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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. If the hemorrhage persists, balloon tamponade of the bleeding and/or an emergent transjugular intrahepatic portosystemic shunt (TIPS) may be necessary. Secondary prophylaxis of variceal bleeding involves nonselective beta blockers, EVL, and/or TIPS placement.
- 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.
- Stabilize the patient: See “ .”
- Consult gastroenterology for EGD and further management immediately.
- Start vasoactive medication: octreotide OR vasopressin infusion
- Administer antibiotic prophylaxis.
- Begin prophylaxis to prevent recurrence.
Airway management 
- Indications for tracheal intubation 
Interventions to reduce the risk of pulmonary aspiration
- Consider .
- Have adequate suction immediately available.
- Consider gastric decompression prior to induction.
- Interventions to mitigate hemodynamic instability
Anticipate video laryngoscope for the first attempt. in patients with ongoing bleeding and consider using a
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 should be performed as soon as possible in unstable patients and within 12 hours in all other patients.
- Variceal ligation
- Injection of a sclerosant into, or adjacent to, the varix
- Used when variceal ligation is technically difficult
- Self-expanding metal stents: bridge therapy to TIPS in refractory bleeding 
Other interventional treatments
Balloon tamponade 
- Definition: orogastric tubes with esophageal and gastric balloons that tamponade bleeding when inflated
Indication: bridge to definitive treatment if 
- Endoscopy is unavailable and vasoactive medications are ineffective
- Endoscopic treatment is unsuccessful
- Consider if pharmacological and endoscopic treatment are unsuccessful. 
- Consider early TIPS (within 72 hours of EVL) in patients at high risk of rebleeding.
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
- Keep NPO.
- Follow ICU setting. and stabilize patient in an
- Consider intubation for airway protection.
- Consult gastroenterology for endoscopic hemostasis.
- Hold anticoagulants if needed.
- Transfuse packed red blood cells if Hb is ≤ 7 g/dL.
- Consider initiating .
- Start octreotide or vasopressin infusion.
- Start antibiotic prophylaxis (e.g., ceftriaxone).
- Esophageal perforation
- Infection: e.g., aspiration pneumonia, spontaneous bacterial peritonitis, bacteremia
- Acute kidney injury: e.g., hepatorenal syndrome, acute tubular necrosis
- Hepatic encephalopathy
- Hematologic: anemia, coagulopathy, thrombocytopenia
We list the most important complications. The selection is not exhaustive.