Esophageal varices

Last reviewed: 23 Aug 2023
Last updated: 07 Jul 2022



History and exam

Key diagnostic factors

  • cirrhosis
  • more severe liver disease
  • alcohol misuse
  • hepatitis B or C infection
  • ascites
  • spider angioma
  • caput medusa
  • jaundice
  • encephalopathy
  • hematemesis
  • melena
  • hematochezia
  • HIV coinfection
More key diagnostic factors

Other diagnostic factors

  • splenomegaly
Other diagnostic factors

Risk factors

  • portal hypertension
  • large varices
  • red wale marks
  • Child-Pugh class
  • ascites
More risk factors

Diagnostic investigations

1st investigations 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)
More 1st investigations to order

Emerging tests

  • capsule endoscopy

Treatment algorithm


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



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

Clinical Research Fellow

Barts Liver Centre

Barts and the London School of Medicine and Dentistry




GED declares that she has no competing interests.


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


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



SS declares that he has no competing interests.

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