Esophageal Varices

Aka: Esophageal Varices, Variceal Bleeding, Bleeding Esophageal Varices, Variceal Hemorrhage

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II. Epidemiology

  1. Incidence: 30-70% of Cirrhosis cases
  2. Bleeding occurs within first year of Esophageal Varices diagnosis in 30% of cases

III. Pathophysiology

  1. See Portal Hypertension
  2. Complication of Cirrhosis (and Portal Hypertension)
    1. Typically involves distal 2-5 cm of Esophagus
    2. Correlated with severity of disease

IV. Evaluation: Screening Protocol

  1. Initial: Endoscopy for all patients with Cirrhosis
  2. Repeat screening
    1. No Varices: Repeat every 3 years
    2. Small Varices: Yearly
    3. Large Varices: Per endoscopist discretion

V. Management: Acute Variceal Bleeding Medical Management

  1. See Gastrointestinal Bleeding Management
  2. Notify GI or surgery on presentation, to ready for emergent endoscopy
  3. See Upper GI Bleed
    1. Proton Pump Inhibitors are not recommended for Variceal Bleeding
  4. ABC Management
    1. Consider Endotracheal Intubation to prevent blood aspiration
  5. Replace blood and Coagulation Factors as needed
    1. Consider Tranexamic Acid (TXA)
    2. Packed Red Blood Cell (pRBC) Transfusion Indications
      1. Restrictive transfusion strategy is preferred (keeping Hemoglobin >7 g/dl) at tertiary centers
      2. However, remote hospitals should initiate blood pruducts per local discretion
      3. Target mean arterial pressure (MAP) >65 mmHg
    3. Massive Transfusion Protocol
      1. Indicated if 3 or more units of pRBC are required within an hour
    4. Platelet Trasfusion Indications
      1. Platelet Count <50,000/uL
      2. Massive Transfusion Protocol
    5. Other Blood components to consider
      1. Fresh Frozen Plasma
      2. Prothrombin Complex Concentrate (PCC4)
      3. Factor 7 (also in PCC4)
      4. Vitamin K
  6. Upper Endoscopy emergently (within 12 hours)
    1. See below under invasive management
  7. Vasoactive agents
    1. Continue for 3 to 5 days
    2. Do not decrease mortality or re-bleeding risk
      1. Gotzsche (2008) Cochrane Database Syst Rev (3): CD000193 [PubMed]
    3. Octreotide or Sandostatin (preferred)
      1. Decreases splanchnic Blood Flow (slows Variceal Bleeding)
      2. Dose: 50-100 mcg IV bolus, then 50 mcg/hour
      3. Long-acting Somatostatin analog
      4. Preferred vasoactive agent in Upper GI Bleed
        1. Avgerinos (1995) J Hepatol 22(2):247-8 [PubMed]
    4. Intravenous Vasopressin
      1. Vasopressin 0.3 to 0,.4 units/min
      2. If not hypotensive, consider with Nitroglycerin (Risk of coronary ischemia)
      3. Stop for cerebral, cardiac, intestinal or extremity ischemia
  8. Non-selective Beta Blocker
    1. Examples: Propranolol, Nadalol, Timolol
    2. Start when stable and continue indefinitely (see dosing below under prevention)
    3. Titration of dose endpoint
      1. Heart Rate at 25% reduction from baseline or
      2. Heart Rate 55 beats per minute or
      3. Adverse Beta Blocker related symptoms
  9. Prophylactic Antibiotics (per AASLD)
    1. Reduces rebleeding, Spontaneous Bacterial Peritonitis (SBP), and mortality rates
    2. Higher infection risk in Child-Pugh Class B-C, longterm Proton Pump Inhibitor, SBP Prophylaxis
    3. Start at bleeding presentation and continue for up to 5-7 days
    4. First-Line Antibiotic options
      1. Norfloxacin 400 mg orally twice daily OR
      2. Ciprofloxacin 400 mg IV (or 500 mg orally twice daily) every 8 to 12 hours
    5. Alternative Antibiotic options
      1. Ceftriaxone 2 gram IV every 24 hours (or other third generation cephaloporin)
    6. References
      1. Moon (2016) Clin Gastroenterol Hepatol 14:1629-37 +PMID:27311621 [PubMed]
      2. O'Leary (2015) Clin Gastroenterol Hepatol 13:753-9 +PMID:25130937 [PubMed]
  10. Balloon tamponade
    1. See Esophageal Balloon Tamponade (Sengstaken-Blakemore Tube, Linton Tube)
    2. Tamponade Varices in refractory cases (60-90% effective)
      1. Esophageal Varices
      2. Gastric fundus Varices
    3. Rebleeding occurs in up to 50% of cases
      1. More definitive therapy needed after bleeding stops
    4. High complication rate (15%)
      1. Perforation
      2. Aspiration
      3. Pressure-induced ulceration
    5. Balloon types
      1. Sengstaken-Blakemore Tube
      2. Linton-Nachlas tube
      3. Minnesota tube

VI. Management: Acute Variceal Bleeding Invasive Management

  1. Endoscopic ligation or banding (preferred, first-line measure)
    1. Recommended within 12 hours of onset
    2. Erythromycin recommended before procedure
    3. Ligation is superior to sclerotherapy
      1. Laine (1995) Ann Intern Med 123(4): 280-7 [PubMed]
    4. Successful banding
      1. Repeat endoscopy at 3 and 6 months and annually
      2. Banding may be repeated at repeat endoscopy
    5. Unsuccessful banding (continued bleeding)
      1. Balloon Tamponade (see above) and
      2. TIPS and other interventions as below
  2. Transjugular intrahepatic Portosystemic Shunt (TIPS)
    1. Shunt from hepatic vein to intrahepatic Portal Vein to lower portal pressure
    2. Commonly effective measure in Variceal Bleeding
    3. Preventive of future rebleeding events
  3. Emergency Surgical portacaval shunts
    1. Rarely effective and high mortality rate

VII. Management: Primary Prevention of Variceal Bleeding

  1. See Portal Hypertension
  2. Indications
    1. Hepatic Vein Pressure Gradient (HPVG) >5 mmHg
    2. Endoscopic criteria
      1. Large Esophageal Varices
      2. Small Esophageal Varices
        1. High Child-Pugh Score
        2. Varices with red wale markings
  3. Contraindications
    1. Do not use non-selective Beta Blockers during acute bleeding episodes (until stable)
  4. Efficacy
    1. Reduce risk of bleeding from 45% to 22%
    2. Do not reduce overall mortality from Esophageal Varices
  5. Mechanism
    1. Reduce portal pressure gradient
    2. Reduce azygous Blood Flow and variceal pressure
  6. Agents (target Heart Rate reduction 20 to 25%)
    1. Goal: Reduce HPVG by 20% or <12 mmHg
    2. Propranolol (preferred first line agent)
      1. Start at 10 mg orally three times daily
      2. Minimum effective dose: 40 mg orally twice daily
      3. Titrate to 80 mg orally twice daily if needed
    3. Nadolol 20 mg orally daily
    4. Isosorbide Mononitrate (alternative)
      1. Use if Propranolol contraindicated
      2. Dose: 20 mg orally twice daily
  7. Surgery: Esophageal banding (Variceal band ligation)
    1. As effective as Propranolol in bleeding prevention
    2. Fewer adverse effects than medication management
    3. Lui (2002) Gastroenterology 123:735-44 [PubMed]

VIII. Prevention: Secondary prevention (prior episode of bleeding)

  1. Isosorbide Mononitrate 20 mg PO bid
  2. Esophageal banding (Variceal band ligation)
  3. Sclerotherapy to Varices (variable efficacy)
  4. Transjugular intrahepatic Portosystemic Shunt (TIPS)
  5. LeVeen Shunt (not recommended due to high mortality)
  6. Liver Transplant

IX. Prognosis

  1. Predictors of mortality with Variceal Bleeding
    1. Active bleeding during endoscopy
    2. Encephalopathy
    3. Ascites
    4. Serum Bilirubin increased
    5. Aspartate Aminotransferase increased
    6. Prothrombin Time increased
    7. Graham (1981) Gastroenterology 80:800-9 [PubMed]
  2. Rebleeding Events after initial bleeding episode
    1. Highest risk in first 72 hours
    2. Rebleeding risk is 50% in first 10 days
    3. Risks for re-bleeding
      1. Age over 60 years
      2. Renal Failure
      3. Large Esophageal Varices
      4. Severe initial bleeding with Hemoglobin < 8 g/dl
  3. Overall Risk of esophageal varice bleeding: 10-30%/year
  4. Risk of bleeding from large Varices: 40 to 45% per year
    1. Higher risk with Varices with red wale markings
    2. Higher risk with advanced Child-Pugh Score
  5. Risk of death from each bleeding episode
    1. In hospital event: 15%
    2. Out of hospital event: Approaches 50%

X. References

  1. Spangler, Swadron, Mason and Herbert (2016) EM:Rap C3, p. 1-11
  2. Swaminathan and Weingart in Herbert (2020) EM:Rap 20(6):8-10
  3. Swencki (2015) Crit Dec Emerg Med 29(11):2-10
  4. Hegab (2001) Postgrad Med 109(2):75-89 [PubMed]
  5. Keating (2022) Am Fam Physician 105(4): 412-20 [PubMed]
  6. Villaneuva (1996) 334:1624-9 [PubMed]
  7. De Franchis (2004) Gastroenterology 126:1860-7 [PubMed]

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Related Studies

Ontology: Esophageal Varices (C0014867)

Definition (NCI) Abnormally dilated vein(s) of the esophagus.
Definition (CSP) longitudinal venous varices at the lower end of the esophagus as a result of portal hypertension; they are superficial and liable to ulceration and massive bleeding.
Concepts Disease or Syndrome (T047) , Acquired Abnormality (T020)
MSH D004932
ICD10 I85 , I85.0, I85.00
SnomedCT 195483009, 312980002, 195473005, 155479001, 28670008
English Esophageal Varix, Varices, Esophageal, Varix, Esophageal, ESOPHAGEAL VARICES, OESOPHAGEAL VARICES, Esophageal Varicies, Esophageal varices NOS, esophageal varices (diagnosis), esophageal varices, Oesophageal varices NOS, Varices esophageal, Varices;oesophageal, Varicose veins;oesophagus, varices esophageal, esophageal varice, esophageal varix, esophagus varicose veins, varicose veins esophagus, varix esophagus, Oesophageal varices NOS (disorder), Esophageal varices NOS (disorder), Oesophageal varices (disorder), Varices oesophageal, Esophageal varices, Esophageal varix, Oesophageal varices, Oesophageal varix, OV - Esophageal varices, OV - Oesophageal varices, Esophageal varices (disorder), esophagus; varices, varices; esophagus, Esophageal varices, NOS, Oesophageal varices, NOS, Esophageal Varices, oesophageal varices, Varices;esophageal, Varicose veins;esophagus, varicose veins on the esophagus, varicose veins on the oesophagus
Portuguese VARIZES ESOFAGICAS, Varizes esofágicas NE, Varizes Esofágicas, Varizes do esófago, Varizes esofágicas
Spanish VARICES ESOFAGICAS, Varices esofágicas NEOM, Varices Esofágicas, várices esofágicas, SAI, várices esofágicas, SAI (trastorno), Oesophageal varices NOS, Esophageal varices NOS, várices esofágicas (trastorno), várices esofágicas, Varices esofágicas y complicaciones, Varices esofágicas
Italian Varici dell'esofago, Varici esofagee non specificate, Varici esofagee
Dutch oesofagusspataderen NAO, oesofagusspataderen, spataderen oesofagus, oesofagus; varices, varices; oesofagus, slokdarmspataderen, varices in de slokdarm, Slokdarmvarices, Slokdarmvarix
French Varices de l'oesophage, Varices - oesophage, Varices oesophagiennes SAI, Varices oesophagiennes, VARICES OESOPHAGIENNES, Varice oesophagienne, Varice de l'oesophage
German Oesophagusvarizen NNB, Ösophagusvarizen, OESOPHAGUSVARIZEN, Oesophagusvarizen, Erweiterungen der Oesophagusvenen, Varizen, Ösophagus-
Japanese 食道静脈瘤, 食道静脈瘤ＮＯＳ, ｼｮｸﾄﾞｳｼﾞｮｳﾐｬｸﾘｭｳ, ｼｮｸﾄﾞｳｼﾞｮｳﾐｬｸﾘｭｳNOS
Czech Jícnové varixy NOS, Jícnové varixy, Varixy jícnu, jícnové varixy, městky jícnu, ezofageální varixy
Korean 식도정맥류
Hungarian Ooesophagealis varixok, Oesophagus varixok k.m.n., Oesophagus visszértágulatok, Oesophagus varixok, Oesophagealis varixok
Norwegian Varicer i spiserøret, Øsofagusvaricer, Åreknuter i spiserøret
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Bleeding esophageal varices (C0155789)

Definition (NCI_CTCAE) A disorder characterized by bleeding from esophageal varices.
Definition (NCI) Bleeding from esophageal varices.
Concepts Disease or Syndrome (T047)
ICD9 456.0
ICD10 I85.0 , I85.01
SnomedCT 236067006, 17709002
English Esophageal varices + bleeding, Oesophageal varices + bleeding, BOV - Bleeding oesoph varices, Bleeding esophageal varices, esophageal varices with hemorrhage (diagnosis), bleeding esophageal varix, esophageal varices with hemorrhage, Esophageal varices hemorrhage, Oesophageal varices haemorrhage, Esophageal Varices Hemorrhage, Esophag varices w bleed, esophageal varices bleeding, esophageal varix bleeding, esophageal varices hemorrhage, bleeding esophageal varice, bleeding esophageal varices, haemorrhage oesophageal varices, Bleeding oesophageal varices (disorder), Esophageal varices ruptured, Oesophageal varices ruptured, Esophageal varices with bleeding, Oesophageal varices with bleeding, Bleeding oesophageal varices, Esophageal varices with hemorrhage, Oesophageal varices with haemorrhage, BOV - Bleeding esophageal varices, BOV - Bleeding oesophageal varices, Bleeding esophageal varices (disorder), esophagus; hemorrhage, varix, esophagus; varix, hemorrhage, hemorrhage; esophagus, varix, varices; esophagus, bleeding
Italian Emorragia di varici esofagee, Varici esofagee con sanguinamento, Sanguinamento di varici esofagee, Rottura di varici esofagee
Dutch oesofagusspataderen met bloeding, bloeding van slokdarmvarices, slokdarmvarices geruptureerd, oesofagusspataderenhemorragie, bloedingoesofagusspataderen, slokdarmspataderen met bloeding, bloeding; oesofagus, varix, oesofagus; bloeding, varix, oesofagus; varix, bloeding, varices; oesofagus, bloedend, Slokdarmvarices met bloeding, oesofagusspataderenbloeding
French Varices oesophagiennes hémorragiques, Rupture de varices oesophagiennes, Varices oesophagiennes avec saignement, Saignement de varices oesophagiennes, Hémorragie de varices oesophagiennes
German Ruptur einer Oesophagusvarize, blutende Oesophagusvarizen, Oesophagusvarizen rupturiert, Oesophagusvarizen mit Blutung
Portuguese Varizes esofágicas com hemorragia, Varizes esofágicas hemorrágicas, Varizes esofágicas com ruptura, Varizes espfágicas hemorrágicas, Hemorragia de varizes esofágicas
Spanish Varices esofágicas con sangrado, Hemorragia por varices esofágicas, Sangrado de varices de esófago, Varices esofágicas sangrantes, Rotura de varices esofágicas, varices esofágicas con hemorragia, várices esofágicas sangrantes (trastorno), várices esofágicas sangrantes, Hemorragia de varices esofágicas
Japanese 食道静脈瘤出血, 食道静脈瘤、出血を伴うもの, 食道静脈瘤破裂, ｼｮｸﾄﾞｳｼﾞｮｳﾐｬｸﾘｭｳｼｭｯｹﾂ, ｼｮｸﾄﾞｳｼﾞｮｳﾐｬｸﾘｭｳﾊﾚﾂ, ｼｮｸﾄﾞｳｼﾞｮｳﾐｬｸﾘｭｳｼｭｯｹﾂｦﾄﾓﾅｳﾓﾉ
Czech Jícnové varixy s krvácením, Krvácní z jícnových varixů, Jícnové varixy krvácející, Ruptura jícnových varixů, Krvácející jícnové varixy
Korean 출혈이 있는 식도정맥류
Hungarian Rupturált oesophagus varixok, Vérző oesophagus varixok, Vérző oesophagus varix, Oesophagus varixok vérzése, Vérző nyelőcső varixok, Nyelőcső eredetű visszértágulatok vérzése, Oesophagus visszértágulat vérzése, Rupturált nyelőcső varixok
Derived from the NIH UMLS (Unified Medical Language System)

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