Esophageal Varices

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

• 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?

This guide comes from the Saudi Gastroenterology Association (SGA) patient library, prepared by the Approved for publication by SGA; individual clinician review is ongoing. Last reviewed: 2026-04-24. It is for education and does not replace your doctor's advice.