should be offered at presentation to patients with suspected or confirmed variceal bleeding. Antibiotic use significantly reduces the mortality of patients who develop acute UGIB in association with chronic liver disease .
- Oesophageal varices:
- Band ligation should be used for patients with UGIB from oesophageal varices.
- TIPS should be considered if bleeding from oesophageal varices is not controlled by band ligation.
- NICE recommends that there is sufficient evidence to show that stent insertion is effective for selected patients with oesophageal varices in whom other methods of treatment have failed to control bleeding .
- Gastric varices:
- Endoscopic injection of N-butyl-2-cyanoacrylate should be offered to patients with UGIB from gastric varices.
- TIPS should be offered if bleeding from gastric varices is not controlled by endoscopic injection of N-butyl-2-cyanoacrylate.
- Assess airway - can easily be compromised, especially if reduced Glasgow Coma Scale.
- In the community, call an ambulance urgently - assess level of shock, lay the patient down and raise their legs (but, if actively vomiting then there is risk of aspiration, so the recovery position is more appropriate); provide oxygen and gain intravenous access if possible.
- Wide-bore access is needed, with a minimum of two cannulae (central access may also be required).
- Provide 40% oxygen if tachypnoeic or confused.
- Begin fluid resuscitation with rapid infusion of crystalloid and colloid solution .
- Give blood (ideally cross-matched) as soon as possible - if a delay is likely then group O rhesus negative blood may need to be given. The initial aim is to correct hypovolaemia. Whilst a large volume of blood may be required, bear in mind that there are risks associated with over-transfusion (raised portal pressure increases risk of re-bleeding). .
- Patients with oesphageal varices should be monitored with a cardiac monitor, blood pressure, pulse rate and urine output (catheterise until the patient is stabilised).
- Correct anaemia and coagulopathy. . Many of the patients will have a coagulopathy, and so give intravenous vitamin K immediately. If INR is prolonged, also give fresh frozen plasma. Platelet transfusion may be required .
- There is some concern that saline infusions may worsen ascites but the nature of the emergency warrants their use.
Consider inserting a central venous line/pulmonary artery catheter in haemodynamically unstable or elderly patients, or those with cardiac or pulmonary disease, to monitor fluid balance (overuse can produce oedema, ascites and hyponatraemia).
- Urgent endoscopy is necessary for variceal haemorrhage. Emergency fibre-optic endoscopy confirms the diagnosis and source of bleeding.
- Urgent endoscopy in unwell patients is not without its risks; adequate staffing and the presence of resuscitation facilities are required.
- Endoscopy allows the bleeding point to be visualised and treated:
- Band ligation is the first choice of treatment.
- Emergency sclerotherapy is still widely used as a first-line therapy for variceal bleeding in patients with cirrhosis, especially when band ligation is not available. However, drug treatment may stop bleeding in the majority of these patients. There is no convincing evidence to support the use of emergency sclerotherapy for variceal bleeding in cirrhosis as the initial single treatment when compared with vasoactive drugs .
- The use of vasoactive agents (terlipressin, octreotide or somatostatin) is associated with a significantly lower risk of acute all-cause mortality and transfusion requirements and improved control of bleeding and shorter hospital stay .
- Terlipressin is an analogue of vasopressin and studies have shown it to be superior to placebo in variceal haemorrhage . Terlipressin is considered the vasoactive agent of choice in acute variceal bleeding . It should be given to all patients presenting with suspected variceal bleeding prior to endoscopy and continued until haemostasis is achieved .
- Vasopressin and terlipressin should not be used in severe hypovolaemic shock and patients with severe cardiac disease.
Variceal obturation with glue
- This involves embolisation of varices with a glue-like substance (N-butyl-2-cyanoacrylate).
- It is particularly good for gastric or gastro-oesophageal variceal bleeding.
- However, there is a risk of embolisation to the lung, spleen or brain.
Balloon tube tamponade (Sengstaken-Blakemore tube)
- Balloon tamponade should be considered as a temporary salvage treatment for uncontrolled variceal haemorrhage .
- The Sengstaken-Blakemore tube (preferably kept in the fridge to stiffen rubber and make passage easier) is inserted through the mouth and into the stomach.
- The gastric balloon is inflated with air and the gastric balloon is then pulled up against the oesophagogastric junction, compressing submucosal varices.
- The Sengstaken-Blakemore tube also contains an oesophageal balloon which is only rarely required when the gastric balloon does not work.
- If bleeding continues, it may be that the tube is wrongly positioned or bleeding is from another source.
Transjugular intrahepatic portosystemic shunt
- Transjugular intrahepatic portosystemic stent shunting is recommended as the treatment of choice for uncontrolled variceal haemorrhage .
- The hepatic vein is cannulated percutaneously via the internal jugular vein, using a needle under ultrasound or fluoroscopic guidance.
- A tract is created through the liver from the hepatic to the portal vein - thus reducing portal pressure. This is dilated and an expandable metal stent inserted to create a shunt.
- This has a high success rate but encephalopathy is found in 25% of cases (as portal blood diverted from the liver) and shunt occludes within one year in up to 50% of cases .
- Oesophageal transection and gastric devascularisation are rare procedures but may have a role for patients with portal and splenic vein thrombosis who are not suitable candidates for shunt procedures and who continue to have variceal bleeding despite endoscopic and pharmacological treatment .
- Liver transplantation is the treatment of choice for patients with advanced liver disease.
Other aspects of management of variceal haemorrhage
- Avoid sedatives if possible.
- Patients are best managed on ITU/HDU.
- Antibiotic prophylaxis - infection occurs in up to 50% of patients and is associated with a worse outcome. It is thought that bacteria release endotoxins that enhance portal pressure and impair coagulation . Antibiotics are therefore given early - eg, ciprofloxacin.
- Treat hepatic encephalopathy if this is also present.
- No specific treatment has been shown to prevent the formation of oesphageal varices.
- Prevention of first variceal haemorrhage depends on the size/characteristics of varices. In patients with small oesphageal varices and high risk of bleeding, non-selective beta-blockers are recommended, while patients with medium/large varices can be treated with either beta-blockers or oesophageal band ligation.
- Prevention of recurrent variceal haemorrhage consists of the combination of beta-blockers and endoscopic band ligation.
- All patients with newly diagnosed cirrhosis should have screening endoscopy, looking for oesophageal varices.
- Presence of moderate or large varices requires beta-blockers in the first instance (indefinite treatment).
- If there are contra-indications to beta-blockers, the varices should be banded or sclerosed .
- In the long term, repeated endoscopic screening is usually required - eg, 2- to 3-yearly in cases of small varices.
- Patients who have survived an oesophageal variceal bleed should receive beta-blockers, ± nitrates and endoscopic screening and treatment.
The use of measures of hepatic vein pressure gradient with an aim to reduce it under 12 mm Hg is associated with a significant reduction in mortality[19, 20] . However, pharmacological options employing this effect have yet to be developed for use in routine medical practice .
Variceal bleeding prognosis
- For patients with cirrhosis, one-year survival is 50% for those surviving two weeks following a variceal bleed.
- Prognosis in non-cirrhotic portal fibrosis is better than for cirrhotics.
- Associated renal, respiratory, cardiovascular and immune disorders account for 20-65% of mortality in patients with oesophageal varices .
Further reading and references
UK guidelines on the management of variceal haemorrhage in cirrhotic patients; British Society of Gastroenterology (2015)
Roberts D, Best LM, Freeman SC, et al; Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev. 2021 Apr 104:CD013155. doi: 10.1002/14651858.CD013155.pub2.
Mohammad S, Chandio B, Shaikh A, et al; Endoscopic Findings in Patients Presenting with Upper Gastrointestinal Bleeding. Cureus. 2019 Mar 1911(3):e4280. doi: 10.7759/cureus.4280.
Meseeha M, Attia M; Esophageal Varices
Dib N, Oberti F, Cales P; Current management of the complications of portal hypertension: variceal bleeding and ascites. CMAJ. 2006 May 9174(10):1433-43.
Sarin SK, Kumar A, Angus PW, et al; Primary prophylaxis of gastroesophageal variceal bleeding: consensus recommendations of the Asian Pacific Association for the Study of the Liver. Hepatol Int. 2008 Dec2(4):429-39. doi: 10.1007/s12072-008-9096-8. Epub 2008 Sep 5.
Garcia-Tsao G, Sanyal AJ, Grace ND, et al; Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007 Sep46(3):922-38.
Bari K, Garcia-Tsao G; Treatment of portal hypertension. World J Gastroenterol. 2012 Mar 2118(11):1166-75.
Acute upper gastrointestinal bleeding in over 16s: management; NICE Clinical Guideline (August 2016)
Stent insertion for bleeding oesophageal varices; NICE Interventional Procedure Guidance, April 2011
Carson JL, Stanworth SJ, Dennis JA, et al; Transfusion thresholds for guiding red blood cell transfusion. Cochrane Database Syst Rev. 2021 Dec 2112:CD002042. doi: 10.1002/14651858.CD002042.pub5.
D'Amico G, Pagliaro L, Pietrosi G, et al; Emergency sclerotherapy versus vasoactive drugs for bleeding oesophageal varices in cirrhotic patients. Cochrane Database Syst Rev. 2010 Mar 17(3):CD002233.
Wells M, Chande N, Adams P, et al; Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther. 2012 Jun35(11):1267-78. doi:
Ioannou G, Doust J, Rockey DC; Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev. 2003(1):CD002147.
Powell M, Journey JD; Sengstaken-Blakemore Tube
Qazi SA, Khalid K, Hameed AM, et al; Transabdominal gastro-esophageal devascularization and esophageal transection for bleeding esophageal varices after failed injection sclerotherapy: long-term follow-up report. World J Surg. 2006 Jul30(7):1329-37.
Thalheimer U, Triantos CK, Samonakis DN, et al; Infection, coagulation, and variceal bleeding in cirrhosis. Gut. 2005 Apr54(4):556-63.
Chalasani N, Boyer TD; Primary prophylaxis against variceal bleeding: beta-blockers, endoscopic ligation, or both? Am J Gastroenterol. 2005 Apr100(4):805-7.
Thalheimer U, Mela M, Patch D, et al; Monitoring target reduction in hepatic venous pressure gradient during pharmacological therapy of portal hypertension: a close look at the evidence. Gut. 2004 Jan53(1):143-8.
D'Amico G, Garcia-Pagan JC, Luca A, et al; Hepatic vein pressure gradient reduction and prevention of variceal bleeding in cirrhosis: a systematic review. Gastroenterology. 2006 Nov131(5):1611-24.
Augustin S, Gonzalez A, Genesca J; Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol. 2010 Jul 272(7):261-74. doi: 10.4254/wjh.v2.i7.261.