Esophageal Varices

Esophageal varices are dilated submucosal veins in the distal esophagus that develop in response to portal hypertension. They are present in roughly half of cirrhotic patients at the time of diagnosis. Variceal bleeding is one of the most lethal complications of portal hypertension — first-bleed mortality is approximately 15–20%, with rebleeding rates over 60% in untreated survivors.

Risk stratification at endoscopy looks at variceal size, the presence of red color signs (red wale marks, cherry-red spots, the nipple sign), and the underlying severity of liver disease. The palisade vein zone at the gastroesophageal junction is the anatomical marker of the venous transition between portal and systemic systems, and the most common site of bleeding.

Endoscopic band ligation (EBL) is the gold-standard endoscopic treatment for both acute hemorrhage and primary/secondary prophylaxis in patients who cannot tolerate non-selective beta blockers. Bands are deployed starting at the bleeding point or distal-most varix and advanced proximally in a spiral. Combination therapy with vasoactive drugs (octreotide, terlipressin) and antibiotic prophylaxis is essential during active bleeding. TIPS is reserved for refractory or recurrent bleeding.