Patient education: Esophageal varices (Beyond the Basics)

ESOPHAGEAL VARICES OVERVIEW — Cirrhosis is a disease in which the liver becomes severely scarred, usually as a result of many years of continuous injury. The most common causes of cirrhosis include fatty liver due to obesity, alcohol use disorder, and chronic hepatitis B or C. Some people have more than one cause of injury to the liver.

Varices are expanded blood vessels in the esophagus, the tube that connects the mouth and stomach. Esophageal varices are a common complication of advanced cirrhosis. (See "Patient education: Cirrhosis (Beyond the Basics)".)

WHAT ARE ESOPHAGEAL VARICES? — Varices are expanded blood vessels that develop most commonly in the esophagus and stomach (figure 1). In people with cirrhosis, varices develop when blood flow through the liver is obstructed (blocked) by scarring, increasing the pressure inside the portal vein, which carries blood from the intestines to the liver; this condition is called portal hypertension.

Portal hypertension leads to an increase in the blood pressure inside the veins in the lower esophagus and stomach. These veins were not designed for the higher pressure, and thus they begin to expand, resulting in varices. Once varices develop, they can remain stable, increase in size (if the liver disease worsens), or decrease in size (if the liver disease improves).

COMPLICATIONS OF ESOPHAGEAL VARICES — Esophageal varices are a potentially serious complication of cirrhosis. Without treatment, between 25 and 40 percent of people with varices will experience an episode of severe bleeding (hemorrhage) resulting in significant illness or even death. Approximately 15 percent of people who bleed from varices will die, emphasizing the importance of preventing bleeding and treating the liver disease.

Varices do not cause symptoms until they rupture, leading to massive bleeding. Signs of bleeding from varices can include vomiting blood or material that looks like coffee grounds, dark-colored or black stools, and lightheadedness. If bleeding is severe, the person may lose consciousness.

Bleeding varices require emergency medical treatment. If not treated quickly, a large amount of blood can be lost and there is a significant risk of dying. If one or more of these symptoms develop, the person needs to seek emergency care, available in the United States by calling 911. Patients who are bleeding should call 911. They should not try to drive to the hospital or have someone else drive them.

Experts recommend that all people with cirrhosis have a screening test to determine if varices are present. If varices are discovered, one or more treatments may be recommended to prevent bleeding.

HOW ARE ESOPHAGEAL VARICES DETECTED? — Because of the serious consequences of bleeding, and because treatment can reduce this risk, experts recommend that all people with cirrhosis undergo testing to determine if varices are present.

Upper endoscopy — The most common way to detect varices is with a procedure known as upper endoscopy. During this procedure, the person is sedated, and a clinician inserts a thin, lighted, flexible tube with a camera through the person's mouth to view the lining of the esophagus and stomach. This procedure is described in detail in a separate topic review. (See "Patient education: Upper endoscopy (Beyond the Basics)".)

If no varices are detected, experts usually recommend repeating the upper endoscopy in two to three years. If varices are detected, endoscopy is usually repeated every one to two years to monitor for enlargement of the varices. If large varices are detected, a medication is given to reduce the risk of bleeding (see 'Beta blockers' below) the endoscopy does not usually need to be repeated. The timing of repeat endoscopy depends upon the appearance of the varices, the cause of the liver disease, and the person's overall health.

Capsule endoscopy — A less commonly used alternative to upper endoscopy involves swallowing a capsule that contains a tiny camera. The patient swallows the capsule while lying on the right side, and then drinks sips of water every 30 seconds. The capsule transmits photographs of the lining of the esophagus and stomach to a recording device worn outside the body. A clinician then reviews the photographs to determine if there are any abnormalities. Capsule endoscopy is more expensive than traditional endoscopy, and it is not available at all centers.

Determining the risk of bleeding from esophageal varices — A person's risk of bleeding from varices depends upon a number of factors, including the size, shape, location, and appearance of the varices, as well as the severity of the person's liver disease and previous history of bleeding from varices. A treatment to reduce the risk of bleeding is recommended in selected patients with esophageal varices.

TREATMENTS TO PREVENT BLEEDING FROM ESOPHAGEAL VARICES — If varices are detected, one or more treatments are usually recommended to reduce the risk of bleeding. The risk of the treatment must be weighed against the benefit for each patient. For example, beta blockers may decrease survival in patients who have refractory ascites (fluid in the abdomen that does not respond to standard treatment). Beta blockers may also make ascites more difficult to treat.

Avoid alcohol — One of the most important ways to reduce the risk of bleeding from varices is to stop drinking alcohol. Alcohol can worsen cirrhosis, increase the risk of bleeding, and significantly increase the risk of dying. It can be extremely difficult to stop drinking alcohol, especially for people who have been drinking heavily for many years. Talk to a health care provider about treatment and support programs for alcohol use disorder. Baclofen is a drug that has been shown to reduce craving for alcohol in patients with cirrhosis. Patients who are able to stop drinking can have dramatic improvement in symptoms related to cirrhosis.

Weight loss — Many people with cirrhosis have fatty liver disease due to obesity. Obesity may be the sole cause of liver damage, or may be a contributing factor. Losing weight can remove fat from the liver and may reduce further injury. Treatments to assist with weight loss are discussed separately. (See "Patient education: Losing weight (Beyond the Basics)" and "Patient education: Weight loss surgery and procedures (Beyond the Basics)".)

Beta blockers — Beta blockers, which are traditionally used to treat high blood pressure, are the most commonly recommended medication to prevent bleeding from varices. Beta blockers decrease pressure inside of the varices, which can reduce the risk of bleeding by 45 to 50 percent [1]. There are several forms of beta blockers. The two most commonly used beta blockers for prevention of bleeding are propranolol (sample brand name: Inderal) and nadolol (brand name: Corgard). The dose of the medication is usually adjusted based upon the person's blood pressure and heart rate. It is important to take the medication every day exactly as directed. The medication may be stopped if the blood pressure gets too low, such as a systolic pressure (top number) decreasing to less than 100 or the mean arterial pressure decreasing to 82 or lower. The mean arterial pressure can be calculated by using the systolic pressure (top number) and the diastolic pressure (bottom number). A published document states that mean arterial pressure can be pushed lower than this threshold, but there is no evidence to support this statement. Blood pressure readings that are taken at home are more helpful to physicians than a single blood pressure recorded during an office visit. Patients can ask their doctors for a prescription for a blood pressure cuff.

Importantly, other types of beta blockers (eg, labetalol, atenolol, metoprolol) may not be effective in reducing the risk of bleeding.

Side effects of beta blockers — The most common side effects of beta blockers are slower pulse rate, lower blood pressure, fatigue, and dizziness. Monitoring pulse rate and blood pressure at home and bringing that information to clinic can help your doctor adjust your beta blocker dose. Beta blockers can also cause insomnia, a decreased ability to exercise, a slow heart rate, erectile dysfunction, and cold hands and feet. The beta blockers used for cirrhosis can worsen symptoms of asthma, other lung diseases, or blood vessel disease (such as peripheral vascular disease). As a result, they normally are not prescribed for people with these conditions. Side effects should be discussed with a health care provider before stopping the medication.

As noted above, beta blockers may decrease survival in patients who have refractory ascites (fluid in the abdomen that does not respond to standard treatment). Beta blockers may also make ascites more difficult to treat. Beta blockers can worsen kidney function and aggravate or trigger the confusion often associated with cirrhosis.

Variceal band ligation — Variceal band ligation is a procedure that is done during endoscopy. A physician places small rubber bands around varices to prevent them from bleeding. Endoscopy is usually repeated approximately every two weeks after the bands are placed to determine if additional bands are needed. Medications to reduce stomach acid, known as proton pump inhibitors (eg, omeprazole, lansoprazole, pantoprazole, esomeprazole, dexlansoprazole) are taken twice daily after banding to help speed healing of the erosions/ulcers that develop when the band falls off of the shrinking varix.

Variceal band ligation is usually performed in people who have bled from varices. However, it can also be performed to prevent bleeding, especially in people whose varices are large and/or have other features that increase the risk of bleeding. It may also be performed in people who cannot tolerate beta blockers.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Esophageal varices (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Cirrhosis (Beyond the Basics)
Patient education: Upper endoscopy (Beyond the Basics)
Patient education: Losing weight (Beyond the Basics)
Patient education: Weight loss surgery and procedures (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Endoscopic variceal ligation
Overview of the management of patients with variceal bleeding
Pathogenesis of variceal bleeding in patients with cirrhosis
Prevention of recurrent bleeding from esophageal varices in patients with cirrhosis
Primary prevention of bleeding from esophageal varices in patients with cirrhosis
Overview of transjugular intrahepatic portosystemic shunts (TIPS)
Methods to achieve hemostasis in patients with acute variceal hemorrhage

The following organizations also provide reliable health information.

●National Library of Medicine

     (www.nlm.nih.gov/medlineplus/ency/article/000268.htm, available in Spanish)

●National Institute of Diabetes and Digestive and Kidney Diseases

     (https://www.niddk.nih.gov/health-information/digestive-diseases)

●The American Liver Foundation

     (www.liverfoundation.org)

●Information about alcohol use disorder from the National Library of Medicine

     (www.nlm.nih.gov/medlineplus/alcoholism.html)