What are esophageal varices?

From the Guidelines

Esophageal varices are abnormally enlarged veins in the lower esophagus that develop when blood flow to the liver is blocked, most commonly due to cirrhosis, and their management involves preventive measures, endoscopic procedures, and acute bleeding treatment to reduce morbidity, mortality, and improve quality of life. These swollen vessels form when portal hypertension (increased pressure in the portal vein system) forces blood to find alternate routes back to the heart, causing veins in the esophagus to enlarge, as noted in a study published in the Journal of the American College of Radiology 1. The primary danger of esophageal varices is their tendency to rupture and bleed severely, which is a medical emergency with a high mortality rate.

Key Points

• Symptoms of bleeding varices include vomiting bright red blood, black tarry stools, lightheadedness, and shock.
• Management includes preventive measures like non-selective beta-blockers to reduce portal pressure, and endoscopic procedures such as band ligation to treat existing varices, with a study in Hepatology suggesting that nonselective beta-blockers have no role in the prevention of the development of esophagogastric varices but are the gold standard in the prevention of first variceal hemorrhage in patients with medium/large varices 1.
• Acute bleeding is treated with immediate resuscitation, vasoconstrictors like octreotide, antibiotics, and urgent endoscopic therapy, with a study published in 2021 showing that combination therapy with vasoactive drugs and endoscopy has become the favored treatment algorithm in managing acute bleeding from esophageal varices 1.
• For patients with cirrhosis, regular endoscopic screening is recommended to detect varices before they bleed, and lifestyle modifications including abstaining from alcohol, maintaining a low-sodium diet, and avoiding NSAIDs are essential to prevent worsening of the underlying liver disease and reduce bleeding risk.

Treatment Approach

• The combination of vasoconstrictive pharmacological therapy and variceal ligation is the preferred approach to the management of acute variceal hemorrhage, as noted in a study published in Hepatology 1.
• Endoscopic variceal ligation has been established as an alternative to nonselective beta-blockers for the prevention of initial variceal hemorrhage, with a study published in the Journal of the American College of Radiology showing that therapeutic endoscopic options for esophageal varices are highly efficacious, achieving 85% to 90% rates of initial control of bleeding 1.

From the Research

Definition of Esophageal Varices

• Esophageal varices are a commonly encountered complication of cirrhosis, characterized by abnormal dilated submucosal and collateral veins in the esophagus wall as a result of portal hypertension due to liver cirrhosis 2.
• They are caused by a permanently increased portal venous pressure, usually due to infectious or ethyltoxic liver cirrhosis, leading to the expansion of the submucosal venous plexus in the lower esophagus 3.

Characteristics and Risks

• Esophageal varices can be life-threatening, especially when bleeding occurs, and are accompanied by high mortality rates 4.
• The risk of bleeding from esophageal varices is high, with about 40% to 80% of patients surviving the first bleeding suffering from a recurrence of variceal bleeding within one year 5.
• The presence of very large varices with red spots increases the risk of hemorrhage 5.

Diagnosis and Treatment

• The current gold standard for identifying esophageal varices is the use of esophagogastroduodenoscopy (EGD), but it has limitations in observing detailed information of varices morphology and esophagogastric hemodynamics 2.
• Endoscopic ultrasound (EUS) is a potential tool in the diagnosis and management of bleeding esophageal varices, providing more accurate diagnostic aspects and beneficial treatment aspects 2.
• Treatment options include vasoactive drugs, endoscopic therapies, antibiotic prophylaxis, and transjugular intrahepatic portosystemic shunt (TIPS) 4, 3.
• Beta-blockers are a well-established cornerstone of the treatment of portal hypertension and primary and secondary prophylaxis for prevention of esophageal variceal bleeding, but may not be suitable for all patients 6, 5.