Esophageal varices
Formal Definition
Dilated submucosal veins in the distal esophagus, most commonly resulting from portal hypertension secondary to liver cirrhosis; varices develop when portal pressure exceeds 10 mmHg; they are at risk of rupture causing massive hematemesis and are a leading cause of death in cirrhotic patients; prophylaxis against first bleed (beta-blockers, endoscopic band ligation) and management of acute hemorrhage (IV Octreotide, endoscopic band ligation, balloon tamponade as bridge) are critical interventions.
How It's Used on the Ward
"Varices" — the dilated veins in the esophagus that are the dangerous consequence of portal hypertension from cirrhosis; when they bleed, the patient vomits blood (hematemesis) in large quantities; the biggest risk in any cirrhotic patient who suddenly starts throwing up blood.
Example
""52-year-old alcoholic cirrhosis patient presents with hematemesis and orthostatic dizziness. BP 90/58, HR 118, Hgb 7.2 g/dL (baseline ~10). NG tube returns bloody aspirate. CT abdomen shows cirrhotic liver with portal hypertension, splenomegaly, ascites. Diagnosis: acute variceal hemorrhage. Two large bore IVs placed, IV octreotide started (portal vasoconstriction), ceftriaxone started for SBP prophylaxis, FFP and platelets ordered. Urgent EGD within 6h: band ligation of bleeding varix. SBP prophylaxis continued for 7 days.""
Clinical Context
Primary prophylaxis: non-selective beta-blockers (propranolol, nadolol) reduce portal pressure and prevent first bleed; EGD screening every 2 years if no varices. Acute management: ABCs (airway protection, large bore IVs, ICU), IV octreotide (somatostatin analog — reduces portal pressure), ceftriaxone (SBP prophylaxis in all cirrhotics with GI bleed), correct coagulopathy (FFP, platelets, vitamin K), restrict fluids if tense ascites. Endoscopic band ligation (EBL) within 12h is definitive treatment. Balloon tamponade (Sengstaken-Blakemore tube) as bridge if unstable and EGD unavailable. TIPS (transjugular intrahepatic portosystemic shunt) for refractory bleeding. Secondary prophylaxis: repeat EBL q2-4weeks until variceal eradication + NSBB. Variceal location: 85% in lower 5cm of esophagus. Gastric varices (fundal) — harder to treat, may need cyanoacrylate glue injection or TIPS.