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Endoscopic signs of esophageal varices

Medical expert of the article

Oncologist, radiologist
, medical expert
Last reviewed: 04.07.2025

Esophageal varices are uneven dilation of esophageal venous trunks with development of reactive changes in surrounding tissues. More often secondary and develop with portal hypertension, caused by formation of portocaval anastomoses. Oxygen starvation sharply increases trophic disorders in the esophageal wall, which leads to development of total esophagitis. Submucous location of venous trunks contributes to their bulging into the lumen of the esophagus, the most pronounced changes are in the lower third of the esophagus and in the cardiac section, where the venous trunks are located subepithelially. When examined against the background of inflammation of the mucosa, varicose veins have the appearance of blue cords. The number of trunks is 1-4.

Classification according to morphofunctional changes.

  • Stage I. The veins are small in caliber, unevenly dilated, located in the thickness of the wall of the lower third of the esophagus. Diameter up to 2 mm. Peristalsis, mucous membrane are unchanged. The cardia closes.
  • Stage II. Vein caliber up to 3-4 mm. They are located in the lower third and often in the middle third. Peristalsis is preserved. Cardia is normal or gaping. Mucous membrane with signs of superficial inflammation or atrophy.
  • Stage III. The diameter of the veins is up to 10-15 mm. The veins are tortuous, may have varicose nodes, are located in the lower and middle third, partially extending to the upper third. Peristalsis is sluggish. The cardia is gaping. The mucosa is thinned, hyperemic, ulcers may be above the varicose nodes. Severe atrophic esophagitis, narrowing of the esophagus by 1/2.
  • Stage IV. A conglomerate of highly tortuous vessels protrudes widely into the lumen of the esophagus, covering the entire esophagus and cardiac region. Peristalsis is absent, the cardia gapes. In the distal regions there are many erosions, often in the form of a chain. Biopsy shows severe atrophic esophagitis. The lumen of the esophagus narrows to 1/3.

Among the complications, the most common is bleeding. In case of primary bleeding, the mortality rate is 40-50%, in case of relapse - up to 80%.

Criteria for distinguishing varicose veins from hypertrophic esophageal folds

  1. The veins are usually knotty, the diameter increases towards the cardia, the color is gray or blue. When inflated with air, they do not collapse. Resistance is determined during instrumental palpation.
  2. The folds, unlike the veins, are relatively smooth, their caliber is the same throughout, they break off at the cardia. Their color does not differ from the mucous membrane of the esophagus, the serrated line is preserved. With a deep breath, the folds are smoothed out, and the veins become more visible.

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