Esophageal varices are dilated collateral veins resulting from increased blood flow due to portal hypertension, often caused by cirrhosis. Nonbleeding varices are typically asymptomatic. Screening for varices with esophagogastroduodenoscopy (EGD) is recommended at the time of cirrhosis diagnosis. Management of nonbleeding esophageal varices focuses on the prevention of bleeding and involves regular surveillance, and, in some cases, primary prophylaxis of bleeding using nonselective beta blockers or eradication of varices using endoscopic variceal ligation (EVL).
Acute variceal hemorrhage is a potentially life-threatening condition. Patients present with clinical features of gastrointestinal bleeding, e.g., sudden hematemesis and melena, and, in some cases, hypovolemic shock. In addition to stabilizing the patient, management involves administration of vasoactive medication and antibiotic prophylaxis in combination with endoscopic treatment. Secondary prophylaxis of variceal bleeding involves nonselective beta blockers and EVL, and, if unsuccessful, placement of a transjugular intrahepatic portosystemic shunt (TIPS).
- Presence of varices
- Size of varices
- Stigmata of recent or impending bleeding (i.e., high-risk endoscopic findings): 
- Red wale marks: longitudinal red streaks on the surface of a varix
- Cherry-red spots
- Hematocystic spots: raised spots that appear as blisters
- Imaging is not routinely indicated but large esophageal varices may be incidentally identified.
- Transient elastography and CBC may be used to rule out high-risk esophageal varices but are not routinely used for confirming the diagnosis.
Management of nonbleeding esophageal varices
- Obtain EGD to screen for esophageal varices at the time of cirrhosis or portal hypertension diagnosis. 
- Assess for stratification”). (see “Risk
- Identify and treat the underlying cause of portal hypertension.
Risk stratification 
- High-risk features for esophageal variceal hemorrhage
- Low-risk features for esophageal variceal bleeding: small esophageal varices without high-risk endoscopic findings
Monitoring of low-risk varices 
|EGD monitoring for the development of high-risk esophageal varices in patients with compensated cirrhosis |
|Small esophageal varices ||Ongoing liver injury||Annual|
|No ongoing liver injury||Every 2 years|
|No varices||Ongoing liver injury|
|No ongoing liver injury||Every 3 years|
Patients with esophageal varices have a 10–15% annual risk of variceal hemorrhage; the risk increases with the severity of liver disease, size of varices, and presence of variceal wall thinning. 
Prevention of first episode of variceal bleeding 
- Medium or large esophageal varices: Provide either pharmacological prophylaxis or EVL. 
- Small esophageal varices with high-risk features for esophageal variceal hemorrhage: Provide pharmacological prophylaxis as indicated.
Pharmacological prophylaxis (off-label) 
- Nonselective beta blockers (recommended) ; 
- Can be continued indefinitely if tolerated
- No EGD surveillance is necessary
In patients without varices, there is no evidence to support the use of to prevent the development of gastroesophageal varices; however, beta blockers may be used for other indications in patients with clinically significant portal hypertension. 
Endoscopic variceal ligation (EVL) 
- Repeat every 1–8 weeks until varices are eradicated.
- Obtain surveillance EGD within 1–6 months of eradication and every 6–12 months thereafter. 
Combination therapy with EVL and pharmacotherapy is not recommended for primary prophylaxis of esophageal variceal hemorrhage.
Management of esophageal variceal hemorrhage
- Stabilize patient: See “ .”
- Pharmacological treatment: Start both vasoactive medication and antibiotic prophylaxis.
- Consult gastroenterology for EGD and further management as soon as possible.
- Prevention of recurrent variceal bleeding
Vasoactive medication and antibiotic prophylaxis are indicated for all patients. 
- Vasoactive medication
- Antibiotic prophylaxis ; 
- Hepatic encephalopathy prevention: Consider lactulose (PO or PR). 
Endoscopic treatment 
- EGD with endoscopic variceal ligation
- Alternatives: if EVL is unsuccessful or not possible
Prevention of recurrent variceal bleeding 
Patients without TIPS: combination therapy with nonselective beta blockers and EVL
- See “ ” for information on dosing and frequency.
- Refer for TIPS if combination therapy is unsuccessful or not tolerated.
- Patients with TIPS: No additional treatment is indicated.
Acute management checklist for esophageal variceal hemorrhage
- Six-week mortality rate after a variceal bleeding event is ∼ 20% 
- Risk of rebleeding within 1 year if left untreated is ∼ 60%