saudigastro.com/patients/esophageal-varices
Category
Serious
Red flags
5
This article is educational and does not replace your doctor's advice. Seek urgent care for any red-flag symptoms.
What is it?
The esophagus (food pipe) carries food from the mouth to the stomach. Esophageal varices are enlarged, fragile veins in its lower part. They form when blood cannot flow easily through a scarred liver (cirrhosis), so the pressure rises in the portal vein, the large vein that carries blood from the gut to the liver (this is called portal hypertension). The blood then finds other routes through small veins in the esophagus and stomach, which swell. Varices usually cause no symptoms until they bleed.
How common is it?
Varices are common in people with cirrhosis, and the chance of having them rises as cirrhosis becomes more advanced. Not all varices will bleed. The risk of bleeding is higher with larger varices, with red marks on their surface, and in more severe liver disease. Bleeding from varices is a medical emergency and can be life-threatening.
Why does it happen?
The main cause is cirrhosis, whatever its origin: for example hepatitis B or C, fatty liver disease, alcohol-related liver disease or autoimmune liver disease. Less often, a blood clot in the portal vein or other conditions that block blood flow can cause varices without cirrhosis. A bleed happens when pressure inside the vein becomes too high and the thin wall tears. Heavy alcohol use, certain painkillers (such as aspirin and anti-inflammatory tablets), and clotting problems can add to the risk.
Symptoms
- Usually NO symptoms until bleeding occurs — which is why screening is important
- Vomiting fresh red blood or material that looks like coffee grounds
- Black, tarry, sticky and foul-smelling stools (melena) or maroon blood in the stool
- Dizziness, light-headedness, fainting, fast heartbeat
- Pale skin, sweating, weakness, feeling cold
- Signs of liver disease that may come with it: yellow eyes, swollen belly, leg swelling
Red flags — seek urgent medical care
Vomiting blood (red or coffee-ground)
Probable variceal bleeding. Call an ambulance or go to the emergency department immediately. Do not wait, drive yourself, or try to treat it at home.
Black, tarry or bloody stools
Blood has passed through the gut — emergency care is needed.
Dizziness, fainting, fast heartbeat or pale cold skin
Significant blood loss with shock — life-threatening emergency.
Confusion or unusual sleepiness after a bleed
Bleeding can trigger liver-related brain confusion (hepatic encephalopathy) — emergency.
Fever or sudden belly swelling and pain in someone with cirrhosis
Possible infection of abdominal fluid — urgent medical assessment.
How is it diagnosed?
Varices are found by upper endoscopy (also called gastroscopy), where a thin flexible camera is passed through the mouth under sedation to look at the esophagus and stomach. Everyone newly diagnosed with cirrhosis is assessed for varices, either by endoscopy or, in some patients, by non-invasive tests (such as liver stiffness and platelet count) that can safely show endoscopy is not needed yet. If none are found, repeat checks are scheduled at intervals set by your doctor. Blood tests and ultrasound assess the liver and other complications.
What the latest science says
Treatment now focuses on preventing the first bleed in people with medium or large varices, and on preventing re-bleeding after one. Newer approaches, such as using early covered stents (TIPS) in selected high-risk patients, are being used in specialist centers. Treating the cause of cirrhosis, such as hepatitis B or C, can also lower portal pressure and improve outcomes.
Outlook — what to expect
A first variceal bleed is serious, but with prompt emergency treatment most people survive the episode. The outlook depends mainly on how advanced the liver disease is. Regular screening, preventive medicines or banding, and treating the cause of cirrhosis can greatly reduce the chance of a bleed. After a bleed, there is a high chance of another unless prevention treatment is continued.
Treatment
Habits & Lifestyle
Looking after the liver and avoiding triggers is part of lowering the risk of bleeding. If you ever think varices are bleeding, this needs emergency care in hospital, not home treatment.
- Avoid alcohol completely.
- Avoid aspirin and anti-inflammatory painkillers (such as ibuprofen) unless your doctor specifically says otherwise.
- Attend every endoscopy and clinic appointment, even when you feel well.
- Keep a note of your medicines and tell any doctor or dentist that you have varices.
- Know the warning signs and your nearest emergency department; keep someone informed so they can call help.
Diet
Good nutrition helps cirrhosis, but there is no diet that shrinks varices. Follow the advice from your liver team and dietitian.
- Eat regular meals and a bedtime snack with enough protein; do not restrict protein unless told to.
- Reduce salt if you have fluid in the belly or leg swelling.
- Avoid raw shellfish; they carry a risk of serious infection in cirrhosis.
- Very hard, sharp or scratchy foods do not cause bleeding by themselves, but chew well and eat slowly.
- Avoid herbal and "liver detox" products unless your doctor approves them.
Medications
Certain medicines lower pressure in the portal vein and reduce the chance of a first or repeat bleed. Your specialist chooses the medicine and dose; never adjust or stop it yourself.
- Non-selective beta-blockers (such as propranolol, nadolol or carvedilol) are commonly used to lower portal pressure; your doctor will check your blood pressure and heart rate.
- During a bleed, hospital teams give medicines into a vein to reduce blood flow to the gut and antibiotics to prevent infection, along with fluids or blood transfusion as needed.
- Treat the underlying liver disease (for example antiviral treatment for hepatitis B or C) as directed.
- Stomach-acid reducing medicines are only taken when there is a clear reason, as advised by your doctor.
Procedures & Surgery
Endoscopic treatment is the main way to treat bleeding varices and to prevent re-bleeding.
- Endoscopic band ligation: small elastic bands are placed around varices to close them; sessions are repeated until the varices are gone.
- Urgent endoscopy within hours of a suspected bleed, once the patient is stabilised.
- TIPS (a tunnel placed inside the liver to redirect blood and lower pressure) may be used when bleeding is not controlled or keeps recurring.
- A balloon tube may be used briefly in hospital as a temporary measure in severe bleeding.
- Liver transplant assessment is considered for advanced liver disease.
Living with the condition
- Carry a note or card saying you have esophageal varices and list your medicines.
- Keep scheduled endoscopy follow-ups even when you feel well.
- Plan how you would reach an emergency department quickly, including transport at night.
- Ask for family education, since they may be the ones to call for help.
In the Saudi context
During Ramadan, ask your liver team whether fasting is safe for you and how to time your medicines; advanced cirrhosis and a recent bleed usually need caution. If you bleed, the fast must be broken and you must go to the hospital. When traveling for Umrah or Hajj, carry your medicines, your medical report, and know the location of the nearest hospital.
Questions to ask your doctor
Save this list or print it before your appointment — doctors appreciate prepared patients.
- Do I have varices, and how large are they?
- Should I take a beta-blocker or have band ligation to prevent a bleed?
- When is my next endoscopy due?
- Which medicines and painkillers should I avoid?
- What exactly should I do and where should I go if I vomit blood?
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Status: Approved for publication by SGA; individual clinician review is ongoing · Published 24/04/2026
For general education only; it does not replace your doctor’s advice. Individual clinician review of this guide is ongoing. SGA clinician? Review this guide