Patient education: Esophageal varices (Beyond the Basics)

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 steatotic (fatty) liver (due mostly to obesity), alcohol use disorder, and chronic hepatitis B or C virus infection. Some people have more than one cause of injury to the liver.

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

WHAT ARE 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 VARICES — 

Esophageal or gastric varices are a potentially serious complication of cirrhosis. Without treatment, varices may rupture and cause severe bleeding (hemorrhage) resulting in significant illness or even death. Some 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 and bleed. Signs of bleeding from varices can include vomiting blood or material that looks like coffee grounds, passing 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.

People with cirrhosis who are at risk for having varices usually undergo a screening test to determine if varices are present. If varices are discovered, strategies to prevent bleeding may be recommended.

HOW ARE VARICES DETECTED?

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 esophageal varices are detected, experts usually recommend repeating the upper endoscopy in one to three years.  

If large varices are detected, a medication is prescribed to reduce the risk of bleeding (see 'Beta blockers' below), and the endoscopy does not usually need to be repeated.

If small esophageal varices are detected, although the risk of bleeding is much lower than with large varices, medication is frequently recommended because it may prevent the development of other complications of portal hypertension. (See "Patient education: Fluid in the belly from cirrhosis (ascites) (The Basics)".)  

The timing of repeat endoscopy depends upon the appearance of the varices, the cause of the liver disease, and the person's overall health.

Other tests — Although other screening methods have been studied, alternatives to upper endoscopy are not routinely used because they are less accurate.

Determining the risk of bleeding from varices — A person's risk of bleeding from varices depends upon a number of factors, including the size, shape, and appearance of the varices, as well as the severity of the person's liver disease and previous history of bleeding from varices. (See 'Strategies to prevent bleeding from varices' below.)

STRATEGIES TO PREVENT BLEEDING FROM VARICES

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. Patients who are able to stop drinking can have dramatic improvement in symptoms related to cirrhosis.

Avoid NSAIDs — Nonsteroidal antiinflammatory drugs, or "NSAIDs," include aspirin, ibuprofen (sample brand names: Advil, Motrin), and naproxen (sample brand names: Aleve, Naprosyn). These drugs do not cause variceal bleeding but may cause upper gastrointestinal (GI) bleeding in people with portal hypertension.  

Weight loss/control of associated conditions — Many people with cirrhosis have steatotic 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)".)

In addition, patients with steatotic liver disease frequently have coexisting conditions such as diabetes mellitus, high cholesterol levels, or hypertension. Managing these conditions usually improves liver disease.

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 the varices, which can reduce the risk of bleeding. There are several forms of beta blockers. Commonly used beta blockers for prevention of bleeding include propranolol (sample brand name: Inderal), nadolol (brand name: Corgard), and carvedilol (brand name: Coreg). The dose of the medication is usually adjusted based on 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). 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 sharing it with your health care provider can help your doctor adjust your beta blocker dose. Beta blockers can also cause other side effects such as insomnia, a decreased ability to exercise, and a slow heart rate. 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.

Variceal band ligation — Variceal band ligation is a procedure that is done during endoscopy. A physician places small rubber bands around esophageal varices to prevent them from bleeding or stop active bleeding. Endoscopy is usually repeated in several weeks after the bands are placed to determine if additional bands are needed.

Variceal band ligation is usually performed in people who have bled from esophageal 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 and 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)