From the Guidelines
The most common cause of esophageal varices globally is portal hypertension secondary to liver cirrhosis, with alcoholic liver disease and viral hepatitis being the predominant underlying etiologies. This is due to increased intrahepatic vascular resistance to portal flow, which leads to the development of portal hypertension, aggravated by splanchnic vasodilation and an increase in portal blood flow caused by hyperdynamic circulation 1. The incidence of varices in cirrhotic patients without varices at baseline is 5–9% at 1 year and 14–17% at 2 years, with the main risk factor for variceal development being a higher hepatic venous pressure gradient (HVPG) 1.
Key Factors Contributing to Variceal Development
- Alcoholic liver disease and viral hepatitis (particularly hepatitis B and C) are the predominant underlying etiologies
- Increased intrahepatic vascular resistance to portal flow
- Splanchnic vasodilation and an increase in portal blood flow caused by hyperdynamic circulation
- Higher hepatic venous pressure gradient (HVPG)
Clinical Significance and Prevention
The development of varices is progressive, and these varices are clinically significant because they can rupture and cause life-threatening gastrointestinal bleeding, which carries a high mortality rate 1. Prevention strategies include addressing the underlying liver disease, regular endoscopic screening for high-risk patients, and prophylactic use of non-selective beta-blockers like propranolol or nadolol in patients with medium to large varices.
Less Common Causes
Less common causes of esophageal varices include portal vein thrombosis, Budd-Chiari syndrome (hepatic vein thrombosis), and congenital hepatic fibrosis, as well as schistosomiasis (particularly Schistosoma mansoni infection) in developing countries, especially in Africa, parts of South America, and the Middle East 1. However, the most recent and highest quality evidence prioritizes liver cirrhosis as the primary cause 1.
From the Research
Causes of Esophageal Varices
- Liver cirrhosis is the primary cause of esophageal varices, with approximately 40% to 95% of people with liver cirrhosis having oesophageal varices 2
- Hepatitis B virus-related cirrhosis is a significant predictor of esophageal varices, with a prevalence of 74.7% in patients with Hepatitis B virus-related cirrhosis 3
- Non-alcoholic fatty liver disease, alcohol, and hepatitis B are also common causes of esophageal varices in patients with compensated advanced chronic liver disease 4
- Portal hypertension is a substantial cause of gastrointestinal varices, including esophageal varices 5
Risk Factors for Esophageal Varices
- Spleen width and portal vein diameter are independent risk factors for the presence of esophageal varices in patients with Hepatitis B virus-related cirrhosis 3
- Platelet count, spleen width, portal vein diameter, and platelet count/spleen width ratio are significantly associated with the presence of esophageal varices on univariate analysis 3
- Liver stiffness measurement (LSM) is a major determinant of the performance of machine learning models to predict variceal bleeding in patients with compensated advanced chronic liver disease 4
Prevention and Treatment of Esophageal Varices
- Successful interferon therapy can prevent or delay the de novo onset of esophageal varices in patients with compensated cirrhosis due to HCV 6
- Endoscopic classification and liver stiffness measurement are essential for predicting variceal bleeding in patients with compensated advanced chronic liver disease 4
- Machine learning models can improve the performance of endoscopic stratification to predict variceal bleeding in patients with compensated advanced chronic liver disease 4