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Gastroenterology & Nutrition

Oesophageal Varices

Oesophageal varices are portosystemic collaterals, usually caused by cirrhosis, that can rupture and cause life-threatening upper gastrointestinal haemorrhage; suspected variceal bleeding needs simultaneous resuscitation, vasoactive treatment, antibiotics and urgent endoscopic control.

In a nutshell

Oesophageal varices are portosystemic collaterals, usually from cirrhosis, that can rupture and cause life-threatening upper gastrointestinal bleeding. Suspected variceal bleeding needs resuscitation, prompt terlipressin, prophylactic IV antibiotics and urgent endoscopy with EVL; refractory bleeding needs expert bridge therapy and TIPS assessment. Secondary prophylaxis is a non-selective beta-blocker plus repeated EVL.

Classic presentation

A person with cirrhosis presents with fresh haematemesis or melaena, tachycardia or shock, and possibly ascites, jaundice or encephalopathy.

Key points

  • Suspected variceal bleeding is an emergency: resuscitate, involve senior hepatology/critical-care support and prepare blood products without unnecessary over-transfusion.
  • Start terlipressin at presentation and give prophylactic IV antibiotics to a person with cirrhosis and upper gastrointestinal bleeding; follow the current BNF and local protocol for prescribing details.
  • Perform endoscopy immediately after resuscitation if unstable and within 24 hours otherwise; EVL is the usual treatment for bleeding oesophageal varices.
  • Persistent bleeding requires expert bridge therapy and urgent TIPS assessment; a bridge is temporary, not definitive.
  • Prevent rebleeding with a non-selective beta-blocker plus repeat EVL after recovery, unless contraindicated or not tolerated.
  • Do not use a PPI solely because varices are present, and do not apply oesophageal-varix treatment to gastric varices without specialist advice.

First-line investigation

Urgent upper gastrointestinal endoscopy after resuscitation: it confirms the source and allows EVL.

Management

Resuscitate and start variceal-bleed treatment

  • Use ABCDE, senior help, airway and aspiration assessment, large-bore access, urgent bloods, crossmatch and continuous monitoring; use a major-haemorrhage pathway when indicated and avoid unnecessary over-transfusion.3,1
  • Start terlipressin and prophylactic intravenous antibiotics as soon as variceal bleeding is suspected; use current BNF and local protocol details and do not wait for endoscopy.3,4,6

Confirm the source and achieve endoscopic haemostasis

  • Arrange endoscopy immediately after resuscitation for unstable severe bleeding and within 24 hours otherwise; use EVL for bleeding oesophageal varices and a separate specialist pathway for gastric varices.3,5

Bridge and decompress when bleeding is uncontrolled

  • Use balloon tamponade or a specialist oesophageal stent only as a temporary bridge in an expert setting, and arrange urgent rescue or selected pre-emptive TIPS assessment through the specialist pathway.5,1

Prevent rebleeding and manage cirrhosis

  • After recovery, use a non-selective beta-blocker plus repeated EVL until eradication when tolerated, arrange hepatology follow-up and give urgent-return advice for recurrent bleeding or decompensation.5,1,4,2

Exam traps

  • Not every upper gastrointestinal bleed in cirrhosis is variceal; endoscopy is still required.
  • Do not wait for endoscopy or a positive culture before starting terlipressin and antibiotics when variceal bleeding is suspected.
  • Balloon tamponade or a specialist stent is only a temporary bridge to definitive treatment.
  • INR is not a standalone measure of bleeding risk in cirrhosis; follow the clinical situation and specialist transfusion protocol.
  • Gastric varices require a different endoscopic or radiological pathway.

Illustrations

Oesophageal varices with red wale signsEndoscopic view of raised serpiginous oesophageal varices with prominent red wale markings, labelled as endoscopic features associated with increased bleeding risk.Samir, Wikimedia Commons · Public domain

Key sources

  1. BSG/AASLD position statement on cirrhosis and portal hypertension (Current BSG position statement: interim UK use of AASLD guidance with caveats)
  2. Cambridge University Hospitals: Screening for varices (Patient information approved 13 March 2025)Published 13 Mar 2025
  3. NICE CG141: Acute upper gastrointestinal bleeding in over 16s: management (CG141 recommendations)Published 13 Jun 2012
  4. NICE NG50: Cirrhosis in over 16s: assessment and management (NG50 recommendations, including upper gastrointestinal bleeding and variceal assessment)Published 6 Jul 2016
  5. BSG: UK guidelines on the management of variceal haemorrhage in cirrhotic patients (Gut 2015;64:1680–1704)Published 1 Nov 2015
  6. BNF: Terlipressin (Current prescribing monograph)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.