Oesophageal varices

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute variceal bleeding

1st line – resuscitation + supportive care

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1st line –

resuscitation + supportive care

Admit any patient with suspected acute variceal bleeding to a high-dependency or intensive care unit.[5]

Prioritise resuscitation in line with standard Airway, Breathing, Circulation (ABC) practice; protect the airway to prevent aspiration and obtain good peripheral venous access.[5]

Give intravenous fluids to all patients.[5][35] Follow your local protocol.

Monitor National Early Warning Score (NEWS2) and use clinical review to determine the infusion rate for your patient. Royal College of Physicians: National Early Warning Score (NEWS) 2 Opens in new window The British Society of Gastroenterology (BSG) and the National Institute for Health and Care Excellence (NICE) in the UK recommend using a crystalloid solution as a bolus of 500 mL in less than 15 minutes in haemodynamically unstable patients.[35][56]
In practice, use the largest possible diameter cannula. Give intravenous fluids to maintain systolic blood pressure >90 to 100 mmHg but beware of over-transfusion. Aim to switch to blood replacement as soon as possible. Give intravenous fluids to maintain systolic blood pressure >90 to 100 mmHg and monitor closely. Aim to switch to blood replacement as soon as possible but beware of over-transfusion - base decisions on blood transfusion on the full clinical picture, with a restrictive approach to transfusion, aiming for a haemoglobin of 70-80 g/L in haemodynamically stable patients.[5]

Give high-flow oxygen, if indicated.[5]

In patients with decompensated cirrhosis, manage any precipitant causes (eg., give Pabrinex® [vitamin B substances with ascorbic acid] if the patient has a history of current excess alcohol consumption) and their complications.[37]

Intubate the patient before endoscopy if there is haematemesis, or there is a perceived risk of a haemodynamically unstable patient having blood in the stomach, or if the patient presents with an altered mental status (i.e., confusion).[5] Make sure the patient is appropriately resuscitated before undergoing endoscopy.

Practical tip

If the patient has been intubated, they will need to be managed in an intensive care or high-dependency unit until extubation.[5]

Request an urgent critical care review for any patient with ongoing haemodynamic instability despite adequate resuscitative efforts.[35] Consider activating major haemorrhage protocols early. See Blood transfusion below.

Consider seeking advice from an appropriate specialist if the patient is taking warfarin or a DOAC.

The British Society of Gastroenterology (BSG) consensus care bundle for acute upper gastrointestinal bleeding and the 2021 update to the BSG and European Society of Gastrointestinal Endoscopy (ESGE) guideline on endoscopy in patients on antiplatelet or anticoagulant therapy recommend:[35][64]
- Suspending DOACs at presentation and seeking advice from a haematologist when managing patients with severe haemorrhage to weigh up the risks and benefits of the DOAC.
- Suspending warfarin at presentation.
  - The BSG consensus care bundle stresses the importance of ensuring a plan is in place for restarting warfarin.[35] Consult a specialist to discuss the risks associated with stopping warfarin and the need for monitoring.[35][64]
In haemodynamically unstable patients, the 2021 update to the BSG and ESGE guideline recommends:[64]
- In patients who are taking warfarin, give intravenous vitamin K and four-factor prothrombin complex concentrate. Fresh frozen plasma can be used if prothrombin complex concentrate is not available.
- If the patient is taking a DOAC, consider the use of reversal agents: idarucizumab in patients taking dabigatran, and andexanet alfa in patients taking anti-factor-Xa. Intravenous four-factor prothrombin complex concentrate can be used if andexanet alfa is not available.
Note that NICE in the UK recommends:[39]
- Prothrombin complex concentrate in patients who are taking warfarin and actively bleeding
- Following local warfarin protocols to treat patients who are taking warfarin and whose upper gastrointestinal bleeding has stopped
- Recombinant factor Vlla (eptacog alfa) when all other methods have failed.

If any medications are temporarily stopped, also seek advice on the appropriate time for these to be restarted. The 2021 update to the BSG and ESGE guideline on endoscopy in patients on antiplatelet or anticoagulant therapy recommends restarting anticoagulation:[64]

As soon as possible after 7 days of anticoagulant interruption in patients with low thrombotic risk
Preferably within 3 days of anticoagulant interruption in patients with high thrombotic risk, with heparin bridging.

If the patient is taking aspirin, other NSAIDs (including cyclo-oxygenase-2 [COX-2] inhibitors), or dual antiplatelet therapy:

In general, continue aspirin in the acute phase, if your patient is taking this for secondary prevention:[35][39][64]
- Consider seeking urgent advice from a specialist if there is major haemorrhage.
  - NICE doesn’t make a specific recommendation about major haemorrhage, but advises continuing aspirin only once haemostasis has been achieved.[39]
  - The BSG consensus care bundle for acute upper gastrointestinal bleeding and the 2021 update to the BSG and ESGE guideline on endoscopy in patients on antiplatelet or anticoagulant therapy recommend continuing aspirin if this is taken as part of dual antiplatelet therapy with a P2Y ₁₂ inhibitor (e.g., clopidogrel, prasugrel, or ticagrelor), and the P2Y ₁₂ is temporarily stopped.[35][64] However, the 2021 update to the BSG and ESGE guideline recommends that, if aspirin is stopped, it should be restarted as soon as haemostasis is achieved or there is no further evidence of haemorrhage.[64]
  - The BSG care bundle cites two studies that demonstrate a three-fold increase in the risk of cardiovascular or cerebrovascular events if aspirin, prescribed for the secondary prevention, is discontinued.[35][65][66]
The 2021 update to the BSG and ESGE guideline recommends considering permanently discontinuing aspirin if the patient is taking it for primary prevention:[64]
If the patient is taking any other NSAIDs (including COX-2 inhibitors), NICE recommends stopping these during the acute phase[39]
If the patient is taking dual antiplatelet therapy, seek advice from the appropriate specialist to weigh up the benefits and risks of continuing the P2Y ₁₂ inhibitor . Discuss the balance of benefits versus risk with your patient. In general, if the patient:[35]
- Does not have coronary artery stents, the P2Y ₁₂ inhibitor should be stopped temporarily until haemostasis is achieved
- Does have coronary artery stents, dual antiplatelet therapy should ideally be continued due to the high risk of stent thrombosis. However, the risks and benefits of doing so need to be carefully considered by a specialist.

Plus – blood transfusion

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Plus –

blood transfusion

Treatment recommended for ALL patients in selected patient group

If the patient has massive bleeding, transfuse with blood, platelets, and clotting factors in line with your local protocols.[5][39][53]

Base decisions on blood transfusion on the full clinical picture; bear in mind that over-transfusion may be as damaging as under-transfusion.[39]
- The British Society of Gastroenterology care bundle recommends considering a higher trigger for transfusion than haemoglobin <70 g/L in patients with ischaemic heart disease or haemodynamic instability.[35]
Give platelet transfusion to patients who are actively bleeding and have a platelet count of <50 × 10 ⁹/L.[5][35][39][53] Higher thresholds may be considered in those with falling platelet counts.[53]
- Give fresh frozen plasma (FFP) to patients who are actively bleeding and have a prothrombin time (or international normalised ratio) or activated partial thromboplastin time >1.5 times normal.[39][53] In ongoing major bleeding, if appropriate coagulation test results are not available, transfuse FFP in at least a 1:2 ratio with units of red blood cells (RBCs).[53]
- Offer fibrinogen supplementation to patients with fibrinogen concentrations <1.5 g/L (excluding pregnant women).[53] Give cryoprecipitate to patients with a fibrinogen level that remains <1.5 g/L despite FFP fresh frozen plasma use.[39]

In haemodynamically stable patients, start transfusion when the haemoglobin level falls to below 70 g/L, and maintain between 70 to 80 g/L.[5]

Blood transfusion above this threshold may increase mortality.[53][63]

Do not offer platelet transfusion to patients who are not actively bleeding and are haemodynamically stable.[39]

Plus – terlipressin or somatostatin analogue

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Plus –

terlipressin or somatostatin analogue

Treatment recommended for ALL patients in selected patient group

Give terlipressin to all patients with suspected variceal bleeding at presentation, unless contraindicated.[5][39] The British Society of Gastroenterology recommends a somatostatin analogue (e.g., octreotide) as an alternative if terlipressin is contraindicated.[5]

Terlipressin is contraindicated and should be used with caution and under close monitoring in patients with arterial disease, hyponatraemia, myocardial ischaemia, severe cardiac failure, or prolonged QTc interval.[67]
Terlipressin is a potent vasoconstrictor; it increases systemic vascular resistance, reduces cardiac output, and reduces portal pressures by approximately 20%.[67][68]
Stop treatment with terlipressin or a somatostatin analogue after definitive haemostasis has been achieved, or after 5 days, unless there is another indication to continue.[5][39]

Note that octreotide is used off-label for this indication in the UK.

Primary options

terlipressin: consult specialist for guidance on dose; dose depends on the brand used

Secondary options

octreotide: consult specialist for guidance on dose

Plus – prophylactic antibiotics

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Plus –

prophylactic antibiotics

Treatment recommended for ALL patients in selected patient group

Give prophylactic antibiotics to all patients with suspected or confirmed variceal bleeding at presentation.[5][17][39]

Give intravenous ceftriaxone immediately. Then, change to an antibiotic (if appropriate) recommended by your local protocols and in consultation with an infectious disease or microbiology specialist; take account of local microbial epidemiology and resistance patterns, and availability.[5][29]
Prophylactic antibiotics reduce the rate of bacterial infection, treatment failure, rebleeding, and mortality.[6][29][69] [ ]

Primary options

ceftriaxone: 1 g intravenously every 24 hours

Plus – endoscopy + endoscopic variceal band ligation

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Plus –

endoscopy + endoscopic variceal band ligation

Treatment recommended for ALL patients in selected patient group

Perform a risk assessment and consider managing the patient with a Glasgow-Blatchford score ≤ 1 as an outpatient if safe and appropriate to do so. This approach is supported by latest evidence and is in line with recommendations from the BSG and ESGE.[35][38] Refer all patients with acute upper gastrointestinal (GI) bleeding for upper GI endoscopy.[35][38][39]

If the patient is unstable with severe acute upper GI bleeding, do this urgently, immediately after resuscitation.[35][39]
For all other patients with upper GI bleeding, do this within 24 hours of admission.[35][39]

Practical tip

Ensure haemodynamically unstable patients are adequately resuscitated before undergoing endoscopy.

Once the haemorrhage is confirmed by endoscopy, endoscopic band ligation is the technique of choice.[5][39][44] Refer patients to a gastroenterology service.[35] This technique is specialised and should only be undertaken by someone with adequate training and experience.

Consider – balloon tamponade or Danis stent

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Consider –

balloon tamponade or Danis stent

Additional treatment recommended for SOME patients in selected patient group

The British Society of Gastroenterology recommends using balloon tamponade (via a Sengstaken Blakemore tube) temporarily if variceal bleeding has continued despite medical therapy and endoscopy is not immediately available.[5] This requires intensive care monitoring; intubation should be considered.[5] Tamponade must be removed after 24 to 36 hours.[55]

Balloon tamponade is a temporary measure for uncontrolled variceal haemorrhage until endoscopy, trans-jugular intrahepatic porto-systemic shunt (TIPS), or shunt surgery is available.[5]
Tamponade provides good control of bleeding in 90% of patients, although 50% will rebleed when the balloon is deflated. Despite being associated with serious complications (e.g., oesophageal ulceration, aspiration pneumonia) in up to 15% to 20% of patients, balloon tamponade can be a life-saving treatment in patients with massive uncontrolled variceal haemorrhage.[5]

The UK National Institute for Health and Care Excellence recommends considering Danis stent instead of balloon tamponade or early TIPS insertion (i.e., done within 72 hours) when:[55]

The patient does not respond to endoluminal therapy and their oesophageal varices are being considered for definitive treatment (until this treatment is done)
Definitive treatment is not appropriate and the patient is likely to be offered palliative care.

Studies indicate that Danis stent is better than the balloon tamponade device in controlling bleeding in the short term. The stent can stay in place for up to 7 days, whereas balloon tamponade needs to be removed after 24 to 36 hours. The use of Danis stent therefore affords more time to stabilise the patient and plan ongoing treatment options. Patients who have Danis stents do not need to stay in the intensive care unit (ICU), unless other aspects of their clinical condition require ICU care.[55][70][71][72]

These techniques are specialised and should only be undertaken by someone with adequate training and experience.

Consider – transjugular intrahepatic portosystemic shunt

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Consider –

transjugular intrahepatic portosystemic shunt

Additional treatment recommended for SOME patients in selected patient group

Transjugular intrahepatic portosystemic shunt (TIPS) is recommended if bleeding is not controlled by band ligation.[5][39][54]

If resources and expertise are available, early covered TIPS (<72 hours of active variceal bleed) can be considered in selected patients with:[5]

Child-Pugh class B cirrhosis and active bleeding
Child-Pugh class C cirrhosis with Child-Pugh score <14.[54] [ Child Pugh classification for severity of liver disease (SI units) Opens in new window ]

Patients who do not undergo early TIPS should continue on intravenous terlipressin or a somatostatin analogue (e.g., octreotide) for 2 to 5 days and then begin non-selective beta-blocker therapy once terlipressin or a somatostatin analogue is discontinued.[6] Rescue TIPS is indicated in these patients if haemorrhage cannot be controlled, or if bleeding recurs despite treatment with a vasoactive drug (e.g., terlipressin, octreotide) plus endoscopic variceal band ligation. Once TIPS is performed successfully, terlipressin or a somatostatin analogue can be discontinued.[6]

ONGOING

no acute variceal bleeding: medium to large varices

1st line – diagnostic endoscopy + non-selective beta-blocker

Consider – endoscopic variceal band ligation

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Consider –

endoscopic variceal band ligation

Additional treatment recommended for SOME patients in selected patient group

Follow your local protocols for guidance on when to use endoscopic variceal band ligation. In practice, some UK experts follow the British Society of Gastroenterology guidelines, which recommend endoscopic variceal band ligation:[5]

For patients who are intolerant to non-selective beta-blockers, or when non-selective beta-blockers are contraindicated
If the patient chooses this as their preferred option.

However, bear in mind that recommendations from the National Institute for Health and Care Excellence (NICE) in the UK differ. NICE only recommends endoscopic variceal band ligation for the primary prevention of bleeding in patients with medium and large oesophageal varices.[17]

Band ligation of oesophageal varices for the primary prevention of bleeding reduces mortality, upper gastrointestinal bleeding, variceal bleeding, and serious adverse events compared with no intervention.[30] Note that band ligation cannot be done successfully in patients with small varices; it is only used in patients with medium to large varices.[30]

no acute variceal bleeding: small varices

1st line – diagnostic endoscopy + annual endoscopy

previous variceal bleed

1st line – non-selective beta-blocker and/or endoscopic variceal band ligation

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1st line –

non-selective beta-blocker and/or endoscopic variceal band ligation

Refer patients to a gastroenterology service.[35]

A combination of a non-selective beta-blocker plus endoscopic variceal band ligation can be used.[5][6][29][73][74][75] The Baveno VII consensus recommends propranolol, carvedilol, or nadolol as first-line agents.[29]

Varices should be banded at 2- to 4-weekly intervals until eradication. Once varices have been eliminated, an endoscopy should be performed at 3 months, and then every 6 months.[29]
Recurrent varices should be treated with further endoscopic variceal band ligation until eradication.[5]

A non-selective beta-blocker or endoscopic variceal band ligation can be used as monotherapy as an alternative to combined treatment, taking into account the patient’s preferences and clinical judgment.[5]

If non-selective beta-blockers alone are used, further endoscopy is not necessary unless clinically indicated.[5]
Endoscopic variceal band ligation alone is an option to eradicate varices if there are contraindications or intolerance to combined use with a non-selective beta-blocker.[5]

The British Society of Gastroenterology (BSG) defines variceal rebleeding as the occurrence of a single episode of clinically significant rebleeding from portal hypertensive sources from day 5.[5] Clinically significant rebleeding is defined by the BSG as recurrent melaena or haematemesis alongside any of the following scenarios:[5]

Hospital admission
Blood transfusion
30 g/L drop in haemoglobin
Death within 6 weeks.

Primary options

propranolol: 40 mg orally twice daily initially, increase gradually according to response, maximum 320 mg/day

carvedilol: 6.25 mg orally once daily initially, increase gradually according to response, maximum 12.5 mg/day

nadolol: 40 mg orally once daily initially, increase gradually according to response, maximum 240 mg/day

Consider – transjugular intrahepatic portosystemic shunt

Consider – shunt surgery

Use of this content is subject to our disclaimer

Oesophageal varices

acute variceal bleeding

resuscitation + supportive care

Practical tip

blood transfusion

terlipressin or somatostatin analogue

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

prophylactic antibiotics

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

endoscopy + endoscopic variceal band ligation

Practical tip

balloon tamponade or Danis stent

transjugular intrahepatic portosystemic shunt

no acute variceal bleeding: medium to large varices

diagnostic endoscopy + non-selective beta-blocker

Primary options

endoscopic variceal band ligation

no acute variceal bleeding: small varices

diagnostic endoscopy + annual endoscopy

previous variceal bleed

non-selective beta-blocker and/or endoscopic variceal band ligation

Primary options

transjugular intrahepatic portosystemic shunt

shunt surgery

Oesophageal varices

Treatment algorithm

acute variceal bleeding

resuscitation + supportive care

Practical tip

blood transfusion

terlipressin or somatostatin analogue

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

prophylactic antibiotics

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

endoscopy + endoscopic variceal band ligation

Practical tip

balloon tamponade or Danis stent

transjugular intrahepatic portosystemic shunt

no acute variceal bleeding: medium to large varices

diagnostic endoscopy + non-selective beta-blocker

Primary options

endoscopic variceal band ligation

no acute variceal bleeding: small varices

diagnostic endoscopy + annual endoscopy

previous variceal bleed

non-selective beta-blocker and/or endoscopic variceal band ligation

Primary options

transjugular intrahepatic portosystemic shunt

shunt surgery