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Oesophageal Varices

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Overview

Oesophageal varices are dilated submucosal veins in the oesophagus and develop secondary to portal hypertension which commonly occurs due to liver cirrhosis. Varices are abnormally dilated blood vessels.

Pathophysiology

The portal vein drains blood from the gastrointestinal tract, gallbladder, pancreas, and spleen to the liver. Liver cirrhosis leads to increased resistance to blood flow which leads to hypertension in the portal vein (portal hypertension). This then leads to increased pressure in the veins draining into the portal vein, including those from the oesophagus.

It is important to note that varices can form in other parts of the body, particularly the stomach, duodenum, and rectal.

Epidemiology

  • Oesophageal varices are one of the most common causes of upper gastrointestinal bleeding
  • Around 40% of people with liver cirrhosis have oesophageal varices

Presentation

Patients typically have features of an upper gastrointestinal bleed, particularly vomiting fresh blood and passing black stool (melaena).

Differential Diagnoses

Peptic ulcer disease

  • Patients tend to have a history of heartburn and dyspepsia

Mallory-Weiss tear

  • Patients tend to have a preceding history of forceful or repeated episodes of vomiting and coughing

Management

Acute variceal haemorrhage

  • 1st-line: ABCDE approach, resuscitate, and correct any clotting abnormalities
  • Terlipressin should be offered as soon as possible, along with prophylactic IV antibiotics then patients should have endoscopic treatment, which is typically via endoscopic band ligation
  • If there is uncontrollable bleeding, a Sengstaken-Blakemore tube should be used
  • If these measures fail, then consider a transjugular intrahepatic portosystemic shunt – this is generally very effective but can precipitate hepatic encephalopathy

Prophylaxis

  • If varices are small: non-selective beta-blockers (e.g. propranolol)
  • If varices are medium/large: non-selective beta-blockers or endoscopic band ligation 

Screening

Any patient that is newly diagnosed with liver cirrhosis should be offered a screening endoscopy for oesophageal varices. Following this, prophylactic measures should be offered.

Prognosis

The prognosis depends on the underlying cause leading to oesophageal varices. Patients with liver cirrhosis who have oesophageal variceal bleeding have a 1-year mortality rate of around 50%.

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