Definition

Esophageal and gastric varices are enlarged venous structures that primarily form in the esophagus and the upper part of the stomach. This condition typically occurs in patients with severe liver disease and is a consequence of increased pressure in the portal venous system.

Pathogenesis

The main cause of esophageal and gastric varices is portal hypertension, which usually results from chronic liver disease, such as cirrhosis. Elevated pressure in the venous system leads to the formation of varices in the esophagus and stomach as a compensatory mechanism for decompression.

Diagnosis

The diagnosis of esophageal and gastric varices is typically made through endoscopy, which allows for direct visual examination of the varices. Additionally, imaging techniques such as liver ultrasound and Doppler ultrasound can be used to assess portal hypertension.

Treatment

Treatment for esophageal and gastric varices primarily focuses on reducing venous pressure and preventing bleeding. This may include:

  • Pharmacological treatment: Beta-blockers to lower venous pressure.
  • Endoscopic techniques: Variceal band ligation to prevent bleeding.
  • Advanced interventions: In severe cases, surgical techniques or the placement of a transjugular intrahepatic portosystemic shunt (TIPS) in the portal vein may be required.

Continuous monitoring and management of the underlying liver disease are also critical for effective treatment and prevention of complications.

Why varices matter

Varices themselves cause no symptoms. Their significance lies entirely in the risk of bleeding, which is one of the most serious complications of cirrhosis. The larger the varix and the higher the portal pressure, the greater the risk.

Who needs screening, and who does not

Not every patient with cirrhosis requires endoscopy. Under the Baveno VII consensus, patients with compensated advanced chronic liver disease who have a liver stiffness below 20 kPa and a platelet count above 150,000 have a very low probability of varices needing treatment, and screening endoscopy can be safely avoided. They are followed with annual measurements instead.

Patients outside those criteria undergo upper endoscopy, which grades the varices and identifies high-risk stigmata.

Prevention of first bleeding

Two approaches are established. Non-selective beta blockers, with carvedilol now preferred because it reduces the risk of decompensation and not only of bleeding, and endoscopic band ligation for patients who cannot tolerate or should not receive beta blockers.

Acute variceal bleeding

This is a medical emergency. Management combines restrictive transfusion, vasoactive drugs, antibiotic prophylaxis, which independently improves survival, and endoscopy within the first hours with band ligation. In selected high-risk patients, early placement of a transjugular intrahepatic portosystemic shunt (TIPS) improves outcomes.

After bleeding

Recurrence risk is high without secondary prophylaxis. The standard is the combination of a non-selective beta blocker and repeated band ligation until the varices are eradicated, followed by surveillance endoscopy.

Key figures: Endoscopy can be omitted when liver stiffness is below 20 kPa with platelets above 150,000. In acute bleeding, endoscopy is performed within the first 12 hours, alongside vasoactive drugs and antibiotic prophylaxis.

Varices develop as a consequence of portal hypertension in cirrhosis. They are identified at gastroscopy.

Frequently asked questions

Do all patients with cirrhosis need an endoscopy?

No. Under the Baveno VII criteria, patients with compensated advanced chronic liver disease whose liver stiffness is below 20 kPa and whose platelet count exceeds 150,000 have a very low probability of varices requiring treatment, and screening endoscopy can be avoided. They are monitored with annual liver stiffness and platelet measurements instead.

Which beta blocker is preferred?

Carvedilol is now favoured over traditional non-selective beta blockers, because it has been shown to reduce the risk of hepatic decompensation and not only the risk of bleeding. The choice and dose are individualised, taking blood pressure and tolerance into account.

Can varices be cured?

The varices themselves can be eradicated with repeated band ligation, but they tend to recur while portal hypertension persists. This is why surveillance endoscopy continues after eradication and why treatment of the underlying liver disease remains the priority.

Sources


Content last updated: September 2026 (14/09/2026).