Oesophageal Varices

Abnormal, enlarged veins in the oesophagus

Aetiology

Portal Hypertension (Primary Cause)

Cause	Mechanism
Liver cirrhosis (most common)	Increased intrahepatic resistance
Portal vein thrombosis	Prehepatic obstruction
Budd–Chiari syndrome	Posthepatic obstruction
Schistosomiasis	Presinusoidal portal hypertension

Other (Less Common)

Non-cirrhotic portal fibrosis

Congenital hepatic fibrosis

Pathophysiology

Chronic liver disease → increased portal venous pressure

Formation of portosystemic collateral circulation

Dilatation of submucosal veins in distal esophagus

Thin-walled vessels exposed to trauma and pressure

Rupture → acute upper GI bleeding

Clinically significant portal hypertension:

Hepatic venous pressure gradient (HVPG) ≥10 mmHg
Bleeding risk increases when HVPG ≥12 mmHg.

Clinical presentation

Asymptomatic

Most patients until bleeding occurs

Acute Variceal Bleeding (Medical Emergency)

Hematemesis

Melena

Hematochezia (massive bleed)

Hypovolemic shock

Associated Signs of Chronic Liver Disease

Jaundice

Ascites

Splenomegaly

Spider angiomas

Hepatic encephalopathy

Classification

By Size (Endoscopic)

Grade	Description
Small	Minimally elevated veins
Medium	Tortuous veins occupying <⅓ lumen
Large	Occupying >⅓ of lumen

High-Risk Stigmata (Endoscopic)

Red wale markings

Cherry red spots

Hematocystic spots

Investigations

Endoscopy

Management

Hemodynamic Stabilization

Crystalloid resuscitation

Restrictive transfusion strategy

Transfuse if Hb <7 g/dL → Target Hb 7–8 g/dL

Avoid over-transfusion (↑ portal pressure)

Primary Prophylaxis

Indications

Medium/large varices

Small varices with red wale signs

Decompensated cirrhosis

Options

Non-selective beta blockers (NSBBs)

NSBBs reduce portal pressure by ↓ cardiac output and splanchnic vasoconstriction.

🚫 Do NOT start NSBBs during active bleeding or shock.

Drug	Starting Dose	Titration	Target	Notes
Propranolol	20 mg twice daily	Increase every 2–3 days	HR 55–60 bpm	Combine with EVL
Nadolol	20–40 mg once daily	Titrate as above	HR 55–60 bpm	Longer half-life
Carvedilol	6.25 mg once daily	Up to 12.5 mg/day	Tolerability	More BP lowering

Endoscopic variceal ligation (EVL)

Acute Variceal Bleeding (Rupture)

Resuscitation - maintain pulse and blood pressure, antibiotics

Drug	Dose	Route	Duration	Indication
Ceftriaxone	1 g 1x1	IV	5–7 days	First-line (advanced cirrhosis, high resistance)
Norfloxacin	400 mg 2x1	PO	5–7 days	Alternative if low resistance & stable
Ciprofloxacin	400 mg 2x1	IV	5–7 days	If ceftriaxone contraindicated

Vasoactive Agents

Drug	Loading Dose	Maintenance Dose	Duration	Key Notes
Terlipressin	2 mg IV bolus	1 mg IV every 4–6 h	2–5 days	↓ portal pressure; improves survival
Octreotide	50 µg IV bolus	50 µg/h IV infusion	2–5 days	Widely available; fewer ischemic effects
Somatostatin	250 µg IV bolus	250 µg/h IV infusion	2–5 days	Alternative to octreotide

Endoscopic variceal ligation (EVL)

Rescue / Bridge Therapy (If Uncontrolled Bleeding)

Therapy	Dose / Use	Duration	Notes
Balloon tamponade	As per device protocol	≤24 h	Temporary bridge to TIPS
TIPS	—	Definitive	For refractory bleeding or early TIPS candidates

Secondary prophylaxis

β- blockers