When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Esophageal varices

Last reviewed: 10 Nov 2024
Last updated: 21 Feb 2024

Summary

Definition

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
  • Child-Pugh class
  • 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)
Full details

Emerging tests

  • capsule endoscopy

Treatment algorithm

ACUTE

decompensated cirrhosis with acute variceal hemorrhage (hepatic venous pressure gradient >12 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

Authors

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

NY

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

NY

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

CA

Disclosures

SS declares that he has no competing interests.

  • Esophageal varices images
  • Differentials

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

    • Management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period
    • Esophageal emergencies
    More Guidelines
  • Patient information

    Hepatitis C: what treatments work?

    Hepatitis B: should I have the vaccine?

    More Patient information
  • Calculators

    Child Pugh classification for severity of liver disease

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

Use of this content is subject to our disclaimer