Medical Oncologist
CION Cancer Clinics
Bevacizumab and bleeding risk when you have varices | CION Cancer Clinics
Bevacizumab can make bleeding from varices more likely. That is why people with liver cancer and cirrhosis have an endoscopy, and any large varices treated, before it is started. This page explains what the team checks, how varices are made safe, who should not have bevacizumab, and the bleeding signs that mean going to hospital immediately. At CION Cancer Clinics, our team supports patients and families through symptoms, follow-up and life during and after treatment.
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Medically reviewed by Dr. Naresh GunduConsultant Medical Oncologist · MBBS, DNB (Internal Medicine), DM (Medical Oncology, AIIMS) · last reviewed October 2026, next review due October 2027
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On this page
- Does bevacizumab make varices more likely to bleed?
- What does the team look at before starting bevacizumab?
- How are varices made safe before treatment starts?
- Which words on an endoscopy report matter for bevacizumab?
- What do families often get wrong about bevacizumab and bleeding?
- Who does bevacizumab not suit, and what can this page not tell you?
- Common questions about bevacizumab and bleeding
The short answer
Does bevacizumab make varices more likely to bleed?
Yes, it can. Bevacizumab slows the growth of new blood vessels, and that same effect makes bleeding from fragile veins more likely. This is why anyone with liver cancer and cirrhosis has their food pipe checked for varices before the medicine is started.
This page is about primary liver cancer, the kind that starts in the liver, usually hepatocellular carcinoma (HCC). Bevacizumab is most often given here together with atezolizumab, an immunotherapy medicine. If your cancer started in the bowel and spread to the liver, the questions are different, and your colon cancer team will guide you.
What varices are, in one sentence
Varices are swollen veins in the lower food pipe or the stomach. They form when scarring in the liver (cirrhosis) pushes blood pressure up in the vein that feeds the liver, called portal hypertension. Our page on varices explained covers this in more detail.
Why this matters more than most side effects
A bleed from varices is the most dangerous emergency in this disease. It can happen suddenly, with no warning, in someone who felt well that morning. The checks before bevacizumab exist to stop that from happening, and they work well when they are done properly.
Bleeding risk is a reason to check and prepare. It is not, on its own, a reason to refuse the treatment.Before the first dose
What does the team look at before starting bevacizumab?
The decision rests on three things: the veins, the liver and the person.
The veins in the food pipe
A recent endoscopy shows whether varices are present, how large they are, and whether they carry red marks that suggest a high chance of bleeding. Large or high-risk varices are treated first.
How well the liver works
Blood tests for bilirubin, albumin and INR (a measure of how well the blood clots) feed into the Child-Pugh score. A liver that is struggling bleeds more easily and copes less well with any treatment.
Also checked
- Platelet count, which is often low in cirrhosis
- Whether there is fluid in the abdomen
- Whether the portal vein is blocked by clot or tumour
Past bleeding
Anyone who has already had a bleed from varices, or from a stomach ulcer, carries a higher risk. The team will ask about any black stools or vomiting of blood, however long ago.
Other medicines and conditions
Blood thinners, aspirin and other painkillers, uncontrolled blood pressure, a recent operation or a wound that has not healed all add to the risk. Bring every tablet you take to the appointment.
Not sure whether this applies to you?
Ask an oncologist
!
Call an ambulance or go to hospital now
If you vomit blood, vomit something that looks like coffee grounds, pass black, sticky or tarry stools, or suddenly feel faint, cold and sweaty, go to the nearest emergency department immediately. Call an ambulance if you can. Do not wait to see if it settles, and do not wait for your next appointment. Tell the hospital you have liver cancer, have cirrhosis and are on bevacizumab. Our page on vomiting blood explains what to do on the way.
Step by step
How are varices made safe before treatment starts?
An endoscopy first
A thin camera is passed through the mouth into the food pipe and stomach, usually under sedation. CION arranges this with a partner gastroenterology team. The reasons are explained on our page on why the endoscopy comes first.
Treating varices that need it
Large varices can be tied off with small rubber bands during the endoscopy. This is called banding. Some people are given a beta-blocker tablet to lower the pressure in the veins instead, or as well.
A short wait, then a decision
After banding, the banding sores need time to heal. The tumour board then decides whether bevacizumab is safe to start, or whether a different first treatment is wiser.
Watching during treatment
Blood tests and blood pressure are checked before each treatment. Repeat endoscopies are planned with the gastroenterology team. Any bleeding, however small, is reported straight away.
On your report
Which words on an endoscopy report matter for bevacizumab?
- Oesophageal varices
- Swollen veins in the lower food pipe. The report usually says whether they are small, medium or large.
- Red wale signs
- Red streaks on the surface of a varix. They suggest a thin wall and a higher chance of bleeding.
- Gastric varices
- Swollen veins in the stomach. They are treated differently from food pipe varices and need specialist planning.
- Portal hypertensive gastropathy
- Fragile, oozing stomach lining caused by high pressure in the portal vein. It can cause slow blood loss and a low blood count.
- Band ligation (EVL)
- Tying off varices with small rubber bands through the endoscope. It may take more than one session.
- No varices seen
- Good news for now. Varices can still appear later, so the team may repeat the check during treatment.
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Commonly believed
What do families often get wrong about bevacizumab and bleeding?
"If there are varices, bevacizumab can never be given."
Varices that have been treated, or small ones with low risk, do not always rule it out. The team decides after the endoscopy and any banding, case by case.
"He has never bled, so the endoscopy is not needed."
Most varices give no symptoms until the first bleed. The endoscopy is how the team finds them before that happens, which is the whole point.
"A little blood in the vomit is nothing to worry about."
On bevacizumab with cirrhosis, any blood in the vomit or any black stool is an emergency. Go to hospital the same day, at any hour.
"Bleeding means the cancer has got worse."
A bleed usually comes from the varices, which are caused by the cirrhosis. It does not tell you how the tumour is responding. That question is answered by scans.
Being straight with you
Who does bevacizumab not suit, and what can this page not tell you?
Bevacizumab is usually not a safe choice for someone who has had a recent serious bleed, has large varices that have not been treated, has very poor liver function, or has had recent surgery with a wound that is still healing. People with certain heart or blood vessel problems, or blood pressure that cannot be controlled, may also be steered away from it. For these people other first treatments exist, including immunotherapy combinations without bevacizumab and tablets such as sorafenib or lenvatinib. Our page on who cannot have atezolizumab plus bevacizumab goes through this in detail.
It cannot weigh your own bleeding risk
Only your oncologist and gastroenterologist, looking at your own endoscopy, blood tests and scans together, can say whether the benefit outweighs the risk for you. Bring every report to the consultation.
It does not cover how the medicine works
Mechanics and other side effects belong to the immunotherapy pages. Read immunotherapy for liver cancer for that.
If you are unsure whether you have had an endoscopy, or what it showed, ask before the first treatment day.Questions we are asked
Common questions about bevacizumab and bleeding
Why do I need an endoscopy before bevacizumab?
Because varices usually give no warning before they bleed, and bevacizumab can make a bleed more likely. The endoscopy finds varices that need banding or tablets first. It is a routine safety step for people with cirrhosis, and it does not mean something is wrong.
How recent does the endoscopy need to be?
It should be a fairly recent one, done in the months shortly before starting. Your team will tell you whether an older endoscopy is still acceptable or needs repeating. Bring the report and any photographs from it to your consultation.
Can bevacizumab start straight after banding?
Usually not on the same day. The banding sores need time to heal, and sometimes more than one banding session is needed. Your oncologist and gastroenterologist agree the timing together, so treatment starts as soon as it is safe and not before.
What if I bleed while on treatment?
Go to the nearest emergency department straight away and tell them you are on bevacizumab. Bevacizumab is usually stopped after a serious bleed. Once you have recovered, the team will discuss whether to continue with immunotherapy alone or move to another treatment.
Does bevacizumab cause other kinds of bleeding?
It can cause nosebleeds and bleeding gums, which are usually mild. Less often, it causes bleeding elsewhere in the gut. Tell your team about any bleeding that does not stop, any blood in the urine, or bruising you cannot explain.
Can I take aspirin or painkillers with it?
Ask before taking any. Aspirin and many common painkillers thin the blood or irritate the stomach, which adds to the bleeding risk. Our page on painkillers and bleeding risk explains which are usually safer with cirrhosis.
Is there a first treatment without bevacizumab?
Yes. Other immunotherapy combinations and targeted tablets are options for people who cannot safely have bevacizumab. Each has its own side effects and suits different people. Your oncologist will explain which fit your liver function and your bleeding risk.
Can CION arrange the endoscopy?
Yes. CION coordinates endoscopy and banding through partner gastroenterology teams, and the tumour board reviews the result before any decision on bevacizumab. Call the helpline and someone will explain the next step and what to bring.
Your Specialists
Meet CION's liver cancer specialists. Bring your scan reports and liver blood tests.
Our medical and surgical oncologists plan liver cancer care together, weighing the tumour and how well your liver works before choosing surgery, a liver-directed procedure or medicines.
Medical Oncologist
Dr. C. Raghavendra Reddy
MBBS(Gold Medal), DNB(General Medicine), DM(Medical Oncology)(Gold Medal)
Medical Oncologist
Dr. Bharati Devi Gorantla
MBBS, MD(General Medicine), DM(Medical Oncology)(Adyar,Chennai), ECMO, MRCP SCE(UK)
Medical Oncologist
Dr. Owais Mohammed
MBBS, MD (General Medicine), DrNB (Medical Oncology), ECMO, MRCP SCE (Medical Oncology) (UK)
Medical Oncologist
Medical Oncologist
Surgical Oncologist
Dr. Muralidhar Muddusetty
MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
Surgical Oncologist
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Sources
- American Cancer Society — Immunotherapy for Liver Cancer
- MedlinePlus — Bleeding esophageal varices
- Cleveland Clinic — Esophageal Varices: Symptoms, Causes & Treatment
- National Cancer Institute — Targeted Therapy for Cancer
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Why you need an endoscopy before bevacizumabThe safety check, explained step by stepWho cannot have atezolizumab plus bevacizumabIf bleeding risk rules it out, what that meansVomiting blood: call an ambulance nowWhat to do in the first minutes of a bleedAtezolizumab plus bevacizumab for liver cancerThe treatment itself, and who it is for
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