Esophageal Varices

Esophageal varices are enlarged, swollen veins in the tube connecting your throat to your stomach. These vessels can rupture without warning, causing life-threatening bleeding that requires immediate medical attention.

Table of contents

• What Are Esophageal Varices?
• What Causes Esophageal Varices?
• Symptoms and Warning Signs
• How Are Esophageal Varices Diagnosed?
• How Common Is This Condition?
• Treatment Options
• Outlook and Prognosis

What Are Esophageal Varices?

varices oesophageal, oesophageal varices, esophageal varix

• Esophagus
• Liver
• Portal vein
• Stomach

Esophageal varices are enlarged veins in the lining of your esophagus, the swallowing tube that connects your mouth to your stomach. These are not ordinary swollen veins like varicose veins you might see in someone’s legs. They are deep inside your chest cavity, usually close to the bottom where your esophagus meets your stomach, so you cannot see or feel them from the outside.^[1][2]

These veins become dangerous because they have weakened walls that can leak or break and bleed. The vessels are extremely dilated and located in the lower third of the esophagus, just beneath the surface lining.^[3] Internal bleeding from a ruptured vein can be sudden, severe, and life-threatening.^[2]

What Causes Esophageal Varices?

The primary cause of esophageal varices is portal hypertension, which is high blood pressure in the portal vein that runs through your liver and the other veins that branch off from it.^[2] This abnormal pressure causes the thin esophageal veins to swell and enlarge. Portal hypertension most commonly results from liver disease.

Cirrhosis, which is severe scarring of the liver, is the most common underlying cause of esophageal varices.^[1][4] Cirrhosis can be caused by diseases such as hepatitis C, hepatitis B, or alcoholic liver disease. The scarring cuts down on blood flowing through the liver. As a result, blood backs up and seeks alternative routes, flowing through smaller blood vessels in the esophagus that are not designed to carry large volumes of blood.^[5]

Normal portal pressure is approximately 9 mmHg. If the portal pressure rises above 12 mmHg, blood flowing through the system is redirected from the liver into areas with lower pressures. This causes collateral circulation to develop in the lower esophagus, abdominal wall, stomach, and rectum. The small blood vessels in these areas become distended and appear as swollen veins called varices.^[3]

Less common causes of esophageal varices include blood clots in the veins leading to and from the liver, a condition called Budd-Chiari syndrome where veins in the liver become partially blocked, and schistosomiasis, a disease caused by parasitic worms.^[3][7] In rare cases, splenic vein thrombosis can cause esophageal varices without raised portal pressure.^[3]

Other rare causes of portal hypertension that can lead to esophageal varices include Wilson disease, alpha-1 antitrypsin deficiency, primary biliary cirrhosis, tuberculosis, severe right-sided heart failure, and constrictive pericarditis.^[4]

Symptoms and Warning Signs

Esophageal varices usually don’t cause symptoms unless they bleed. You’re not likely to feel them when you swallow, and they typically don’t cause any discomfort until bleeding occurs.^[1][2]

If there is only a small amount of bleeding, the only symptom may be dark or black streaks in the stools.^[5] However, if larger amounts of bleeding occur, symptoms may include:^[1][2]

• Vomiting large amounts of blood
• Black, tarry stools or bloody stools
• Lightheadedness due to blood loss
• Pale complexion, as though the blood has drained out of your face
• Feeling tired, weak, and dizzy
• Loss of consciousness in severe cases

A slow blood leak may show up as dried, coagulated blood in vomit, which looks like coffee grounds. A ruptured vein will produce fresh, red blood in your vomit. If you swallow blood and it passes through your digestive system, it will usually be black by the time it comes out in your stool, making it look like tar.^[2]

A healthcare professional might suspect that you have esophageal varices if you have signs of liver disease or have been diagnosed with liver cirrhosis. These signs include:^[1][2]

• Yellow coloration of your skin and eyes, known as jaundice
• Easy bleeding or bruising
• Fluid buildup in your belly, called ascites
• Swollen legs and feet
• Upper abdominal pain (your liver or spleen might be sore)
• Itching, with no visible rash
• Confusion or disorientation

If you develop symptoms of severe blood loss and hypovolemic shock, seek emergency medical care immediately. These symptoms include fast heart rate, fast breathing, cold and clammy skin, sweating, anxiety and confusion, and loss of consciousness.^[2]

How Are Esophageal Varices Diagnosed?

If someone is diagnosed with cirrhosis, a healthcare professional will typically screen for esophageal varices. How often screening tests are done depends on someone’s condition.^[8]

The main test used to diagnose esophageal varices is upper endoscopy. This procedure uses a tiny camera on the end of a flexible tube to visually examine the upper digestive system. The tube is inserted through your mouth and down into your esophagus. This is the preferred method of screening for esophageal varices.^[8]

During the endoscopy, the medical professional looks for dilated veins. If found, the enlarged veins are measured and checked for red streaks and red spots, which usually indicate a significant risk of bleeding. Treatment can be performed during the same exam.^[8]

Some providers suggest upper endoscopy for people who are newly diagnosed with mild to moderate cirrhosis. This test screens for esophageal varices and treats them before there is bleeding.^[5]

Other tests that can help diagnose esophageal varices include:^[8]

• Abdominal CT scans
• Doppler ultrasounds of the splenic and portal veins
• Transient elastography, an ultrasound test used to measure scarring in the liver

Your healthcare provider will also do a physical exam which may show bloody or black stool, low blood pressure, rapid heart rate, and signs of chronic liver disease or cirrhosis.^[5]

How Common Is This Condition?

In people diagnosed with cirrhosis of the liver, 30% already have portal hypertension and esophageal varices at the time of diagnosis. Up to 90% will develop them over the next 10 years.^[2][4] The condition is more common in males than in females.^[4]

Bleeding is the most serious risk of esophageal varices. Not everyone will experience bleeding, but up to 50% will.^[2][4] The risk increases as portal hypertension increases. The 1-year rate of first bleeding is 5% for small varices and 15% for large varices.^[4]

An episode of bleeding from esophageal varices has a mortality rate of around 20%, and bleeding often comes back.^[2] Bleeding varices are the most common cause of hospitalization and death in people with cirrhosis.^[2]

Treatment Options

The primary aim in treating esophageal varices is to prevent bleeding. Bleeding esophageal varices are life-threatening, so if bleeding happens, treatments are available to stop it as quickly as possible.^[8]

Emergency Treatment for Bleeding

If massive bleeding occurs, a person may need to be put on a ventilator to protect their airway and prevent blood from going down into the lungs.^[5] The goal of treatment is to stop acute bleeding as soon as possible to prevent shock and death.

To stop the bleeding, the provider may pass an endoscope into the esophagus:^[5]

• A clotting medicine may be injected into the varices
• A rubber band may be placed around the bleeding varices, called banding or band ligation. This is the most common endoscopic treatment for esophageal varices

Other treatments to stop the bleeding include:^[5]

• A medicine to tighten blood vessels may be given through a vein. Examples include octreotide or vasopressin
• Rarely, a tube may be inserted through the nose into the stomach and inflated with air. This produces pressure against the bleeding veins, called balloon tamponade

Preventing Initial and Repeat Bleeding

Once the bleeding is stopped, other varices can be treated with medicines and medical procedures to prevent future bleeding. These include:^[5][8]

• Drugs called beta blockers, such as propranolol, nadolol, and carvedilol, that reduce portal vein pressure and the risk of bleeding
• A rubber band can be placed around the varices during an endoscopy procedure
• Medicines can be injected into the varices during endoscopy to cause them to clot

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure to create new connections between two blood vessels in your liver. This can decrease pressure in the varices and prevent bleeding episodes from happening again.^[5]

In rare cases, emergency surgery may be used to treat people if other treatment fails. Surgical shunts or surgery to reduce the pressure in the esophageal varices are treatment options, but these procedures are risky.^[5]

People with bleeding varices from liver disease may need more treatment for their liver disease, including a liver transplant.^[5]

Outlook and Prognosis

Bleeding esophageal varices are a serious complication of liver disease and have a poor outcome.^[5] Bleeding often comes back with or without treatment. If you have bleeding from this problem, there is a risk that it will happen again, so it’s important to follow up with your doctor.^[5]

When portal hypertension results from chronic liver disease, which is most of the time, it worsens as your liver condition worsens. People with advanced liver disease have other concerns besides esophageal varices. In general, more severe cirrhosis leads to increasing pressure and larger varices, which are more likely to rupture.^[2]

The most important predictor of bleeding is the size of varices, with the highest risk of first bleeding occurring in patients with large varices. Other important predictors of bleeding are decompensated cirrhosis and the endoscopic finding of red markings on the varices.^[12]