Can cigar smoking worsen esophageal varices?

Impact of Cigar Smoking on Esophageal Varices

Yes, cigar smoking can worsen esophageal varices by increasing portal pressure and exacerbating the underlying factors that contribute to variceal bleeding. 1

Mechanism of Impact

Cigar smoking affects esophageal varices through several mechanisms:

1. Portal Pressure Effects:

   • Smoking increases portal pressure, which is directly related to the risk of variceal development and bleeding 1
   • A hepatic venous pressure gradient greater than 12 mm Hg is necessary for varices to develop and bleed, and smoking can contribute to this pressure elevation

2. Variceal Wall Tension:

   • Smoking can increase tension on the variceal wall, which is a key factor in variceal rupture 1
   • The increased pressure from coughing or straining associated with smoking can directly impact variceal wall tension

3. Continued Hepatic Injury:

   • In patients with alcoholic cirrhosis, continued tobacco use can worsen hepatic injury 1, 2
   • Studies have shown that varices can regress with abstinence from alcohol, but continued smoking may impede this improvement 1

Evidence from Clinical Guidelines

The British Society of Gastroenterology guidelines highlight that factors predisposing to variceal hemorrhage include:

• Pressure within the varix
• Variceal size
• Tension on the variceal wall
• Severity of liver disease 1

Smoking negatively impacts several of these factors, particularly by increasing pressure and tension on the variceal wall.

Risk Factors for Variceal Bleeding

Patients with the following risk factors should be especially cautious about cigar smoking:

• Large varices (>5 mm in diameter) 1
• Red wale marks on varices 1
• Child-Pugh class B or C cirrhosis 1, 3
• History of previous variceal bleeding 3

Management Considerations

For patients with esophageal varices who smoke cigars:

• Complete smoking cessation should be strongly recommended
• Regular endoscopic surveillance is essential - typically every 1-2 years depending on variceal size and liver function 1
• Consider earlier implementation of prophylactic measures such as:
  • Non-selective beta-blockers (NSBBs) 3
  • Endoscopic variceal ligation (EVL) 3

Special Considerations

• Smoking cessation is particularly important in patients with alcoholic cirrhosis, as continued smoking can impede improvement in portal hypertension even with alcohol abstinence 2
• The risk of variceal progression is higher in patients with post-alcoholic cirrhosis, Child-Pugh class B or C, and red wale marks 4
• The two-year risk of bleeding from small varices is significantly higher than in patients without varices (12% vs. 2%) 4

Conclusion

Cigar smoking should be strongly discouraged in patients with esophageal varices as it can worsen portal hypertension, increase variceal wall tension, and contribute to continued hepatic injury. This recommendation is particularly important for patients with additional risk factors for variceal bleeding, such as large varices, advanced liver disease, or a history of previous bleeding.