Esophageal varices

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 17 Sep 2025

Last updated: 26 Mar 2025

Esophageal varices are a direct consequence of portal hypertension as a progressive complication of cirrhosis.

The development of bleeding carries significant morbidity and mortality.

Nonselective beta-blockers and/or endoscopic ligation can prevent the development of variceal bleeding.

Acute hemorrhage can be managed with resuscitation, a vasoactive therapy, and endoscopic ligation. Additional management may include transjugular intrahepatic shunt therapy and prophylactic antibiotics.

Diagnosis and surveillance are important aspects of management.

Definition

Esophageal varices are dilated collateral blood vessels that develop as a complication of portal hypertension, usually in the setting of cirrhosis. They can be seen on endoscopy. In the US and Europe, the major cause of cirrhosis is alcoholic liver disease. Worldwide, hepatitis B virus infection and hepatitis C virus infection are the major causes of cirrhosis.[1][2] Once cirrhosis has developed, increasing hepatic vein pressure gradient and deteriorating liver function may result in the formation of esophageal varices.

Rupture of esophageal varices can cause life-threatening bleeding. The most important predictor of variceal hemorrhage is the size of varices, with the highest risk of first hemorrhage occurring in patients with large varices (15% per year).[3][4] Other important predictors of hemorrhage are decompensated cirrhosis (Child-Pugh B/C) and the endoscopic finding of red wale marks.[3][5]

History and exam

Key diagnostic factors

cirrhosis
severe liver disease
alcohol misuse
hepatitis B or C infection
ascites
spider angioma
caput medusa
jaundice
encephalopathy
hematemesis
melena
hematochezia
HIV coinfection

Full details

Other diagnostic factors

splenomegaly

Full details

Risk factors

portal hypertension
size of varices
red wale marks
decompensated cirrhosis
ascites

Full details

Diagnostic tests

1st tests to order

hepatic venous pressure gradient (HPVG)
complete blood count
coagulation profile (INR/prothrombin time)
serum LFTs
BUN and creatinine
blood typing/cross-matching
hepatitis B surface antigen (HBsAg)
anti-hepatitis C virus IgG (anti-HCV IgG)
esophago-gastro-duodenoscopy (EGD)
liver stiffness measurement (LSM)

Full details

Emerging tests

capsule endoscopy

Full details

Treatment algorithm

ACUTE

decompensated cirrhosis with acute variceal hemorrhage (hepatic venous pressure gradient ≥10 mmHg)

decompensated cirrhosis with acute variceal hemorrhage and failed endoscopic/pharmacologic therapy

ONGOING

compensated cirrhosis with mild portal hypertension (hepatic venous pressure gradient >5 and <10 mmHg)

compensated cirrhosis with clinically significant portal hypertension (hepatic venous pressure gradient ≥10 mmHg): without gastroesophageal varices

compensated cirrhosis with clinically significant portal hypertension (hepatic venous pressure gradient ≥10 mmHg): with gastroesophageal varices (no bleeding)

previous variceal bleed

Contributors

Expert advisers

Savio John, MD, AGAF, FACG

Chief (Division of Gastroenterology), Director (Hepatology), Associate Professor

Department of Medicine

State University of New York Upstate Medical University

Syracuse

Disclosures

SJ serves as editor of the hepatology section for Stat Pearls.

Kelita Singh, MD

Associate Professor of Medicine

Department of Gastroenterology

State University of New York Upstate Medical University

Syracuse

Disclosures

KS declares that she has no competing interests.

Acknowledgements

Dr Savio John and Dr Keilita Singh would like to gratefully acknowledge Dr Grace E. Dolman, Dr Gennaro D'Amico, Dr Giuseppe Malizia, Dr Vikram Boolchand, and Dr Thomas Boyer, previous contributors to this topic.

Disclosures

GED, GDA, GM, VB, and TB declare that they have no competing interests.

Peer reviewers

Shreyas Saligram, MD, MRCP, FACG, FASGE

Assistant Professor

Department of Gastroenterology

University of California

San Francisco

Disclosures

SS declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Kaplan DE, Ripoll C, Thiele M, et al. AASLD practice guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology. 2024 May 1;79(5):1180-211.Full text Abstract

de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno VII - renewing consensus in portal hypertension. J Hepatol. 2022 Apr;76(4):959-74.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Hiatal hernia
- Gastric varices
- Mallory-Weiss tear
More Differentials
Guidelines
- AASLD practice guidance on risk stratification and management of portal hypertension and varices in cirrhosis
- American College of Gastroenterology–Canadian Association of Gastroenterology clinical practice guideline: management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period
More Guidelines
Calculators
Child Pugh classification for severity of liver disease
Más Calculadoras
Folletos para el paciente
Hepatitis B: should I have the vaccine?
Hepatitis C: what is it?
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Esophageal varices

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Emerging tests

Treatment algorithm

decompensated cirrhosis with acute variceal hemorrhage (hepatic venous pressure gradient ≥10 mmHg)

decompensated cirrhosis with acute variceal hemorrhage and failed endoscopic/pharmacologic therapy

compensated cirrhosis with mild portal hypertension (hepatic venous pressure gradient >5 and <10 mmHg)

compensated cirrhosis with clinically significant portal hypertension (hepatic venous pressure gradient ≥10 mmHg): without gastroesophageal varices

compensated cirrhosis with clinically significant portal hypertension (hepatic venous pressure gradient ≥10 mmHg): with gastroesophageal varices (no bleeding)

previous variceal bleed

Contributors

Expert advisers

Savio John, MD, AGAF, FACG

Disclosures

Kelita Singh, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Shreyas Saligram, MD, MRCP, FACG, FASGE

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Calculators

Folletos para el paciente

Inicie sesión o suscríbase para acceder a todo el BMJ Best Practice

Inicie sesión o suscríbase para acceder a todo el BMJ Best Practice

Inicie sesión para acceder a todo el BMJ Best Practice