What Is Esophageal Varices? A Plain-Language Guide to the Enlarged Veins That Can Cause Life-Threatening Bleeding
Updated: 8 hours ago
Medically reviewed by Dr. Baraa Alnahhal, MD · Last reviewed: November 9, 2026
Quick Answer
Esophageal varices are enlarged veins in the esophagus that most often form in people with serious liver disease, when blocked liver blood flow raises portal vein pressure. They usually cause no symptoms until they bleed, causing vomiting of blood and black stools. People with cirrhosis are screened by endoscopy. Bleeding is a life-threatening emergency needing immediate treatment. [1] [2]
What the Research Says
Varices are very common in cirrhosis, and many bleed. A Cochrane network meta-analysis reports that approximately 40% to 95% of people with cirrhosis have esophageal varices, and about 15% to 20% of them bleed within about one to three years. (Roccarina et al., Cochrane Database Syst Rev, 2021) [3]
Bleeding carries a real risk of death. In two large cohorts from the United States and Singapore, 1,349 people with cirrhosis presented with acute variceal bleeding, and the overall 6-week mortality was 14.4%. (Wong et al., Clin Gastroenterol Hepatol, 2025) [4]
Bands and medicines both work, with some differences. A meta-analysis of 14 randomized trials (1,345 people) found band ligation was more effective than propranolol at preventing esophageal variceal bleeding (risk ratio 1.40; 95% CI 1.02-1.91), with no difference in bleeding-related deaths or in deaths from any cause (risk ratio 0.93; 95% CI 0.76-1.14). (Süffert et al., Hepatol Int, 2025) [5]
Early TIPS lowered deaths and rebleeding in acute bleeding. A network meta-analysis of 24 randomized trials (1,894 people) found that, compared with standard treatment, early TIPS was associated with a lower risk of death from any cause (odds ratio 0.53; 95% CrI 0.30-0.94) and of rebleeding (odds ratio 0.19; 95% CrI 0.11-0.28); the authors advise weighing each person's bleeding severity, liver disease and overall condition before choosing it. (Huang et al., Int J Surg, 2024) [7]
Emergency care follows a clear sequence. A clinical review recommends antibiotics and vasoactive drugs for people with cirrhosis who have upper gastrointestinal bleeding, with endoscopy within 24 hours; band ligation is used for esophageal varices, and recurrent variceal bleeding is generally treated with TIPS. (Stanley & Laine, BMJ, 2019) [8]
What Are Esophageal Varices?
Esophageal varices are enlarged veins in the esophagus. They form when regular blood flow to the liver is blocked by a clot or scar tissue in the liver. To go around the blockage, blood flows into smaller blood vessels that are not designed to carry large volumes of blood. The vessels can leak blood or even burst, causing life-threatening bleeding. [1]
A few medicines and medical procedures are available to help prevent or stop bleeding from esophageal varices.
What Are the Symptoms of Esophageal Varices?
Esophageal varices usually don't cause symptoms unless they bleed. That is what makes them so dangerous: they can grow quietly for years without any warning. [1]
The symptoms of bleeding esophageal varices include:
Vomiting large amounts of blood.
Black, tarry, or bloody stools.
Lightheadedness due to blood loss.
Loss of consciousness in severe cases.
A healthcare professional might suspect esophageal varices if someone has signs of liver disease or has been diagnosed with cirrhosis. Those signs include yellow coloration of the skin and eyes (jaundice), easy bleeding or bruising, and fluid buildup in the belly (ascites). For more on this condition, see Cirrhosis of the Liver.
When should you call a doctor?
Make an appointment with a healthcare professional if you have symptoms that worry you. If you've been diagnosed with liver disease, ask your care team about your risk of esophageal varices, what you can do to reduce it, and whether you should have a procedure to check for them.
If you've been diagnosed with esophageal varices, you will likely be told to watch for signs of bleeding. Bleeding esophageal varices are an emergency. Call 911 or your local emergency services right away if you have black or bloody stools, or bloody vomit. [1]
What Causes Esophageal Varices?
Esophageal varices sometimes form when blood flow to the liver is blocked. This is most often caused by scar tissue in the liver from liver disease, known as cirrhosis. The blood flow begins to back up, which increases pressure within the large vein that carries blood to the liver, the portal vein. This is called portal hypertension. [1] To learn how this vein works, see The Portal Vein.
Portal hypertension forces blood to seek other pathways through smaller veins, such as those in the lowest part of the esophagus. These thin-walled veins balloon with the added blood, and sometimes they rupture and bleed. The portal vein carries blood from the intestine, pancreas, and spleen to the liver, so when that flow is blocked, pressure builds and blood searches for side roads. There are three main causes:
Severe liver scarring (cirrhosis): several liver diseases, including hepatitis infection, alcohol-related liver disease, fatty liver disease, and a bile duct disorder called primary biliary cholangitis, can result in cirrhosis. Scar tissue blocks regular blood flow. [1]
A blood clot (thrombosis): a clot in the portal vein or in the splenic vein, which feeds into the portal vein, can cause esophageal varices. [1]
Parasitic infection: schistosomiasis, found in parts of Africa, South America, the Caribbean, the Middle East, and East Asia, can damage the liver, as well as the lungs, intestine, bladder, and other organs. [1]
What Raises the Risk of Bleeding?
Although many people with advanced liver disease develop esophageal varices, most won't have bleeding. But certain factors make bleeding more likely: [1]
High portal vein pressure: the risk of bleeding increases as the pressure in the portal vein increases.
Large varices: the larger the varices, the more likely they are to bleed.
Red marks on the varices: long red streaks or red spots, seen through an endoscope, suggest a high risk of bleeding.
Severe cirrhosis or liver failure: most often, the more serious the liver disease, the more likely varices are to bleed.
Continued alcohol use: the risk of variceal bleeding is far greater for people who continue to drink, especially if the disease is alcohol related.
A previous bleed: if someone had bleeding from esophageal varices before, they are more likely to have varices that bleed again.
What Happens if Esophageal Varices Bleed?
The most serious complication of esophageal varices is bleeding. If a person has a bleeding episode, the risk of another bleeding episode greatly increases. If a person loses enough blood, they can go into shock, which can lead to death. [1] [4]
How Are Esophageal Varices Diagnosed?
An upper endoscopy involves inserting a long, flexible tube called an endoscope down your throat and into your esophagus. A tiny camera on the end allows views of your esophagus, stomach, and the beginning of your small intestine, called the duodenum. If someone is diagnosed with cirrhosis, a healthcare professional will typically screen for esophageal varices. How often screening is done depends on the person's condition. [2]
Upper endoscopy: the preferred method of screening. The professional looks for dilated veins, measures any enlarged veins found, and checks for red streaks and red spots, which usually indicate a significant risk of bleeding. Treatment can be performed during the exam.
Abdominal CT scan: imaging that can suggest the presence of esophageal varices.
Doppler ultrasound of the splenic and portal veins: imaging that can suggest the presence of esophageal varices.
Transient elastography (ultrasound): measures scarring in the liver, which can help determine whether someone has portal hypertension that may lead to esophageal varices.
How Are Esophageal Varices Treated?
The primary aim in treating esophageal varices is to prevent bleeding. Bleeding esophageal varices are life-threatening, and if bleeding happens, treatments are available to try to stop it. [2]
How do doctors prevent bleeding?
Treatments that lower blood pressure in the portal vein may reduce the risk of bleeding.
Beta blocker medicines: a type of blood pressure drug that may help reduce pressure in the portal vein, decreasing the likelihood of bleeding. Examples include propranolol and nadolol. [2]
Endoscopic band ligation: recommended if varices appear to have a high risk of bleeding, or if they have bled before. Using an endoscope, the professional uses suction to pull the varices into a chamber at the end of the scope and wraps them with an elastic band. It carries a small risk of complications, such as bleeding and scarring of the esophagus. [2]
A key limit: beta blockers are effective in preventing bleeding in many people with esophageal varices, but they don't stop varices from forming, and currently no treatment can prevent the development of esophageal varices in people with cirrhosis. [1] Research comparing the two approaches for preventing a first bleed found band ligation was more effective than propranolol, with no difference in bleeding-related deaths. [5]
What happens during a bleeding emergency?
Bleeding esophageal varices are life-threatening, and immediate treatment is essential. Treatments used to stop bleeding and reverse the effects of blood loss include: [2]
Elastic bands: wrapped around the bleeding varices during an endoscopy.
Portal-vein flow medicines: octreotide and vasopressin slow the flow of blood to the portal vein. Medicine is usually continued for up to five days after a bleeding episode. A 2025 randomized trial of 220 people who also had band ligation found a 1-day and a 5-day octreotide infusion gave similar 5-day rebleeding (1.83% vs 1.80%) and 6-week mortality (5.50% vs 6.31%), so the duration is chosen by the treating team. [6]
TIPS (shunt): a transjugular intrahepatic portosystemic shunt creates an opening between the portal vein and the hepatic vein, which carries blood from the liver to the heart. It reduces pressure in the portal vein and often stops bleeding, but can cause serious complications, including liver failure and mental confusion. It is mainly used when all other treatments have failed or as a temporary measure for people awaiting a liver transplant. See Understanding the Hepatic Veins.
Balloon tamponade: a balloon is inflated to put pressure on the varices for up to 24 hours, temporarily stopping bleeding before other treatments can be performed. It carries a high risk of bleeding recurrence after the balloon is deflated and can cause serious complications.
Blood transfusion and clotting factor: to replace lost blood and help stop bleeding.
Antibiotics: the risk of infection rises with bleeding, so an antibiotic may be prescribed.
Liver transplant: an option for people with severe liver disease or recurrent bleeding. Although often successful, the number of people awaiting transplants far outnumbers the available organs.
What about preventing rebleeding?
There is a high risk that bleeding will recur in people who've had bleeding from esophageal varices. Beta blockers and endoscopic band ligation are the recommended treatments to help prevent rebleeding. After initial banding, a healthcare professional will repeat an upper endoscopy at regular intervals, and more banding may be done until the varices are gone or small enough to reduce the risk of further bleeding. [2]
What treatments are being researched?
Researchers are exploring an experimental emergency therapy that involves spraying an adhesive hemostatic powder through a catheter during an endoscopy. It sticks to the varices and may stop bleeding. Another possible option when all other measures fail is the use of self-expanding metal stents, placed during an endoscopy to put pressure on the bleeding varices. They could damage tissue and can migrate, the stent should be removed within seven days, and bleeding could recur. Both options are experimental and not yet widely available. [2]
How Can You Protect Your Liver and Lower Your Risk?
If you've been diagnosed with liver disease, ask a healthcare professional about ways to avoid complications. To keep your liver healthy:
Don't drink alcohol: the liver processes alcohol, and continued drinking raises variceal bleeding risk far more, especially in alcohol-related disease. [1]
Eat a healthy diet: choose fruits and vegetables, whole grains, and lean sources of protein, and reduce fatty and fried foods.
Maintain a healthy weight: excess body fat can damage your liver, and obesity is associated with a greater risk of cirrhosis complications.
Use chemicals sparingly and carefully: follow directions on household chemicals such as cleaning supplies and insect sprays, and workplace safety precautions.
Reduce your risk of hepatitis: sharing needles and unprotected sex can increase your risk of hepatitis B and C. Get tested for hepatitis A, B, and C, and ask your healthcare professional whether you should be vaccinated for hepatitis A and B.
How Should You Prepare for Your Appointment?
You might start by seeing someone on your primary healthcare team, or you may be referred to a gastroenterologist, a specialist in digestive disorders. If you're having symptoms of internal bleeding, call 911 or your local emergency number to be taken to the hospital for urgent care.
When you make the appointment, ask if there's anything you need to do in advance, such as fasting before a test. Make a list of your symptoms, key personal information (including recent travel, family and medical history, and your alcohol use), all medicines, vitamins, and supplements you take with doses, and questions to ask. Take a family member or friend along if possible, to help you remember information.
Your doctor will likely ask when your symptoms began, whether they have stayed the same or gotten worse, whether you've had signs of bleeding such as blood in your stools or vomit, whether you've had hepatitis or jaundice, whether you've traveled recently and where, and, if you drink alcohol, when you started and how much you drink. While you wait for your appointment, if you develop bloody vomit or stools, call 911 or your local emergency number or go to an emergency room immediately.
Conclusion
Esophageal varices are enlarged veins in the esophagus that form when liver scarring, blood clots, or certain parasitic infections block blood flow to the liver and force pressure into small veins not built for it. They rarely cause symptoms until they bleed, and a bleed is a life-threatening emergency. If you live with liver disease, ask your doctor about your varices risk and about screening with an upper endoscopy. With beta blockers, elastic banding, and modern emergency treatments, bleeding can often be prevented or stopped. Protect your liver, know the warning signs, and never hesitate to call for emergency help.
Frequently Asked Questions
What are esophageal varices?
Esophageal varices are enlarged veins in the esophagus, the tube that connects the throat and stomach. They most often happen in people with serious liver diseases. [1]
What causes esophageal varices?
Esophageal varices form when regular blood flow to the liver is blocked, most often by scar tissue from cirrhosis, but also by blood clots or a parasitic infection called schistosomiasis. Pressure backs up in the portal vein and blood is forced into thin-walled veins that balloon out. [1]
How common are esophageal varices in people with cirrhosis?
A Cochrane review reports that approximately 40% to 95% of people with cirrhosis have esophageal varices, and about 15% to 20% of them bleed within about one to three years after diagnosis. [3]
Do esophageal varices cause symptoms?
Usually not, unless they bleed. That is why screening matters for people with cirrhosis. Bleeding causes vomiting large amounts of blood, black or bloody stools, lightheadedness, and sometimes loss of consciousness. [1]
Is bleeding from esophageal varices dangerous?
Yes. Bleeding esophageal varices are a life-threatening emergency. Losing enough blood can cause shock, which can lead to death. In a study of 1,349 people with cirrhosis and acute variceal bleeding, 14.4% died within six weeks. [4] Call 911 or your local emergency services right away if you have black or bloody stools or bloody vomit.
How are esophageal varices found?
People diagnosed with cirrhosis are typically screened, mainly with an upper endoscopy, a thin flexible tube with a tiny camera passed down the throat. Imaging tests such as CT scans and ultrasounds can also suggest varices. [2]
Can esophageal varices be prevented?
No treatment can prevent esophageal varices from developing in people with cirrhosis. But bleeding can often be prevented with beta blocker medicines or by tying off the veins with elastic bands during an endoscopy. [2]
What is endoscopic band ligation?
During an endoscopy, suction pulls the varices into a chamber at the end of the scope, and elastic bands are wrapped around them. This essentially cuts off blood flow so the veins can't bleed. [2]
Are bands or beta blockers better at preventing the first bleed?
A 2025 meta-analysis of 14 randomized trials (1,345 people) found band ligation was more effective than propranolol at preventing esophageal variceal bleeding, with no difference in bleeding-related deaths. The best choice depends on the person, so it is decided with a gastroenterologist. [5]
What happens if bleeding can't be stopped with bands or medicines?
A shunt procedure called TIPS may redirect blood flow away from the portal vein. A balloon may be inflated against the varices as a temporary measure. A transfusion can replace lost blood, antibiotics can prevent infection, and a liver transplant is an option for severe or recurrent cases. [2]
Can esophageal varices bleed again after a first episode?
Yes. The risk of another bleeding episode greatly increases after one episode. Beta blockers and endoscopic band ligation are recommended to prevent rebleeding, with repeat endoscopies at regular intervals. [2]
How can I lower my risk of variceal bleeding if I have liver disease?
Don't drink alcohol, eat a diet rich in fruits, vegetables, whole grains and lean protein, maintain a healthy weight, use household and workplace chemicals carefully, and protect yourself against hepatitis A, B and C, including asking about vaccination for hepatitis A and B.
Related Reading on Rinnit.com
Cirrhosis of the Liver: What It Is, How Permanent Scarring Damages Your Liver, and What Treatment Involves: the most common cause of esophageal varices.
Portal Vein: Anatomy, Function, Conditions and Testing: the vein whose raised pressure drives varices to form.
Understanding the Hepatic Veins: Anatomy, Function, and Health: the veins that connect to the TIPS shunt.
References
Mayo Clinic Staff. Esophageal varices: Symptoms and causes. Mayo Clinic. March 6, 2025. https://www.mayoclinic.org/diseases-conditions/esophageal-varices/symptoms-causes/syc-20351538
Mayo Clinic Staff. Esophageal varices: Diagnosis and treatment. Mayo Clinic. March 6, 2025. https://www.mayoclinic.org/diseases-conditions/esophageal-varices/diagnosis-treatment/drc-20351544
Roccarina D, et al. Primary prevention of variceal bleeding in people with oesophageal varices due to liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev. 2021;4(4):CD013121. PMID 33822357. https://doi.org/10.1002/14651858.CD013121.pub2
Wong YJ, et al. Nonalcohol-related Cirrhosis Leads to Higher 6-week Mortality After Acute Variceal Bleeding Than Alcohol-related Cirrhosis. Clin Gastroenterol Hepatol. 2025;23(10):1776-1785.e10. PMID 39675401. https://doi.org/10.1016/j.cgh.2024.10.022
Süffert LC, Beis LPP, Padilha IH, et al. Propranolol versus endoscopic variceal ligation for primary prophylaxis of esophageal varices in cirrhosis: a systematic review and meta-analysis of randomized controlled trials. Hepatol Int. 2025;19(6):1444-1453. PMID 40968192. https://doi.org/10.1007/s12072-025-10903-6
Chirapongsathorn S, et al. One vs Five Days of Octreotide Infusion for Acute Esophageal Variceal Bleeding: A Randomized Controlled Trial. Am J Gastroenterol. 2026;121(8):1885-1894. PMID 41090987. https://doi.org/10.14309/ajg.0000000000003791
Huang Y, Wang X, Li X, et al. Comparative efficacy of early TIPS, Non-early TIPS, and Standard treatment in patients with cirrhosis and acute variceal bleeding: a network meta-analysis. Int J Surg. 2024;110(2):1149-1158. PMID 37924494. https://doi.org/10.1097/JS9.0000000000000865
Stanley AJ, Laine L. Management of acute upper gastrointestinal bleeding. BMJ. 2019;364:l536. PMID 30910853. https://doi.org/10.1136/bmj.l536
Medical disclaimer
This content is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you are vomiting blood or passing black or bloody stools, call 911 or your local emergency number immediately.
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