Oesophageal varices

Last reviewed: 27 Dec 2022
Last updated: 22 Mar 2022



History and exam

Key diagnostic factors

  • presence of risk factors for variceal bleeding
  • haematemesis
  • melaena
  • haematochezia
  • cirrhosis
  • severe liver disease
  • alcohol misuse
  • intravenous drug use
  • hepatitis B or hepatitis C infection
  • ascites
  • spider angioma
  • caput medusa
  • jaundice
  • encephalopathy
  • HIV co-infection
Full details

Other diagnostic factors

  • splenomegaly
Full details

Risk factors

  • portal hypertension
  • large varices
  • red wale marks
  • decompensated cirrhosis
  • ascites
Full details

Diagnostic investigations

1st investigations to order

  • gastroscopy
  • full blood count
  • electrolytes
  • serum LFTs
  • serum urea and creatinine
  • coagulation profile (INR/prothrombin time)
  • blood typing/cross-matching
  • hepatitis B surface antigen (HBsAg)
  • anti-hepatitis C virus IgG (anti-HCV IgG)
Full details

Investigations to consider

  • capsule endoscopy
  • liver ultrasound
Full details

Treatment algorithm


acute variceal bleeding


no acute variceal bleeding: medium to large varices

no acute variceal bleeding: small varices

previous variceal bleed


Expert advisers

Joe Geraghty, BSC (Hons), MB BS (Dist), MRCP, PhD

Consultant Gastroenterologist

Department of Gastroenterology

Manchester Royal Infirmary

Central Manchester University Hospitals NHS Foundation Trust




JG declares that he has no competing interests.


BMJ Best Practice would like to gratefully acknowledge the previous expert contributor, whose work has been retained in parts of the content:

Grace E. Dolman, PhD, MA (Cantab), MRCP

Clinical Research Fellow

Barts Liver Centre

Barts and the London School of Medicine and Dentistry



Peer reviewers

Andrew Austin, PhD, FRCP

Consultant Hepatologist

Lead Clinician in Gastroenterology

Royal Derby Hospital




AA declares that he has no competing interests.


Helena Delgado-Cohen

Section Editor, BMJ Best Practice


HDC declares that she has no competing interests.

Tannaz Aliabadi-Oglesby

Lead Section Editor, BMJ Best Practice


TAO declares that she has no competing interests.

Annabel Sidwell

Comorbidities Editor, BMJ Best Practice


AS declares that she has no competing interests.

Adam Mitchell

Drug Editor, BMJ Best Practice


AM declares that he has no competing interests.

  • Oesophageal varices images
  • Differentials

    • Hiatal hernia
    • Gastric varices
    • Mallory-Weiss tear
    More Differentials
  • Guidelines

    • Acute upper gastrointestinal bleeding in over 16s: management
    • UK guidelines on the management of variceal haemorrhage in cirrhotic patients
    More Guidelines
  • Calculators

    Blatchford Score for Gastrointestinal Bleeding

    Rockall Score for Upper Gastrointestinal Bleeding

    More Calculators
  • Patient leaflets

    Hepatitis C: what treatments work?

    Hepatitis B: should I have the vaccine?

    More Patient leaflets
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer