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Gastroesophageal varices

Definition
GEV are abnormally dilated submucosal distal veins developing at sites near the formation of gastroesophageal collateral circulation.
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Pathophysiology
GEV are most frequently caused by portal hypertension (a result of ALD cirrhosis, NASH, and hepatitis C infection).
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Epidemiology
The rate of hospitalization due to esophageal varices in the US is estimated at 1,181 per 100,000 population/year.
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Disease course
GEV correlate with the severity of liver disease and are present with other symptoms of chronic liver disease including spider nevi, jaundice, palmar erythema, splenomegaly, ascites, encephalopathy, and caput medusae. The disease increases the risk of variceal bleeding and rebleeding and is associated with increased morbidity and mortality.
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Prognosis and risk of recurrence
The six-week mortality rate of patients with index esophageal variceal bleeding is approximately 20%.
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Key sources
The following summarized guidelines for the evaluation and management of gastroesophageal varices are prepared by our editorial team based on guidelines from the European Association for the Study of the Liver (EASL 2023; 2018), the European Society of Gastrointestinal Endoscopy (ESGE 2022), the American Gastroenterological Association (AGA 2021), the American Association for the Study of Liver Diseases (AASLD 2017), the American College of Gastroenterology (ACG 2016), the British Society of Gastroenterology (BSG 2015), the American Society for Gastrointestinal Endoscopy (ASGE 2014), and the American College of Gastroenterology (ACG/AASLD 2007).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per EASL 2018 guidelines, obtain screening upper gastrointestinal endoscopy for GEV, if not previously diagnosed and treated, in patients with decompensated cirrhosis.
B
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2.Classification and risk stratification

Endoscopic classification: as per AGA 2021 guidelines, do not use endoscopic classification systems for the appearance of gastric varices to guide primary prophylaxis of gastric varices bleeding.
D

3.Medical management

Primary prevention of variceal hemorrhage
As per ESGE 2022 guidelines:
Initiate nonselective β-blockers (preferably carvedilol), if not contraindicated, to prevent the development of variceal bleeding in patients with compensated advanced chronic liver disease and clinically significant portal hypertension (hepatic venous pressure gradient > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa).
B
Perform endoscopic band ligation as the endoscopic prophylactic treatment of choice in patients unable to receive nonselective β-blocker therapy with high-risk esophageal varices on screening upper gastrointestinal endoscopy. Repeat endoscopic band ligation every 2-4 weeks until variceal eradication is achieved. Obtain surveillance upper gastrointestinal endoscopy every 3-6 months in the first year following eradication.
B

More topics in this section

  • Secondary prevention of variceal hemorrhage

  • Management of beta-blockers

4.Specific circumstances

Pregnant patients: as per EASL 2023 guidelines, initiate or continue β-blockers during pregnancy for primary or secondary prophylaxis of variceal hemorrhage, provided there are no contraindications.
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5.Preventative measures

Primary prevention: as per AASLD 2017 guidelines, insufficient evidence to support the use of nonselective β-blockers for the prevention of varices formation.
I

6.Follow-up and surveillance

Surveillance endoscopy: as per BSG 2015 guidelines, consider repeating endoscopy at 2-3-year intervals if no varices are found at the time of the first endoscopy.
C
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