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Health condition · Clinically reviewed

Oesophageal varices, portal hypertension, band ligation and when TIPS fits.

A condition where advanced liver disease reroutes blood through fragile veins in the oesophagus. Screen, protect, and act fast if they bleed.

Jump to treatment
A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against Baveno VII, BSG and AASLD sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including carvedilol first-line, band ligation and pre-emptive TIPS.

Key facts

Oesophageal varices at a glance.

The essentials, in plain English - what they are, how they are found, and how the UK treats them today.

  • What it is

    Dilated submucosal veins in the lower oesophagus and gastric fundus, driven by portal hypertension in advanced liver disease.

  • Who gets them

    Around half of people with cirrhosis have varices at diagnosis, and more develop them over time.

  • Why they matter

    They are a leading cause of major upper gastrointestinal bleeding, with a six-week mortality around 20 percent after a bleed.

  • How they are found

    Upper GI endoscopy is the reference test; non-invasive Baveno VII criteria (elastography plus platelets) help select who needs it.

  • First-line drug

    Non-selective beta-blockers, with carvedilol preferred as a Baveno VII first-line for lowering portal pressure.

  • Endoscopic option

    Endoscopic variceal band ligation reduces bleeding risk and treats active haemorrhage.

Why this guide matters

Silent until they bleed - and then, minutes matter.

Varices are the classic complication of cirrhosis. Screening, non-selective beta-blockers and endoscopic banding save lives - and if a bleed happens, so does fast, protocolised care.

  • Screen everyone with cirrhosis

    Baveno VII non-invasive criteria or upper GI endoscopy pick up varices needing treatment before they bleed.

  • Prophylaxis works

    Carvedilol or band ligation reduces first bleeds and rebleeds. Consistency with the beta-blocker matters more than the exact dose.

  • A bleed is a 999 call

    Haematemesis or melaena in someone with liver disease needs immediate hospital care - resuscitation, antibiotics, terlipressin and endoscopy within 12 hours.

How the diagnosis is made

From liver disease to a clear surveillance plan.

The steps a UK hepatology team will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    Establish liver disease

    A careful history, examination and liver panel to confirm chronic liver disease and its cause.

  2. 02

    Assessing

    Non-invasive risk assessment

    Baveno VII expanded criteria combine transient elastography and platelet count to identify varices needing treatment.

  3. 03

    Assessing

    Cross-sectional imaging

    Ultrasound, MRE or CT to look for cirrhosis, portal vein thrombosis, Budd-Chiari and portal collaterals.

  4. 04

    Confirming

    Upper GI endoscopy

    The reference test - grades varices (small versus large, red signs) and rules out other bleeding sources. See our gastroscopy guide.

  5. 05

    Confirming

    Rule out other bleeds

    Portal hypertensive gastropathy, gastric varices and non-variceal ulcers can all bleed - endoscopy clarifies the source.

  6. 06

    Planning

    Specialist hepatology review

    A hepatologist matches prophylaxis and follow-up to Child-Pugh class, HVPG estimates and bleeding risk.

  7. 07

    Planning

    MDT plan

    Hepatology, gastroenterology, interventional radiology and, where relevant, transplant services agree the long-term plan.

Typical pathway: a hepatology review, a scope, and a plan tailored to your liver disease.

Symptoms

What varices actually look like.

Most people are asymptomatic until a bleed. When symptoms come, they come suddenly - and the priority shifts from surveillance to emergency care.

  • Usually silent

    Most people have no symptoms until a bleed - which is why screening endoscopy or non-invasive assessment matters.

  • Haematemesis

    Vomiting fresh red or coffee-ground blood is the classic sign of variceal haemorrhage - an emergency.

  • Melaena

    Black, tarry, foul-smelling stools mean upper GI blood - a common presentation of a variceal bleed.

  • Haemodynamic collapse

    Low blood pressure, tachycardia, dizziness or fainting after upper GI bleeding is a red flag.

  • Jaundice and ascites

    Yellowing of the skin and eyes and abdominal swelling point to decompensated liver disease behind the varices.

  • Encephalopathy

    Confusion, drowsiness or a flapping tremor can appear after a bleed and needs urgent hospital care.

  • Chronic liver signs

    Spider naevi, palmar erythema, gynaecomastia and caput medusae hint at long-standing portal hypertension.

  • Red flag - suspected bleed

    Any vomiting of blood, black stools or collapse in someone with liver disease is a 999 emergency.

Treatment

How oesophageal varices are treated in the UK.

Non-selective beta-blockers and endoscopic band ligation for prevention. Resuscitation, terlipressin, urgent endoscopy and TIPS for a bleed.

  • Carvedilol (NSBB)

    Baveno VII first-line non-selective beta-blocker for primary and secondary prophylaxis - dual alpha and beta blockade lowers portal pressure.

  • Propranolol or nadolol

    Alternative non-selective beta-blockers where carvedilol is not tolerated - specialist hepatology titrates the dose.

  • Endoscopic band ligation

    Rubber bands strangle large varices - used for primary prophylaxis, active bleeding and secondary prevention.

  • Resuscitation bundle

    IV access, restrictive transfusion to a haemoglobin around 7 to 8, and prophylactic ceftriaxone which reduces mortality.

  • Vasoactive drugs

    Terlipressin (Glypressin), octreotide or somatostatin lower portal pressure while the patient is stabilised for endoscopy.

  • Urgent gastroscopy

    Within 12 hours of a bleed - band ligation, adrenaline injection or cyanoacrylate glue for gastric varices.

  • TIPS

    Transjugular intrahepatic portosystemic shunt as rescue therapy and pre-emptively for high-risk bleeders per Baveno VII.

  • Liver transplant

    For end-stage liver disease driving recurrent variceal bleeding - assessed by a specialist transplant centre.

Supporting care

Treat the underlying liver disease.

Varices are a downstream problem. Alcohol abstinence, direct-acting antivirals for hepatitis C, weight loss for MASLD (see fatty liver disease), immunosuppression for autoimmune hepatitis, venesection for haemochromatosis, and considered anticoagulation for portal vein thrombosis. Nutritional support with a specialist dietitian, vaccinations (hepatitis A and B, pneumococcal, influenza, COVID, RSV), and, where appropriate, referral to a specialist commissioned transplant centre and the British Liver Trust.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and international specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your hepatology team knows your liver, imaging and endoscopy history and can tell you which parts apply to you. If you have any bleeding symptoms, call 999.

  • Baveno VII Consensus Workshop. Personalising care in portal hypertension.

  • British Society of Gastroenterology (BSG). UK guidelines on the management of variceal haemorrhage in cirrhotic patients.

  • AASLD. Practice guidance on portal hypertensive bleeding in cirrhosis.

  • NICE. Cirrhosis in over 16s: assessment and management (NG50).

  • British Liver Trust. Patient information on varices and portal hypertension.

Red flags

When varices need urgent attention.

Surveillance is calm and outpatient. These are the situations that are not - and where an emergency admission or specialist commissioned centre is needed.

  • Active haematemesis

    Vomiting fresh or altered blood needs a 999 call - variceal bleeding can be catastrophic within minutes.

  • Melaena with collapse

    Black stools with dizziness, fainting or a racing pulse mean significant blood loss - emergency admission.

  • New confusion

    Hepatic encephalopathy can follow a bleed - see our hepatic encephalopathy guide and seek urgent review.

  • Rebleeding after discharge

    Any repeat vomiting of blood or melaena after a variceal bleed is a re-attendance emergency.

  • Suspected gastric varices

    Deep, brisk bleeding from the fundus may need cyanoacrylate glue or TIPS at a specialist commissioned centre.

  • Refractory ascites plus varices

    A sign of advancing decompensation - warrants urgent hepatology review and transplant discussion.

  • Jaundice with fever

    May indicate spontaneous bacterial peritonitis or cholangitis complicating decompensated liver disease.

  • Portal vein thrombosis

    A new PVT on imaging changes the treatment plan and needs specialist input on anticoagulation.

  • Child-Pugh C bleeder

    High-risk group - Baveno VII supports pre-emptive TIPS within 72 hours in selected patients.

Living with it

A serious condition, with a clear plan.

Four things that make the biggest difference day to day - alcohol, medication, nutrition and vaccines. Small habits, kept up, matter.

A quiet reminder

Consistency with your beta-blocker matters most.

The single most protective thing after diagnosis is taking your NSBB every day and keeping your surveillance endoscopies.

  1. 01 Alcohol

    Stop drinking, fully

    Complete abstinence is the single biggest thing most people can do to slow cirrhosis and reduce bleeding risk.

  2. 02 Medication

    Take the beta-blocker every day

    Carvedilol or propranolol only works if it is taken consistently - do not stop without speaking to your hepatologist.

  3. 03 Nutrition

    Eat enough protein

    Malnutrition is common in cirrhosis - a specialist dietitian can help balance protein needs with encephalopathy risk.

  4. 04 Vaccines

    Keep vaccinations up to date

    Hepatitis A and B, pneumococcal, influenza, COVID and RSV vaccines are recommended in chronic liver disease.

Frequently asked

Everything we get asked about oesophageal varices.

Quick answers on screening, carvedilol, band ligation, emergency bleeds and TIPS.

  • What are oesophageal varices?

    Oesophageal varices are enlarged, thin-walled veins in the lower oesophagus and gastric fundus. They form when scarring in the liver, most often from cirrhosis, forces blood to divert through smaller veins that were never designed to carry that pressure. The veins swell, and can rupture and bleed.

  • How do I know if I have varices?

    Most people have no symptoms until they bleed. If you have chronic liver disease your hepatologist will screen you - either with upper GI endoscopy or with the Baveno VII non-invasive criteria (transient elastography and platelet count). See our gastroscopy guide for what endoscopy involves.

  • What happens if a varix bleeds?

    A variceal bleed is a medical emergency. You may vomit fresh red or coffee-ground blood, pass black tarry stools, feel dizzy or collapse. Call 999. In hospital you will get IV fluids, a restrictive blood transfusion, antibiotics (ceftriaxone), a vasoactive drug like terlipressin and an urgent endoscopy within 12 hours.

  • What is carvedilol and why is it first-line?

    Carvedilol is a non-selective beta-blocker that also blocks alpha receptors, lowering the pressure inside the portal vein. Baveno VII recommends it as the first-line drug for both primary and secondary prevention of variceal bleeding in people with clinically significant portal hypertension.

  • What is TIPS and when is it used?

    TIPS stands for transjugular intrahepatic portosystemic shunt - an interventional radiology procedure that creates a channel between the portal and hepatic veins to decompress the liver. It is used as rescue therapy for uncontrolled bleeding, for recurrent bleeds despite standard treatment, and pre-emptively within 72 hours in selected high-risk patients (Child-Pugh C or Child-Pugh B with active bleeding at endoscopy).

  • Do varices ever go away?

    They can shrink or disappear if the underlying liver disease is reversed - for example after successful hepatitis C treatment, weight loss for MASLD, or complete abstinence from alcohol. Endoscopic band ligation can also obliterate them, though repeat surveillance is still needed because they can recur.

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