Esophageal Varices — Prophylaxis and Endoscopic Treatment

What Are Esophageal Varices?

Esophageal varices are abnormally dilated veins in the lower portion of the esophagus. They develop when blood flow through the liver is obstructed, causing blood to back up and find alternative routes through smaller vessels that are not designed to handle high-pressure flow. These swollen veins are fragile and can rupture, causing massive, life-threatening hemorrhage.

Esophageal varices are a direct consequence of portal hypertension — elevated pressure in the portal venous system that carries blood from the digestive organs to the liver. They are one of the most serious complications of advanced liver disease and a leading cause of death in patients with cirrhosis.

Causes

The underlying cause of esophageal varices is portal hypertension, which most commonly results from:

• Liver cirrhosis — the most common cause worldwide. Any cause of cirrhosis can lead to varices, including:
  • Alcohol-related liver disease
  • Chronic hepatitis B or C
  • Non-alcoholic steatohepatitis (NASH/metabolic-associated liver disease)
  • Autoimmune hepatitis
  • Primary biliary cholangitis
  • Primary sclerosing cholangitis
• Portal vein thrombosis — blood clot in the portal vein
• Budd-Chiari syndrome — obstruction of the hepatic veins
• Schistosomiasis — a parasitic infection causing portal hypertension (common in endemic regions)

Approximately 50% of patients with cirrhosis have esophageal varices at the time of diagnosis. Among those without varices at initial evaluation, new varices develop at a rate of approximately 5-10% per year.

Grading

Esophageal varices are classified by their endoscopic appearance:

• Small varices (Grade I) — minimally elevated veins above the esophageal mucosal surface, straightened by air insufflation during endoscopy
• Medium varices (Grade II) — tortuous veins occupying less than one-third of the esophageal lumen, not obliterated by air insufflation
• Large varices (Grade III) — large, coil-shaped veins occupying more than one-third of the esophageal lumen

Additional high-risk features include red signs (cherry red spots, red wale marks) on the variceal surface, which indicate thin-walled areas at high risk of rupture.

Symptoms and Bleeding Signs

Esophageal varices themselves are asymptomatic until they bleed. When variceal hemorrhage occurs, it is a medical emergency presenting with:

• Hematemesis — vomiting large amounts of bright red blood or dark, clotted blood
• Melena — black, tarry stools
• Hematochezia — passage of red blood rectally (with massive bleeding)
• Signs of hypovolemic shock — rapid heartbeat, low blood pressure, pallor, cold sweaty skin, dizziness, confusion
• Syncope — fainting or near-fainting

Variceal bleeding carries a mortality rate of 15-20% per episode, making prevention and rapid treatment critical.

Screening Recommendations

All patients diagnosed with liver cirrhosis should undergo screening endoscopy to assess for esophageal varices:

• Compensated cirrhosis without varices — repeat endoscopy every 2-3 years (or annually if active liver disease or decompensation occurs)
• Compensated cirrhosis with small varices — repeat endoscopy every 1-2 years
• Non-selective beta-blocker therapy — may be used as an alternative to repeated screening endoscopy in some patients
• Transient elastography (FibroScan) and platelet count — can help identify patients at low risk who may safely defer screening endoscopy

Endoscopic Variceal Band Ligation (EVL)

Endoscopic variceal band ligation is the primary endoscopic treatment for esophageal varices. During therapeutic endoscopy, small rubber bands are placed around the base of each varix:

• The bands occlude the varix, causing thrombosis and eventual scarring
• Bands are placed starting at the gastroesophageal junction, moving upward in a helical pattern
• Multiple varices can be banded in a single session
• Sessions are repeated every 2-4 weeks until varices are eradicated (typically 2-4 sessions)
• Surveillance endoscopy is performed 3-6 months after eradication, then every 6-12 months to detect recurrence

Prophylactic vs. Emergency Treatment

Primary Prophylaxis (Preventing First Bleed)

For patients with medium or large varices who have never bled:

• Non-selective beta-blockers (propranolol, nadolol, carvedilol) — reduce portal pressure and variceal wall tension. First-line therapy.
• Endoscopic band ligation — an effective alternative for patients who cannot tolerate or are non-compliant with beta-blockers
• Primary prophylaxis reduces the risk of first variceal hemorrhage from approximately 25-30% to 15%

Emergency Treatment of Acute Variceal Bleeding

• Hemodynamic resuscitation — intravenous fluids and blood transfusion (targeting hemoglobin 7-8 g/dL)
• Vasoactive drugs — octreotide or terlipressin started immediately to reduce portal pressure
• Prophylactic antibiotics — ceftriaxone to prevent bacterial infection
• Emergency endoscopy — within 12 hours with band ligation as the primary hemostatic method
• Balloon tamponade — temporary bridge measure in uncontrolled bleeding
• TIPS (Transjugular Intrahepatic Portosystemic Shunt) — considered early (within 72 hours) for high-risk patients or as rescue therapy when endoscopic treatment fails

Secondary Prophylaxis (Preventing Rebleeding)

After surviving a variceal bleed, the combination of non-selective beta-blockers AND repeated band ligation sessions is recommended to minimize the risk of recurrence.

Medical Therapy

• Non-selective beta-blockers — reduce heart rate and portal pressure. Propranolol is typically dosed twice daily, titrated to reduce resting heart rate by 25% or to 55-60 beats per minute. Carvedilol may be more effective at reducing portal pressure.
• Beta-blockers should be avoided or used with extreme caution in patients with refractory ascites, spontaneous bacterial peritonitis, or severe hypotension
• Regular monitoring of heart rate and blood pressure is essential during therapy

Diet and Lifestyle

• Complete alcohol abstinence — essential for all patients with liver disease. Continued alcohol use accelerates disease progression and increases bleeding risk.
• Soft diet during active treatment — avoid hard, rough, or sharp foods that could mechanically irritate varices (hard bread crusts, chips, nuts, raw vegetables)
• Small, frequent meals — easier to digest and less likely to increase portal pressure
• Adequate protein intake — important for maintaining muscle mass, unless hepatic encephalopathy requires restriction
• Sodium restriction — typically 2 grams per day for patients with ascites
• Avoid NSAIDs — ibuprofen, aspirin, and other NSAIDs increase bleeding risk and can worsen kidney function in cirrhosis
• Moderate physical activity — avoid extreme exertion and heavy lifting, but regular light exercise is beneficial

When to Seek Emergency Care

Variceal bleeding is a life-threatening emergency. Call emergency services immediately if you experience:

• Vomiting blood (any amount)
• Black, tarry stools (melena)
• Feeling faint, dizzy, or losing consciousness
• Rapid heartbeat with weakness
• Cold, clammy skin
• Confusion or disorientation

Do not wait. Variceal hemorrhage can cause fatal blood loss within minutes to hours. Immediate hospitalization with endoscopic intervention is critical.

Long-Term Management

Esophageal varices are a manifestation of advanced liver disease, and long-term management must address the underlying condition:

• Regular follow-up with a hepatologist/gastroenterologist
• Treatment of the underlying liver disease (antiviral therapy for hepatitis B/C, abstinence for alcohol-related disease, weight management for NASH)
• Surveillance endoscopy after variceal eradication (every 6-12 months)
• Hepatocellular carcinoma screening (ultrasound every 6 months)
• Evaluation for liver transplantation in appropriate candidates
• Management of other portal hypertension complications (ascites, hepatic encephalopathy, hepatorenal syndrome)
• Adherence to prescribed beta-blocker therapy
• Coordination of care between hepatologist, endoscopist, and transplant team when applicable