3. Hiatus Hernia

📄 Definition

Oesophageal varices are dilated submucosal veins in the lower third of the oesophagus, which develop due to portal hypertension, usually secondary to liver cirrhosis. They are at risk of rupture, causing life-threatening upper gastrointestinal bleeding.

🛡️ Aetiology / Risk Factors (Mnemonic: PORTAL)

  • Portal hypertension (most common cause)

  • Overuse of alcohol → cirrhosis

  • Right heart failure (rare)

  • Thrombosis of portal vein

  • Autoimmune liver disease (e.g. PBC, PSC)

  • Liver cirrhosis (e.g. viral hepatitis, NAFLD)

📋 Clinical Features (Mnemonic: VOMIT)

Often asymptomatic until bleeding occurs

  • Vomiting blood (haematemesis)

  • Orthostatic hypotension / shock

  • Melaena (black tarry stool)

  • Iron-deficiency anaemia (chronic blood loss)

  • Tachycardia & signs of hypovolaemia

In known cirrhosis: signs include jaundice, ascites, caput medusae, encephalopathy

⚠️ Red Flag = Suspected Upper GI Bleed

  • Immediate referral for urgent resuscitation and endoscopy

  • ABCDE assessment → Major Haemorrhage Protocol if unstable

  • Crossmatch blood and activate GI bleed team

🔬 Investigations

  • Urgent OGD (gold standard for diagnosis & treatment)

  • FBC – anaemia, thrombocytopenia

  • U&Es – renal function, hyponatraemia

  • LFTs – assess underlying liver disease

  • Clotting screen (INR/PT) – bleeding risk

  • Group & Save / crossmatch

  • CT/MRI abdomen – assess liver, portal vein, and splenic vasculature

💊 Management

📍 Acute Bleed (Resuscitation & Stabilisation)

  • High-flow O2, large-bore cannulas

  • Fluid resuscitation ± blood transfusion

  • Terlipressin IV (splanchnic vasoconstrictor)

  • Antibiotic prophylaxis: e.g. IV ceftriaxone

  • Endoscopy within 12 hours: band ligation ± sclerotherapy

  • Balloon tamponade (e.g. Sengstaken-Blakemore tube) if uncontrolled bleeding

  • Discuss TIPS if refractory

Secondary Prevention

  • Non-selective beta-blocker: propranolol or carvedilol

  • Regular surveillance endoscopy: typically every 1–3 years

  • Repeat band ligation if varices reappear

  • Consider TIPS (Transjugular Intrahepatic Portosystemic Shunt) if high-risk or rebleeding

Primary Prevention (in known cirrhosis)

  • Screen with OGD at diagnosis

  • If medium/large varices:

    • Start non-selective beta-blocker, or

    • Offer prophylactic band ligation

  •  

Complications (Mnemonic: SHOCKED)

  • Severe haemorrhage → hypovolaemic shock

  • Hepatic encephalopathy

  • Oesophageal perforation (post-intervention)

  • Coagulopathy-related bleeding

  • Kidney injury (hepatorenal syndrome)

  • End-organ hypoperfusion

  • Death (high mortality if untreated)

Last updated in line with NICE NG50 (Cirrhosis in over 16s: assessment and management)
Published: July 2016 • Last updated: March 2023
Last reviewed: July 2025
PASSMAP ensures all content is NICE-aligned and reviewed for Physician Associate Registration Assessment (PARA) success.

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