Esophageal varices are swollen, enlarged veins in the lower part of the esophagus, the tube that connects your throat to your stomach. They develop when blood flow through the liver is blocked or slowed, forcing blood to reroute through smaller veins that aren’t built to handle the volume. Between 60% and 80% of people with liver cirrhosis develop them, and the biggest danger is that these fragile, overstretched veins can rupture and cause life-threatening bleeding.
How Esophageal Varices Form
Your portal vein carries a large volume of blood, over 1,500 milliliters per minute, from your digestive organs to your liver for processing. When the liver is scarred or diseased, that blood meets resistance. Pressure in the portal vein rises from its normal range of 5 to 10 mmHg to as high as 15 to 20 mmHg. This is called portal hypertension.
Because the portal venous system has no valves, there’s nothing to stop blood from flowing backward when pressure builds. Your body tries to relieve the congestion by rerouting blood through alternative pathways, called collateral vessels, that connect to the general circulation. One of the most important of these pathways runs along the lower esophagus. Over time, the small veins there become engorged, twisted, and fragile. These are esophageal varices. The thin walls of these veins were never designed to handle high-pressure blood flow, which is why they carry a significant risk of rupturing.
What Causes Them
Cirrhosis is by far the most common cause. Any condition that scars the liver enough to obstruct blood flow can lead to portal hypertension and, eventually, varices. The leading drivers of cirrhosis include chronic alcohol use, hepatitis B, and hepatitis C. Less common causes of portal hypertension include blood clots in the portal vein or in the hepatic veins that drain the liver, as well as parasitic infections like schistosomiasis, which is a significant cause in parts of Africa, South America, and Southeast Asia.
Symptoms Before and During Bleeding
Esophageal varices themselves produce no symptoms until they bleed. You can have large varices for years without knowing it. That’s what makes them particularly dangerous: the first sign is often a medical emergency.
When a varix ruptures, the signs are dramatic. You may vomit large amounts of blood, which can be bright red or look like dark coffee grounds. Black, tarry stools are another hallmark, caused by digested blood moving through the intestines. Rapid blood loss leads to lightheadedness, a racing heart, a drop in blood pressure, and in severe cases, loss of consciousness. The mortality rate within six weeks of a variceal bleeding episode is 15% to 25%, making it one of the most dangerous complications of liver disease.
Some indirect warning signs may suggest you have portal hypertension even before bleeding occurs. These include a swollen abdomen from fluid buildup (ascites), an enlarged spleen, and visible spider-like blood vessels on the skin. None of these confirm varices on their own, but they signal that your liver is under significant stress.
How Varices Are Found
The standard method for detecting esophageal varices is an upper endoscopy, where a thin, flexible camera is passed down your throat to visually inspect the esophagus and stomach. This procedure identifies whether varices are present, how large they are, and whether they show “red signs” on their surface that indicate a higher risk of bleeding.
Current guidelines from the American Association for the Study of Liver Diseases recommend that people with cirrhosis undergo endoscopic screening for varices. If no varices are found, repeat endoscopy is generally recommended every two to three years, though the interval depends on how active the liver disease is and whether the cirrhosis is stable or worsening. If you’re already taking a blood pressure medication to manage portal hypertension, screening endoscopy may not be necessary.
Preventing a First Bleed
Once varices are detected, the priority shifts to preventing them from ever rupturing. The risk of bleeding in someone with known varices is 25% to 35%, so prevention is taken seriously.
The first-line approach for many patients is a type of blood pressure medication called a nonselective beta blocker. These drugs work by reducing the heart rate and lowering the pressure in the portal vein, which takes some of the strain off the swollen veins. The dose is gradually increased over days to weeks until the resting heart rate drops to around 55 to 60 beats per minute. This medication is typically continued indefinitely. For people who can’t tolerate it or have contraindications, endoscopic banding (described below) is an alternative.
Treating Active Bleeding
A ruptured esophageal varix is a medical emergency that requires immediate intervention. The primary treatment is endoscopic variceal ligation, commonly called banding. During this procedure, small elastic bands are placed around the base of each bleeding varix through an endoscope, cutting off its blood supply and stopping the hemorrhage. Banding is considered the first-line endoscopic treatment for esophageal variceal bleeding.
An older technique called sclerotherapy involves injecting a chemical agent directly into or around the varix to seal it shut. While still used in some situations, particularly for varices in the stomach that are harder to reach with bands, banding has largely replaced it for esophageal varices because of better outcomes and fewer complications.
After a bleeding episode is controlled with banding, the rebleeding rate within six weeks is about 7.5%, and the six-week mortality rate is approximately 16.5%. These numbers underscore why ongoing treatment and monitoring are essential after a first bleed.
When Standard Treatments Aren’t Enough
For patients whose varices keep bleeding despite medication and repeated banding sessions, a procedure called TIPS (transjugular intrahepatic portosystemic shunt) may be recommended. In this procedure, a radiologist creates a new channel within the liver that connects the portal vein directly to a vein draining into the heart, bypassing the scarred liver tissue and immediately reducing portal pressure.
TIPS is generally reserved for people who have failed both medication and endoscopic treatment after their first variceal bleed. However, newer evidence suggests that patients at very high risk of rebleeding, particularly those with advanced cirrhosis or very high portal pressures, may benefit from early TIPS placement within 72 hours of their initial endoscopic treatment. For people with end-stage liver disease, liver transplantation remains the only treatment that addresses the underlying cause of portal hypertension.
Dietary Adjustments
If you have esophageal varices, what you eat matters. Hard, sharp, or rough-textured foods can physically irritate or scrape the thin walls of swollen veins. While diet alone won’t prevent a bleed, minimizing mechanical irritation is a reasonable precaution.
Foods to be cautious about include:
- Hard or crunchy items: raw vegetables, crackers, chips, popcorn, nuts, hard candy, and crusty bread
- Tough meats: steak, chops, ribs, bacon, sausage, and shellfish like clams and mussels
- Foods with rough textures: whole grains, rice, dried fruits, seeds, raw salads, and fruits with skins or seeds like apples, berries, and oranges
- Sticky or chewy foods: caramels, licorice, and peanut butter (unless blended into a smoothie)
Softer foods are generally safer: well-cooked vegetables, smooth soups without chunks, tender proteins like fish, soft-cooked eggs, and fruits without skins or seeds. Spicy foods are also worth avoiding, as they can irritate the esophageal lining. If you have cirrhosis, your doctor may also recommend limiting sodium to help control fluid retention, which indirectly affects portal pressure.