Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Prediction of variceal hemorrhage in patients with cirrhosis

Arun J Sanyal, MD
Jasmohan S Bajaj, MD
Section Editor
Bruce A Runyon, MD
Deputy Editor
Kristen M Robson, MD, MBA, FACG


Cirrhosis affects 3.6 out of every 1000 adults in North America, and is responsible for more than one million days of work-loss and 32,000 deaths annually. A major cause of cirrhosis-related morbidity and mortality is the development of variceal hemorrhage, a direct consequence of portal hypertension [1]. Each episode of active variceal hemorrhage is associated with 30 percent mortality [2,3]. In addition, survivors of an episode of active bleeding have a 70 percent risk of recurrent hemorrhage within one year of the bleeding episode [4].

Variceal hemorrhage occurs in 25 to 40 percent of patients with cirrhosis [5]. While several modalities are available for primary prophylaxis of variceal bleeding, many are associated with significant adverse effects.

Accurate identification of patients at highest risk of bleeding permits stratification in an attempt to avoid potentially harmful preventive treatments in the 60 to 75 percent of patients who will never have variceal bleeding.

This topic will review the formation and progression of varices and the predictive factors and risk classification for variceal bleeding. Primary prophylaxis for variceal hemorrhage, the treatment of variceal hemorrhage, and the prevention of recurrent variceal hemorrhage in patients with cirrhosis are discussed elsewhere. (See "Primary and pre-primary prophylaxis against variceal hemorrhage in patients with cirrhosis" and "General principles of the management of variceal hemorrhage" and "Prevention of recurrent variceal hemorrhage in patients with cirrhosis".)


Portal pressure is determined by the product of portal flow volume and resistance to outflow from the portal vein. Portal hypertension (defined as hydrostatic pressure >5 mmHg) results initially from obstruction to portal venous outflow. Obstruction may occur at a presinusoidal (portal vein thrombosis, portal fibrosis, or infiltrative lesions), sinusoidal (cirrhosis), or postsinusoidal (veno-occlusive disease, Budd-Chiari syndrome) level. Cirrhosis is the most common cause of portal hypertension; in these patients, elevated portal pressure results from both increased resistance to outflow through distorted hepatic sinusoids, and enhanced portal inflow due to splanchnic arteriolar vasodilation.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jul 29, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med 2010; 362:823.
  2. Smith JL, Graham DY. Variceal hemorrhage: a critical evaluation of survival analysis. Gastroenterology 1982; 82:968.
  3. de Dombal FT, Clarke JR, Clamp SE, et al. Prognostic factors in upper G.I. bleeding. Endoscopy 1986; 18 Suppl 2:6.
  4. Graham DY, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology 1981; 80:800.
  5. Grace ND. Prevention of initial variceal hemorrhage. Gastroenterol Clin North Am 1992; 21:149.
  6. D'Amico G, Garcia-Pagan JC, Luca A, Bosch J. Hepatic vein pressure gradient reduction and prevention of variceal bleeding in cirrhosis: a systematic review. Gastroenterology 2006; 131:1611.
  7. Garcia-Tsao G, Groszmann RJ, Fisher RL, et al. Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology 1985; 5:419.
  8. Merli M, Nicolini G, Angeloni S, et al. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol 2003; 38:266.
  9. Bruno S, Crosignani A, Facciotto C, et al. Sustained virologic response prevents the development of esophageal varices in compensated, Child-Pugh class A hepatitis C virus-induced cirrhosis. A 12-year prospective follow-up study. Hepatology 2010; 51:2069.
  10. Treeprasertsuk S, Kowdley KV, Luketic VA, et al. The predictors of the presence of varices in patients with primary sclerosing cholangitis. Hepatology 2010; 51:1302.
  11. Sarin SK, Lahoti D, Saxena SP, et al. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16:1343.
  12. North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med 1988; 319:983.
  13. Beppu K, Inokuchi K, Koyanagi N, et al. Prediction of variceal hemorrhage by esophageal endoscopy. Gastrointest Endosc 1981; 27:213.
  14. Kim T, Shijo H, Kokawa H, et al. Risk factors for hemorrhage from gastric fundal varices. Hepatology 1997; 25:307.
  15. de Franchis R, Primignani M. Why do varices bleed? Gastroenterol Clin North Am 1992; 21:85.
  16. D'Amico G, Morabito A, Pagliaro L. Six week prognostic indicators in upper gastrointestinal hemorrhage in cirrhotics. Front Gastrointest Res 1986; 9:247.
  17. Singal AG, Volk ML, Jensen D, et al. A sustained viral response is associated with reduced liver-related morbidity and mortality in patients with hepatitis C virus. Clin Gastroenterol Hepatol 2010; 8:280.
  18. Bosch J, Bordas JM, Rigau J, et al. Noninvasive measurement of the pressure of esophageal varices using an endoscopic gauge: comparison with measurements by variceal puncture in patients undergoing endoscopic sclerotherapy. Hepatology 1986; 6:667.
  19. Nevens F, Bustami R, Scheys I, et al. Variceal pressure is a factor predicting the risk of a first variceal bleeding: a prospective cohort study in cirrhotic patients. Hepatology 1998; 27:15.
  20. Sanyal AJ, Fontana RJ, Di Bisceglie AM, et al. The prevalence and risk factors associated with esophageal varices in subjects with hepatitis C and advanced fibrosis. Gastrointest Endosc 2006; 64:855.
  21. Reverter E, Tandon P, Augustin S, et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology 2014; 146:412.