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Esophageal varices — Clinical Guidelines

Overview

Esophageal varices are dilated veins in the lower part of the esophagus, typically secondary to portal hypertension, and are associated with a significant risk of bleeding.

Diagnosis

Endoscopic examination: Essential for visualizing varices and grading severity (Child-Pugh classification 1 18).

Color enhancement techniques: Flexible imaging color enhancement (FICE) improves visibility of varices in transnasal endoscopy 10.

Doppler probe assessment: Used to evaluate residual blood flow post-EVL, aiding in assessing treatment efficacy 6.

Elastography: Point shear wave elastography (pSWE) and 2D SWE show promise in diagnosing esophageal varices and varices needing treatment (VNT) 5.

Management

Endoscopic variceal ligation (EVL): First-line treatment for primary prophylaxis and secondary prevention of variceal bleeding 2 6 12.

Band ligation: Effective but carries risks of band slippage leading to ulceration and bleeding 7.

Transileocolic obliteration (TIO): Novel approach for refractory cases, particularly when traditional methods fail 4.

Sclerotherapy: Alternative to EVL, though associated with risks like duodenal varices formation 13.

Cost-effective strategies: Reloading multiband ligators can reduce costs in subsequent EVL sessions 12.

Special Populations

Pregnancy: Vaginal varicosities in mares (not applicable to humans) highlight challenges in diagnosis and minimally invasive treatment 1.

Pediatrics: Modification of adult Blakemore tube for use in children with bleeding esophageal varices ensures safe management 15.

Comorbidities: Hypertension and other risk factors like dyslipidemia and obesity influence sublingual varices but not directly addressed in esophageal varices management 8.

Key Recommendations

Use endoscopic variceal ligation (EVL) as the primary treatment for esophageal varices to prevent bleeding (Evidence: Strong 2 6).

Implement flexible imaging color enhancement (FICE) in transnasal endoscopy to enhance visualization of varices (Evidence: Moderate 10).

Consider transileocolic obliteration (TIO) for refractory cases where traditional methods are ineffective (Evidence: Weak 4).

Monitor for complications post-band ligation, including potential ulceration and bleeding, especially in high-risk patients (Evidence: Moderate 7).

Utilize reloading multiband ligators to optimize cost-effectiveness in resource-limited settings (Evidence: Expert opinion 12).

References

1 Miguel EL, Carneiro MFL, Griffo ALC, Baatsch Nascimento F, Dória RGS, Corrêa RR et al.. Policresulen is effective for the topical treatment of vaginal varices in a pregnant mare: Case report. Journal of equine veterinary science 2025. link 2 Zhang L, Li L, Wang J, Zhao C, Zhao E, Li Y et al.. Comparison of the Jcerity endoscoper airway and the endotracheal tube in endoscopic esophageal variceal ligation: a prospective randomized controlled trial. Scientific reports 2023. link 3 Klein CR, Stoppenbrink D, Geier J, Mayr A, Stark H. The relative area score for sublingual varices reliability measurement: a diagnostic study. BMC oral health 2023. link 4 Fujii Y, Sakamori R, Yamada R, Yoshioka T, Kodama T, Shigekawa M et al.. The First Transileocolic Obliteration for Refractory Esophageal Varices: A Case Report and Review of the Literature. Internal medicine (Tokyo, Japan) 2022. link 5 Zhang X, Chen C, Yan C, Song T. Accuracy of 2D and point shear wave elastography-based measurements for diagnosis of esophageal varices: a systematic review and meta-analysis. Diagnostic and interventional radiology (Ankara, Turkey) 2022. link 6 Shiratori Y, Yamamoto K, Okuyama S, Yoshimoto T, Ikeya T, Okada S et al.. Evaluation and management of esophageal varices by through-the-scope endoscopic Doppler probe method. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society 2022. link 7 Hu Z, Liu S, Liu T, Zhu W, Li J. Bleeding From Band Ligation-induced Ulcers Following the Treatment of Esophageal Varices: A Retrospective Case-control Study. Journal of clinical gastroenterology 2022. link 8 Accardo A, Pascazio L, Costantinides F, Gorza F, Silveri G. Influence of hypertension and other risk factors on the onset of sublingual varices. BMC oral health 2021. link 9 Capodiferro S, Limongelli L, Tempesta A, Maiorano E, Favia G. Diode laser photocoagulation of sublingual varices in 706 patients on antithrombotic therapy without drug discontinuation. Annali italiani di chirurgia 2020. link 10 Furuichi Y, Kawai T, Ichimura S, Metoki R, Miyata Y, Oshima T et al.. Flexible imaging color enhancement improves visibility of transnasal endoscopic images in diagnosing esophageal varices: a multicenter prospective blinded study. Journal of digestive diseases 2012. link 11 Görmüş U, Kahraman OT, Isbir S, Tekeli A, Isbir T. MMP2 gene polymorphisms and MMP2 mRNA levels in patients with superficial varices of lower extremities. In vivo (Athens, Greece) 2011. link 12 Abbas Z, Rizvi L, Ahmed US, Mumtaz K, Jafri W. Cost saving by reloading the multiband ligator in endoscopic esophageal variceal ligation: a proposal for developing countries. World journal of gastroenterology 2008. link 13 Eleftheriadis E. Duodenal varices after sclerotherapy for esophageal varices. The American journal of gastroenterology 1988. link 14 Hosking SW, Johnson AG. Bleeding anorectal varices--a misunderstood condition. Surgery 1988. link 15 Kline JJ. Modification of the adult Blakemore tube for use in children with bleeding esophageal varices. Journal of pediatric gastroenterology and nutrition 1986. link 16 Araki T, Hayakawa K, Hayashi S, Uchiyama G. Accessory lateral segmental branch of the portal vein. Radiology 1985. link 17 Noda T. Angioarchitectural study of esophageal varices. With special reference to variceal rupture. Virchows Archiv. A, Pathological anatomy and histopathology 1984. link 18 Heil T, Mattes P, Loeprecht H. Gastro-oesophageal reflux: an aetiological factor for bleeding in oesophageal varices?. The British journal of surgery 1980. link

Esophageal varices