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Esophageal Varices


Parswa Ansari

, MD, Hofstra Northwell-Lenox Hill Hospital, New York

Last full review/revision Dec 2019| Content last modified Dec 2019
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Esophageal varices are enlarged veins in the esophagus, which can cause major bleeding.

  • Esophageal varices are caused by high blood pressure in blood vessels in and around the liver (portal hypertension).

  • Esophageal varices usually cause no symptoms but can bleed spontaneously.

  • Bleeding can be very severe and cause shock or rarely death.

  • Doctors diagnose and treat esophageal varices using endoscopy.

Varices also can form in the upper part of the stomach near where the esophagus enters. These are called gastric varices and they cause similar symptoms.


Esophageal varices are caused by

The portal vein is the large vein that brings blood to the liver from the intestines and other abdominal organs such as the spleen, pancreas, and gallbladder. High blood pressure in the portal vein is called portal hypertension. The most common cause of portal hypertension is liver scarring due to cirrhosis.

View of the Liver and Gallbladder

The portal vein receives blood from the entire intestine and from the spleen, pancreas, and gallbladder and carries that blood to the liver. After entering the liver, the portal vein divides into right and left branches and then into tiny channels that run through the liver. When blood leaves the liver, it flows back into the general circulation through the hepatic vein.

View of the Liver and Gallbladder

Portal hypertension leads to the development of new veins (called collateral vessels) that bypass the liver. These veins directly connect the portal blood vessels to veins that take blood away from the liver into the general circulation. Collateral vessels develop at specific places. The most important are located at the lower end of the esophagus and at the upper part of the stomach. Here, the vessels enlarge and become full of twists and turns—that is, they become varicose veins in the esophagus (esophageal varices) or stomach (gastric varices). These enlarged vessels are fragile and prone to bleeding. Usually, there is no obvious trigger of the bleeding.


People with esophageal varices usually have no symptoms until the varices begin to bleed. Then, people vomit bright red blood, sometimes in large amounts. The bleeding is painless. People who lose a lot of blood may have signs of shock, including feeling lightheaded, weak, and sweaty. Their heart may beat quickly and their blood pressure may be low.


  • Endoscopy

Doctors suspect bleeding esophageal varices when people who are known to have chronic liver disease, particularly cirrhosis, begin vomiting blood. Then doctors put a flexible viewing tube (endoscope) through the mouth to look at the esophagus. If they see varices, they can also do treatments through the endoscope to stop the bleeding.


  • Fluids given by vein (intravenously) and sometimes blood transfusion

  • Endoscopic treatments to stop the bleeding

  • Intravenous octreotide

  • Sometimes a portosystemic shunting procedure

People with variceal bleeding usually need fluids given intravenously to replace their blood loss. If they have lost a lot of blood, they may need a blood transfusion.

During endoscopy, doctors can do treatments to stop the bleeding. Most often, doctors apply bands around the varices to close them off (a procedure called endoscopic banding). Sometimes they inject the varices with substances that seal them closed (a procedure called injection sclerotherapy). At the same time, doctors may give the drug octreotide or vasopressin intravenously to help stop the bleeding.

If bleeding continues despite these treatments, doctors may do a procedure called portosystemic shunting. This procedure connects the portal vein or one of its branches to a vein in the general circulation and reroutes most of the blood that normally goes to the liver so that it bypasses the liver. This bypass (called a shunt) lowers pressure in the portal vein so that bleeding is easier to control. There are various types of portosystemic shunt procedures. In one type, called transjugular intrahepatic portosystemic shunting (TIPS), doctors, using x-rays for guidance, insert a catheter with a needle into a vein in the neck and thread it to veins in the liver. The catheter is used to create a passage (shunt) that connects the portal vein (or one of its branches) directly with one of the hepatic veins. Less commonly, portosystemic shunts are created surgically.

If the person's life is in immediate danger from severe bleeding while waiting for the shunt procedure, doctors may place a tube with balloons down the person's esophagus. They inflate the balloons to squeeze (compress) the varices, which controls the bleeding. This tube is only a temporary measure.

Even after successful treatment, esophageal varices can bleed again, particularly if the person's liver disease remains active. Doctors may give drugs such as beta-blockers to help control portal hypertension, but people who continue to have problems may need liver transplantation.

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