Esophageal Varices: Symptoms, Types, Causes and Treatment

Esophageal varices are enlarged veins in the lining of the esophagus, which can become fragile and prone to bleeding. Most often associated with severe liver disease, particularly cirrhosis, these varices represent a significant risk for life-threatening hemorrhage. Understanding the symptoms, types, underlying causes, and treatment options for esophageal varices is crucial for patients, caregivers, and healthcare professionals alike. This article provides a comprehensive, evidence-based overview of esophageal varices, synthesizing insights from recent clinical research.

Symptoms of Esophageal Varices

Recognizing the symptoms of esophageal varices early can be life-saving, although many people remain asymptomatic until a bleed occurs. The clinical features vary depending on whether the varices are actively bleeding or not. Early detection and prompt intervention are essential to prevent complications.

Symptom	Description	Risk Level	Source(s)
Hematemesis	Vomiting blood	High	5 6 7
Melena	Black, tarry stools	High	5 6
Shock	Low blood pressure, rapid pulse	Critical	7 11
Asymptomatic	No symptoms until bleeding occurs	Variable	7 11

Table 1: Key Symptoms

Bleeding Signs

The most alarming symptom is gastrointestinal bleeding, which may manifest as hematemesis (vomiting blood) or melena (black, tarry stools). These are medical emergencies requiring immediate attention, as significant blood loss can lead to shock—a critical drop in blood pressure, rapid heart rate, and even loss of consciousness 5 6 7.

Non-Bleeding Symptoms

In many cases, esophageal varices cause no symptoms until they rupture. This silent progression is dangerous, as patients may not be aware of their risk. Occasionally, non-specific symptoms such as mild discomfort or difficulty swallowing (dysphagia) may occur, particularly if the varices are large, but this is less common 11.

Complications

Acute bleeding from esophageal varices is associated with high rates of rebleeding and mortality. The six-week mortality following a bleeding episode can be as high as 20%, underscoring the importance of early recognition and intervention 7 11. Recurrent bleeding episodes are also common, especially without effective treatment.

Types of Esophageal Varices

Not all esophageal varices are the same. Their classification depends on their anatomical location, underlying cause, and relationship to portal hypertension. Understanding the types helps guide diagnosis and management.

Type	Location/Feature	Prevalence	Source(s)
Uphill	Distal/lower esophagus; portal HTN	Most common	1 3 6
Downhill	Proximal/upper esophagus; SVC obs.	Rare (~0.1%)	2 5 6
GOV1	Esophageal varices to stomach	Common variant	1 3
GOV2/IGV	Extend to fundus or isolated gastric	Less common	1 3

Table 2: Types of Esophageal Varices

Uphill Varices

The majority of esophageal varices are "uphill" varices, forming in the lower (distal) esophagus due to increased pressure in the portal vein system—commonly as a result of liver cirrhosis or portal hypertension. These are most frequently encountered and carry the highest risk for bleeding 1 3 6.

Downhill Varices

"Downhill" varices are rare, accounting for about 0.1% of all cases, and are found in the upper (proximal) esophagus. Unlike uphill varices, they result from obstruction of the superior vena cava (SVC), which can be caused by tumors, benign strictures, or even long-term use of dialysis catheters. Their management differs significantly from that of portal hypertension-related varices 2 5 6.

Gastroesophageal Varices (GOV) and Isolated Gastric Varices (IGV)

Sometimes, esophageal varices extend into the stomach, classified as GOV1 (along the lesser curvature) or GOV2 (into the fundus). Isolated gastric varices (IGV) occur solely in the stomach. These distinctions matter because the risk profiles and treatment strategies differ from those for pure esophageal varices 1 3.

Causes of Esophageal Varices

The development of esophageal varices is most often a consequence of increased venous pressure in the portal or systemic circulation, but several etiologies exist.

Cause	Mechanism	Relative Frequency	Source(s)
Cirrhosis/Portal Hypertension	Liver scarring increases pressure	Most common	1 3 4
Schistosomiasis	Parasitic liver fibrosis	Variable (by region)	4
SVC Obstruction	Blocked blood flow via SVC	Rare	2 5 6
Extrahepatic Portal Vein Thrombosis	Blocked portal vein	Less common	4

Table 3: Causes of Esophageal Varices

Portal Hypertension

Chronic liver diseases, especially cirrhosis, are the leading cause of esophageal varices. Cirrhosis leads to scarring and distortion of liver architecture, which in turn increases pressure in the portal vein, resulting in the formation of varices as blood seeks alternative pathways back to the heart 1 3 4. This is the predominant cause worldwide.

Schistosomiasis

In some regions, particularly in Africa, schistosomiasis—a parasitic infection—can cause liver fibrosis and portal hypertension, leading to esophageal varices. In these areas, schistosomiasis rivals cirrhosis as a major cause 4.

Superior Vena Cava (SVC) Obstruction

Obstruction of the SVC, usually due to tumors, indwelling catheters, or fibrosis, leads to the formation of downhill varices. This cause is rare but clinically significant, especially in patients on long-term dialysis or those with mediastinal masses 2 5 6.

Other Causes

Other less common causes include extrahepatic portal vein thrombosis and idiopathic portal hypertension. In some cases, the cause may remain unidentified despite thorough investigation 4.

Treatment of Esophageal Varices

Managing esophageal varices focuses on preventing bleeding, controlling acute hemorrhage, and reducing the risk of recurrence. Treatments are tailored based on the underlying cause, type, and risk of bleeding.

Treatment	Purpose	Main Benefit	Source(s)
Endoscopic Band Ligation	Bleeding control & prevention	Fewer complications	3 7 10 11
Sclerotherapy	Variceal obliteration	Effective, but more side effects	7 8 9 10
Beta-blockers (NSBBs)	Lower portal pressure	Prevents first/recurrent bleed	11
TIPS	Shunt to reduce portal pressure	For refractory cases	11
Treat Underlying Cause	(e.g., SVC stenting)	Definitive for downhill varices	5 6

Table 4: Treatments for Esophageal Varices

Endoscopic Therapies

Band Ligation

Endoscopic variceal ligation (EVL) is the first-line endoscopic treatment for both acutely bleeding and non-bleeding large varices. A small rubber band is placed around the varix, causing it to slough off and scar over. This method is highly effective, with fewer complications and lower rebleeding rates than sclerotherapy 3 7 10 11.

Sclerotherapy

Endoscopic injection sclerotherapy involves injecting a sclerosing agent directly into the varix, causing it to harden and eventually disappear. While effective, it is associated with more complications and a higher rate of recurrence compared to band ligation 7 8 9 10.

Other Endoscopic Options

Less commonly, endoscopic tissue adhesives, endoloops, or thermal therapies may be used, particularly for gastric or complex varices. Their roles are still being evaluated 3 11.

Pharmacologic Treatments

Non-selective beta-blockers (NSBBs) such as propranolol or nadolol are used to lower portal vein pressure and reduce the risk of both first-time and recurrent bleeding. NSBBs may be used in combination with EVL for maximum benefit 11.

Advanced and Supportive Therapies

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

For patients who fail endoscopic and drug therapy, a TIPS procedure can be performed. TIPS creates a channel within the liver to connect the portal and hepatic veins, reducing portal pressure and the risk of further bleeding. It is reserved for refractory or severe cases due to potential complications 11.

Management of Downhill Varices

For downhill varices caused by SVC obstruction, the primary goal is to relieve the underlying blockage—often through angioplasty or stenting. Endoscopic therapy can be used to control acute bleeding but is not definitive 5 6.

Prevention and Surveillance

Patients with cirrhosis should undergo regular screening for varices. Those at high risk can benefit from early prophylactic treatment, significantly lowering the risk of first bleeding and improving survival 1 8 11.

Conclusion

Esophageal varices are a serious complication of portal hypertension and other vascular blockages, presenting a significant risk for life-threatening bleeding. Early recognition and tailored treatment strategies are essential for improving outcomes.

Key Takeaways:

• Symptoms: Most patients are asymptomatic until a bleed, which can manifest as vomiting blood or black stools and lead to shock 5 6 7 11.
• Types: Varices are classified as uphill (common, due to portal hypertension) or downhill (rare, due to SVC obstruction), with additional variants involving the stomach 1 2 3 5 6.
• Causes: Cirrhosis and portal hypertension are the main causes globally; schistosomiasis, SVC obstruction, and portal vein thrombosis are important in certain populations 1 3 4 5 6.
• Treatment: Endoscopic band ligation is the preferred method for most cases, with sclerotherapy and TIPS reserved for specific scenarios. Treating the underlying cause is essential for downhill varices 3 7 10 11 5 6.

Ongoing research and improved surveillance are key to further reducing the risks associated with esophageal varices. For patients with liver disease or at risk, regular screening and proactive management can be life-saving.