[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [General pathology](https://durgical.com/en/general-pathology/) › [Gastrointestinal tract](https://durgical.com/en/general-pathology/areas/gi/) › Oesophageal varices: portosystemic collaterals and why they bleed # Oesophageal varices: portosystemic collaterals and why they bleed - Lesion When blood cannot pass easily through the liver, it detours through veins in the lower oesophagus, which swell and can burst. Updated Nov 12, 2026 ## Key points - Present in about a third of compensated and more than half of decompensated cirrhosis. - Rupture causes massive haematemesis; each bleed carries a high death rate, and rebleeding is common. - Schistosomiasis is a leading cause of non-cirrhotic portal hypertension worldwide. - Other portosystemic sites: rectum (anorectal varices), umbilicus (caput medusae), retroperitoneum. - Low platelet count from hypersplenism is a clue to portal hypertension. ## What it is Portal hypertension forces portal blood into collateral channels wherever the portal and systemic veins meet. At the gastro-oesophageal junction, the left gastric (coronary) vein connects with oesophageal veins that drain to the azygos system; these thin submucosal veins dilate into varices. Most cases are due to cirrhosis, but presinusoidal (portal vein thrombosis, schistosomiasis) and postsinusoidal (Budd–Chiari) obstruction also cause them. ## Structure - Gross: tortuous dilated veins in the submucosa of the distal oesophagus and proximal stomach; they collapse after death, so they are easy to miss at autopsy. - Micro: thin-walled dilated veins in the submucosa and lamina propria with thinned overlying epithelium. - After rupture: haemorrhage into the lumen or wall, mucosal ulceration and necrosis; later thrombosis, inflammation and changes from earlier band ligation or sclerotherapy. ## Step by step - Resistance to portal flow rises (most often from cirrhosis). - Portal pressure rises and blood is diverted into portosystemic collaterals. - The left gastric to oesophageal (azygos) connection carries much of the flow. - Submucosal veins dilate and their walls and covering mucosa thin. - Erosion of the mucosa or a further pressure rise ruptures the varix. ## Clinical notes - Variceal bleeding is an emergency managed with splanchnic vasoconstrictors, endoscopic band ligation, balloon tamponade or a portosystemic shunt. - Bleeding can tip a patient with cirrhosis into hepatic encephalopathy, because blood in the gut is a protein load. ## Memory aid Blocked at the liver, blood takes the side road through the oesophagus, and the road is paper-thin. ## Test yourself Think of the answer, then tap the question to see it. ## Which venous connection forms oesophageal varices? The left gastric (coronary) vein of the portal system joining oesophageal veins that drain into the azygos system. ## Why can varices be missed at autopsy? The veins collapse when blood pressure is lost, so they flatten unless specially prepared. ## Which non-cirrhotic cause of varices is common in endemic regions? Schistosomiasis, which causes presinusoidal portal hypertension through periportal fibrosis. [Add to my cards (3)](https://durgical.app/estudiar/?add=/en/general-pathology/oesophageal-varices-portosystemic-collaterals-and-why-they-bleed/) [More Pathology questions →](https://durgical.com/en/practice/?f=pathology) ## Connections ## Related 6 - [Portal hypertension](https://durgical.com/en/general-pathology/portal-hypertension/) - [Cirrhosis: morphology](https://durgical.com/en/general-pathology/cirrhosis-morphology/) - [Oesophageal lacerations: Mallory–Weiss tear and Boerhaave rupture](https://durgical.com/en/general-pathology/oesophageal-lacerations-mallory-weiss-tear-and-boerhaave-rupture/) - [The anal canal: haemorrhoids, condyloma and anal carcinoma](https://durgical.com/en/general-pathology/the-anal-canal-haemorrhoids-condyloma-and-anal-carcinoma/) - [Hemorrhage: petechiae, purpura, ecchymosis, hematoma, and what blood loss does](https://durgical.com/en/general-pathology/hemorrhage-petechiae-purpura-ecchymosis-hematoma-and-what-blood-loss-does/) - [Hyperemia and congestion (the nutmeg liver, heart-failure cells)](https://durgical.com/en/general-pathology/hyperemia-and-congestion/) ## Related conditions 7 - [Portal hypertension](https://durgical.com/en/conditions/portal-hypertension/) - [Cirrhosis](https://durgical.com/en/conditions/cirrhosis/) - [Upper gastrointestinal bleeding](https://durgical.com/en/conditions/upper-gastrointestinal-bleeding/) - [Budd-Chiari syndrome](https://durgical.com/en/conditions/budd-chiari-syndrome/) - [Portal vein thrombosis](https://durgical.com/en/conditions/portal-vein-thrombosis/) - [Metabolic dysfunction-associated steatotic liver disease (MASLD/NAFLD)](https://durgical.com/en/conditions/metabolic-dysfunction-associated-steatotic-liver-disease/) - [Hepatic encephalopathy](https://durgical.com/en/conditions/hepatic-encephalopathy/) [← All of general pathology](https://durgical.com/en/general-pathology/) Educational content on the mechanisms of disease; not a diagnostic or treatment guide and no substitute for a health professional's advice. No doses are given. Sources: [Bleeding esophageal varices: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/000268.htm) (MedlinePlus, US National Library of Medicine, 2025); [Upper Gastrointestinal Bleeding](https://www.ncbi.nlm.nih.gov/books/NBK470300/) (StatPearls (NCBI Bookshelf), 2025). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/general-pathology/oesophageal-varices-portosystemic-collaterals-and-why-they-bleed/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/general-pathology/oesophageal-varices-portosystemic-collaterals-and-why-they-bleed/