Why do varices bleed?

About one third of cirrhotic patients with esophageal varices eventually bleed from ruptured varices. The incidence of rebleeding is extremely high during the first 6 weeks after the initial bleeding but declines gradually thereafter. Later, the rebleeding risk returns to baseline levels, i.e., equals that of patients who have never bled. The size of varices and the presence of red color signs on the variceal wall are recognized by most investigators as important in assessing the risk of variceal hemorrhage. Prognostic indexes such as the NIEC index, which incorporate the endoscopic signs with clinical data such as the Child-Pugh score, have been shown to predict the probability of first variceal hemorrhage of individual patients reliably. Other important parameters are the presence of ascites and, in alcoholic cirrhotics, the lack of abstinence from alcohol. The presence of endoscopic signs of bleeding or of stigmata of recent bleeding, of large varices, or of liver failure at the time of first bleeding are risk factors for early rebleeding. The most important risk factors for late rebleeding are the presence of large varices, overt signs of hepatic decompensation, the development of hepatocellular carcinoma, and lack of alcohol abstinence.