Esophageal Varices: Portal Hypertension Pathophysiology, Bleeding Risk, and Management

Esophageal varices are dilated submucosal veins in the distal esophagus, caused by portal hypertension (elevated pressure in the portal vein). Common etiologies: cirrhosis (most common), portal vein thrombosis, schistosomiasis.

Pathophysiology

Portal obstruction → portosystemic collateral formation (esophageal, gastric, rectal, caput medusae). Varices have thin walls, high flow, and are prone to rupture.

Bleeding Risk Stratification

• Size (large >5 mm), red wale marks, Child-Pugh class C.
• HVPG >12 mmHg (hepatic venous pressure gradient).

Management

• Primary prophylaxis: Non-selective beta-blockers (propranolol, nadolol) or endoscopic band ligation (EBL).
• Acute bleed: Vasoactives (terlipressin, octreotide) + antibiotic prophylaxis + urgent EBL (within 12h).
• Secondary prophylaxis: NSBB + EBL surveillance.
• Refractory: TIPS, BRTO, or surgery.