oesophageal varices

Last edited 08/2021 and last reviewed 12/2021

Oesophageal varices are varicosities of branches of the azygos vein which anastomose with tributaries of the portal vein in the lower oesophagus, due to portal hypertension in conditions such as cirrhosis of the liver

Prevalence of oesophageal varices varies between 40% and 95% in people with cirrhosis

• annual incidence of oesophageal varices in people with cirrhosis varies from 3% to 22%
• is more likelihood of bleeding with increasing size of the varicosities

Gastroesophageal varices (gastric varices) are present in 50% of cirrhotics, and approximately 25% of patients with portal hypertension have gastric varices

• commonly classified as GOVs (gastric varices in continuity with esophageal varices) and isolated gastric varices (IGVs)
  • further divided into GOV1 (GOVs along the lesser curve of the stomach), GOV2 (GOVs along the fundus), IGV1 (IGVs in the fundus), and IGV2 (IGVs in the gastric body, pylorus, or antrum)
  • although the prevalence and risk of bleeding of gastric varices are lower than those of esophageal varices, gastric variceal bleeding tends to be more severe, requires more transfusions, and is associated with higher mortality (approx 45%)
  • gastric varices tend to be larger and more tortuous compared with oesophageal varices, characteristics that, combined with their anatomical location (particularly fundic varices), make endoscopic management more challenging

A systematic review concluded (4):

• beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates may decrease the death rate compared to no treatment in people with high-risk oesophageal varices in people with cirrhosis and no history of bleeding
• variceal band ligation may result in a higher number of serious side effects than beta-blockers
• evidence indicates considerable uncertainty about the effect of beta-blockers versus variceal band ligation on variceal bleeding

Reference:

• Herman J, Baram M. Blood and volume resuscitation for variceal hemorrhage. Annals of the American Thoracic Society 2015;12(7):1100-2
• Merli M, Nicolini G, Angeloni S, Rinaldi V, De Santis A, Merkel C, et al. Incidence and natural history of small esophageal varices in cirrhotic patients. Journal of Hepatology 2003;38(3):266-72
• Kochar R, Dupont AW.Primary and secondary prophylaxis of gastric variceal bleeding. F1000 Med Rep. 2010 Apr 12;2
• Roccarina  D, Best  LMJ, Freeman  SC, Roberts  D, Cooper  NJ, Sutton  AJ, Benmassaoud  A, Plaz Torres  MCorina, Iogna Prat  L, Csenar  M, Arunan  S, Begum  T, Milne  EJ, Tapp  M, Pavlov  CS, Davidson  BR, Tsochatzis  E, Williams  NR, Gurusamy  KS. Primary prevention of variceal bleeding in people with oesophageal varices due to liver cirrhosis: a network meta-analysis. Cochrane Database of Systematic Reviews 2021, Issue 4. Art. No.: CD013121. DOI: 10.1002/14651858.CD013121.pub2. Accessed 29 August 2021.