Key Facts

Oesophageal varices are dilated portosystemic collateral veins in the submucosa of the oesophagus, developing as a consequence of portal hypertension. Variceal haemorrhage is one of the most serious complications of cirrhosis.

Epidemiology

Varices are present in approximately 50% of patients with cirrhosis at diagnosis — 40% in compensated cirrhosis, 60% in decompensated. Annual rate of new variceal development is ~5-8% per year. First variceal bleeding occurs at a rate of ~15% per year for large varices. Mortality per bleeding episode is 15-20% with current management.

Aetiology

• Cirrhosis (>90% of cases in UK): alcohol-related liver disease, NAFLD/MASLD, hepatitis B/C, autoimmune
• Pre-hepatic portal hypertension: portal vein thrombosis, splenic vein thrombosis
• Post-hepatic: Budd-Chiari syndrome, right heart failure, constrictive pericarditis
• Non-cirrhotic portal hypertension: schistosomiasis, sarcoidosis, nodular regenerative hyperplasia

Pathophysiology

Portal hypertension develops when resistance to portal blood flow increases (intrahepatic — cirrhotic nodules compressing sinusoids + activated stellate cells; or pre/post-hepatic). When HVPG exceeds 10 mmHg, portosystemic collaterals develop at sites of portal-systemic anastomosis. The oesophageal submucosal veins are thin-walled and become progressively dilated. Bleeding occurs when wall tension exceeds wall strength (LaPlace's law) — larger varices, higher portal pressure, and thinner walls increase rupture risk.

Acute Variceal Bleeding

• Massive haematemesis (bright red or coffee-ground)
• Melaena (may have fresh PR bleeding if massive)
• Haemodynamic compromise: tachycardia, hypotension, cool peripheries
• Signs of chronic liver disease: jaundice, spider naevi, palmar erythema, ascites, hepatosplenomegaly
• Hepatic encephalopathy: may be precipitated by GI bleed

Unruptured Varices

• Usually asymptomatic — discovered at screening OGD
• Features of underlying liver disease

Red Flags

• Haematemesis in a patient with known/suspected liver disease — assume variceal until proven otherwise
• Rapidly falling Hb with haemodynamic instability
• Signs of coagulopathy (bruising, prolonged bleeding)
• Encephalopathy developing after GI bleed

Bedside

• ABG/VBG: lactate, Hb (may take hours to drop)
• Observations: pulse, BP, RR, SpO₂, urine output
• GCS: encephalopathy assessment

Bloods

• FBC: Hb (may be falsely normal initially), platelets (often low in cirrhosis)
• Coagulation (INR/PT): often deranged in cirrhosis
• U&Es: AKI (hepatorenal syndrome), urea rises with GI bleed
• LFTs: bilirubin, albumin (prognostic — Child-Pugh/MELD scoring)
• Group and crossmatch: at least 4 units packed red cells
• Blood cultures: if sepsis suspected

Imaging

• OGD (oesophagogastroduodenoscopy): diagnostic and therapeutic — within 12 hours of presentation (after resuscitation)
  • Variceal grading: small (<5 mm), medium/large (>5 mm)
  • Red signs: cherry red spots, red wale markings (increased bleed risk)
• Doppler ultrasound: portal vein patency, flow direction, spleen size
• CT abdomen with portal phase: portal vein thrombosis, hepatocellular carcinoma screening

Special Tests

• HVPG measurement: gold standard for portal hypertension quantification (>10 mmHg = clinically significant); mainly research/specialist centres
• Transient elastography (FibroScan): liver stiffness >20 kPa suggests clinically significant portal hypertension; platelet count <150 also predictive (Baveno VII criteria)

Non-pharmacological

• Acute resuscitation: A-E approach; large-bore IV access; target Hb 70-80 g/L (over-transfusion increases portal pressure); correct coagulopathy with caution (target INR-based factor replacement is debated)
• Airway protection: intubation if GCS <8, massive haematemesis, or high aspiration risk
• Sengstaken-Blakemore tube: temporary tamponade (max 24 hours) as bridge to definitive treatment if endoscopy unavailable or failed; Danis stent as alternative

Pharmacological

• Acute bleed:
  • Terlipressin 2 mg IV stat then 1-2 mg every 4-6 hours for up to 5 days — reduces portal pressure; ONLY vasoactive drug licensed for variceal bleeding in UK
  • Prophylactic antibiotics: ceftriaxone 1 g IV OD (or ciprofloxacin 500 mg BD PO) for 5-7 days — reduces mortality and rebleeding
  • PPI: omeprazole 40 mg IV if ulcer co-exists; avoid routine use in variceal bleeding
• Primary prophylaxis (medium/large varices, no prior bleed):
  • NSBB: propranolol 40 mg BD (titrate to HR 55-60 bpm) OR carvedilol 6.25-12.5 mg OD (may be superior — reduces HVPG more)
  • OR VBL (variceal band ligation) every 2-4 weeks until eradicated
  • Baveno VII: patients with compensated cirrhosis, LSM <20 kPa and platelets >150 can avoid screening OGD
• Secondary prophylaxis (after first bleed):
  • Combination VBL + NSBB (most effective)
  • VBL every 2-4 weeks until eradication, then surveillance OGD

Surgical/Interventional

• OGD band ligation: first-line endoscopic treatment for acute variceal bleed; apply bands from GOJ upwards
• TIPSS (transjugular intrahepatic portosystemic shunt): for refractory/recurrent bleeding despite endoscopic + pharmacological therapy; early TIPSS (<72 hours) in high-risk patients (Child C <14 or Child B with active bleed) reduces mortality
• Balloon-occluded retrograde transvenous obliteration (BRTO): for gastric varices
• Liver transplantation: definitive treatment for underlying cirrhosis

Referral Criteria

• Emergency GI/hepatology referral for acute variceal bleeding
• Hepatology referral for all cirrhotic patients (variceal screening)
• Interventional radiology for TIPSS
• Transplant assessment if appropriate

First variceal bleed mortality is 15-20% per episode (down from >40% with modern management). 6-week mortality after first bleed is ~20%. Rebleeding rate without secondary prophylaxis is ~60% within 1 year. With combination VBL + NSBB, rebleeding rate is ~20-30%. Early TIPSS in high-risk patients reduces 1-year mortality. Child-Pugh C patients have worst prognosis (~50% 6-week mortality after variceal bleed). Liver transplantation offers definitive cure of portal hypertension.

Acute Variceal Bleed Protocol

Child-Pugh Score