What is Variceal Bleeding?
Variceal bleeding is hemorrhage from enlarged submucosal veins (varices) that develop in the esophagus or stomach as a direct consequence of portal hypertension in patients with liver cirrhosis, representing one of the most dangerous and life-threatening complications of advanced liver disease. 1
Pathophysiology and Development
Portal hypertension drives variceal formation through a specific mechanism:
- Increased intrahepatic vascular resistance from cirrhosis elevates portal pressure above 5 mm Hg, defining portal hypertension 2
- When hepatic venous pressure gradient (HVPG) reaches ≥10 mm Hg (clinically significant portal hypertension), collateral vessels begin forming at sites where portal and systemic circulation communicate 1, 2
- Varices develop as these collaterals enlarge, with approximately 50% of cirrhotic patients having varices at diagnosis 1
- Bleeding occurs when HVPG exceeds 12 mm Hg—below this threshold, variceal hemorrhage does not occur 1
Types and Classification
Varices are classified by anatomic location:
- Esophageal varices (EVs): Most common type, graded as small (<5 mm) or large (≥5 mm) 1
- Gastroesophageal varices (GOV): Extensions of esophageal varices into the stomach, subdivided into GOV1 (along lesser curvature, 74% of cases) and GOV2 (extending to fundus) 1
- Isolated gastric varices (IGV): Occur without esophageal varices, classified as IGV1 (fundal) or IGV2 (body, antrum, pylorus) 1
Clinical Significance and Mortality
Variceal bleeding carries substantial morbidity and mortality:
- Occurs in approximately 12% of cirrhotic patients with varices per year (5% for small varices, 15% for large varices) 1
- Despite modern therapy, 6-week mortality remains 12-22% 1
- Bleeding stops spontaneously in only 40% of cases 1
- Without treatment, rebleeding occurs in 60% of patients within 1 year 1, 3
- Gastric varices bleed less frequently (25% at 2 years) but cause more severe hemorrhage with higher mortality than esophageal varices 1
Risk Factors for Bleeding
Three critical factors predict variceal hemorrhage:
- Variceal size: Larger varices have dramatically higher bleeding risk 1, 4
- Red color signs: Red wale marks (longitudinal dilated venules) or red spots on variceal surface indicate imminent rupture risk, with 80% of patients with these findings experiencing bleeding 1, 4
- Severity of liver disease: Child-Pugh class B/C and decompensated cirrhosis significantly increase bleeding risk 1, 4
Hemodynamic Predictors
Portal pressure measurements provide prognostic information:
- HVPG >20 mm Hg measured within 24 hours of bleeding predicts failure to control hemorrhage (83% vs 29%) and 1-year mortality (64% vs 20%) compared to lower pressures 1
- HVPG ≥16 mm Hg is strongly associated with death 2
Common Pitfall to Avoid
Do not confuse portal hypertensive gastropathy with variceal bleeding—portal hypertensive gastropathy causes a snake-skin or mosaic mucosal pattern on endoscopy and typically presents with chronic bleeding and anemia rather than acute massive hemorrhage, requiring different management strategies focused on portal pressure reduction rather than endoscopic variceal therapy 1