Esophageal Varices

Background

• Varices are collateral portosystemic venous channels, most commonly found in the esophagus and/or stomach, but can be found in other sites.
• Varices are complications of portal hypertension, most commonly seen in cirrhosis and advanced chronic liver disease. They may also be seen in splenic vein thrombosis (presenting as isolated gastric varices due to left sided or “sinistral” portal hypertension), and a variety of prehepatic and posthepatic disease processes.
• Varices have significant risk for severe gastrointestinal bleeding and morbidity/mortality.

Evaluation

• There are no physical findings specific for esophageal varices but physical findings of cirrhosis or portal hypertension may be evident.
• Upper endoscopy is recommended at the time of cirrhosis diagnosis to assess for varices and for determining their size and location (Strong recommendation).
• Upper gastrointestinal bleeding, findings of cirrhosis, advanced chronic liver disease, or portal hypertension should prompt investigation for presence of varices (Strong recommendation).
• Upper endoscopy screening for varices can be avoided in patients with a platelet count that is > 150,000/mm³ and a liver stiffness measurement that is < 20 kPa, kPa as measured by transient elastography, due to very low risk (< 5%) of having high-risk varices.
• In patients with acute gastrointestinal hemorrhage, perform esophagogastroduodenoscopy within 12 hours (Strong recommendation).
  • Assess for presence of endoscopic high-risk signs of bleeding, such as:
    • red wale sign
    • cherry-red spot
    • hematocystic spot
    • recent or active bleeding (overlying clot, "white nipple" sign)
• See Portal hypertension and Cirrhosis of the liver topics for information on these conditions.

Management

• See Acute variceal hemorrhage - treatment topic for treatment of acute variceal hemorrhage.
• The goal of treatment is to prevent variceal hemorrhage.
• Treat nonbleeding esophageal varices with either endoscopic band ligation or nonselective beta blockers (NSBBs) (Strong recommendation). See Esophageal variceal hemorrhage - primary prophylaxis topic for preventing a first time variceal bleed.
• Combination of NSBBs plus endoscopic variceal ligation is considered the best option for secondary prophylaxis of variceal hemorrhage (Strong recommendation). See Esophageal variceal hemorrhage - prevention of rebleeding topic for preventing recurrent variceal bleeding
• Bleeding esophageal varices are treated with a combination of resuscitation, blood transfusions to maintain a hemoglobin >7, infusion of splanchnic vasoconstrictors (for example, octreotide), and urgent endoscopy with band ligation. See Acute variceal hemorrhage - treatment topic for treatment of acute variceal hemorrhage.
• Hepatic venous pressure gradient measurement may be used as a prognostic indicator in centers with adequate expertise and equipment during treatment with beta blockers (Weak recommendation).
• Endoscopic treatments target variceal manifestations of portal hypertension but not underlying portal hypertension.
• Placement of surgical or percutaneous shunts (transjugular intrahepatic portosystemic shunt [TIPS]) in patients with cirrhosis is indicated in patients who are not responding well to medical or endoscopic treatments during both acute variceal bleeding episodes and to prevent rebleeding.