Oesophageal Varices

Overview – Oesophageal Varices

Oesophageal varices are engorged, tortuous veins in the lower oesophagus that develop due to portal hypertension, most commonly in the setting of liver cirrhosis. They are a life-threatening cause of upper gastrointestinal (GI) bleeding, making early detection and management critical. For final-year medical students, understanding the pathophysiology, clinical red flags, and emergency interventions for oesophageal varices is essential in both academic exams and clinical rotations.

Definition

Engorged submucosal veins in the lower third of the oesophagus, arising secondary to portal hypertension. These varices have a high risk of rupture and are a medical emergency when bleeding occurs.

Aetiology

Portal Hypertension – classified based on anatomical location:

• Prehepatic:
  • Portal vein thrombosis
• Intrahepatic:
  • Liver cirrhosis (most common cause)
• Posthepatic:
  • Hepatic vein obstruction (e.g. Budd-Chiari syndrome)

Pathophysiology

• ↑ Portal pressure → formation of portosystemic collaterals
• One key collateral pathway: left gastric (coronary) vein → oesophageal submucosal veins
• Venous engorgement in the lower oesophagus leads to the development of varices

Morphology

• Tortuous, dilated, and engorged veins beneath the oesophageal mucosa
• Visibly similar to varicose veins on endoscopy
• Often fragile and prone to rupture, particularly with elevated intraluminal pressure

Clinical Features

• Haematemesis (vomiting of fresh blood)
• Melena (black, tarry stools)
• Signs of anaemia due to chronic or acute blood loss:
  • Dyspnoea
  • Dizziness, light-headedness
  • Syncope
• Signs of underlying liver disease (cirrhosis):
  • Jaundice
  • Hepatic encephalopathy (e.g. confusion, asterixis/hepatic flap)
  • Small, nodular liver on palpation
• Signs of chronic alcoholism:
  • Intoxication
  • Dupuytren’s contracture

Investigations

• Liver Function Tests (LFTs):
  • ↑ AST, ALT
  • ↓ Albumin
  • ↑ ALP, GGT
• FBC:
  • Anaemia (Hb ↓)
• B12/Folate:
  • Often low in alcoholics
• U&Es:
  • Monitor for electrolyte imbalances
• Definitive Test:
  • Upper GI Endoscopy: Direct visualisation and grading of varices

Management

Supportive Care

• Thiamine, B12, Folate supplementation – especially in chronic alcohol users
• PPI therapy (e.g. Omeprazole) – to reduce acid and risk of ulceration

Bleeding Varices

• Endoscopic Band Ligation – first-line treatment for active bleeding
• May require sclerotherapy or balloon tamponade in refractory cases
• Consider beta-blockers (e.g. propranolol) for secondary prophylaxis

Complications

• Rupture → Massive upper GI bleed → Hypovolaemic shock → Death
• Risk of aspiration pneumonia
• Rebleeding is common
• Associated with high morbidity and mortality

Summary – Oesophageal Varices

Oesophageal varices are dilated submucosal veins in the lower oesophagus caused by portal hypertension, most commonly due to cirrhosis. They are a major cause of upper GI bleeding, with symptoms ranging from haematemesis to signs of shock. Prompt diagnosis via endoscopy and emergency management — including endoscopic band ligation and medical stabilisation — are essential. For a broader look at digestive tract pathology, visit our Gastrointestinal Overview page.