Medical Oncologist
CION Cancer Clinics
Grades of varices: what grade 1, 2 and 3 mean for bleeding risk | CION Cancer Clinics
The grade on your endoscopy report tells you how large the swollen veins in your food pipe are. Small veins bleed less often than large ones, and red marks on the vein wall raise the risk at any size. This page explains each grade, what usually happens next, and the warning signs that mean going to hospital straight away, whatever the grade. 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
- What does the grade of my varices actually mean?
- What do grade 1, grade 2 and grade 3 varices look like?
- What happens once your varices have been graded?
- What do the words on an endoscopy report mean?
- What do families often get wrong about varices?
- What can this page not tell you?
- Common questions about grades of varices
The short answer
What does the grade of my varices actually mean?
The grade describes how large the swollen veins in your food pipe looked during the endoscopy. Small veins are usually called grade 1, medium veins grade 2 and large veins grade 3. A higher grade, or certain marks on the vein wall, means a higher chance of bleeding, so it usually means more active treatment to prevent a bleed.
Why the veins swell in the first place
Varices form when scarring in the liver, or a tumour pressing on the main vein into the liver, pushes blood back under pressure. Doctors call that portal hypertension. The blood finds a detour through thin veins in the lower food pipe and the top of the stomach. Those veins were never built for that load, so they stretch. Our page on why liver disease causes varices explains this step by step.
The grade is a snapshot, not a verdict
A grade tells you about the veins on the day of the scope. It does not tell you how long anyone will live, and it does not tell you whether the liver cancer is growing. Veins can grow larger if pressure rises, and they can shrink after banding. That is why the grade is checked again at later endoscopies.
Every grade of varices can bleed. A low grade lowers the chance. It does not remove it.Grade by grade
What do grade 1, grade 2 and grade 3 varices look like?
Different hospitals use slightly different scales. Some use three grades, some use four, and some simply write small or large. Ask which scale your report uses.
Grade 1: small
The veins are slightly raised and flatten when the doctor puffs a little air into the food pipe. The chance of a bleed is lower than with larger veins. Many people at this grade are simply watched with repeat endoscopies.
Grade 2: medium
The veins are clearly raised and do not flatten with air, but they do not yet block much of the food pipe. Many doctors now group medium with large veins, because the plan to prevent a bleed is often the same.
Grade 3: large
The veins are big, twisted and take up a good part of the food pipe. This grade carries the highest chance of bleeding. Prevention usually starts straight away, with tablets, banding, or both.
Marks that matter as much as size
The report may mention extra signs on the vein wall. These raise the chance of bleeding even when the veins are small.
- Red wale marks: red streaks along the vein
- Cherry red spots on the surface
- Varices in the stomach as well as the food pipe
Not sure whether this applies to you?
Ask an oncologist
!
Whatever the grade, this cannot wait
If anyone with varices vomits blood, brings up material that looks like coffee grounds, passes black sticky stools, or suddenly feels faint and cold, call an ambulance or go to the nearest hospital emergency department now. Do not wait for the morning or for a clinic appointment. A variceal bleed can become dangerous very quickly. Say the person has liver disease and varices, and carry the endoscopy report with you.
After the report
What happens once your varices have been graded?
The team reads the grade with your liver
Your oncologist and the hepatologist look at the grade alongside your liver function and your cancer plan. The same grade can mean a different plan in two different people.
Small veins: watch and recheck
If the veins are small with no red marks, you may simply be booked for another endoscopy later. Some people are started on a tablet that lowers the pressure.
Medium or large veins: prevent the first bleed
The usual choices are a beta-blocker tablet or banding, where small rubber rings tie off the veins. See our pages on beta-blockers and banding.
Before cancer treatment starts
Some cancer medicines raise bleeding risk. Your oncologist will want large veins controlled first. CION coordinates the endoscopy and any banding through accredited partner hospitals.
On your report
What do the words on an endoscopy report mean?
- Oesophageal varices
- Swollen veins in the food pipe, the tube between the mouth and the stomach. This is the most common place for them.
- Gastric varices
- Swollen veins at the top of the stomach. They are graded and treated differently, and are covered on our stomach varices page.
- Red wale signs
- Red streaks on the surface of a vein. They show a thin, stretched wall and a higher chance of bleeding.
- Portal hypertensive gastropathy
- A mosaic or snakeskin pattern on the stomach lining caused by the same high pressure. It can ooze slowly and cause a low blood count.
- Small or large
- A simpler two-step version of the grade. Many reports now use this instead of numbers.
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Commonly believed
What do families often get wrong about varices?
"It is only grade 1, so we do not need to worry about bleeding."
Small veins bleed less often, not never. The warning signs above apply to every grade. Keep the follow-up endoscopy that was booked, because small veins can grow.
"Grade 3 means the cancer has become very advanced."
The grade is about pressure in the veins, not about the tumour. Large varices can come from cirrhosis alone. Your cancer stage is a separate question for your oncologist.
"If there is no pain, the veins cannot be bleeding."
Variceal bleeding is usually painless. Black stools, a sudden faint feeling or a falling blood count can be the only signs.
"Once the veins are banded, the problem is gone for good."
Banding closes the veins that are there. While the pressure stays high, new ones can form, so repeat checks continue.
Being straight with you
What can this page not tell you?
It cannot tell you what your own grade means for you. That depends on the exact words in your report, the signs on the vein wall, how well your liver is working, and which cancer treatment is being planned. The doctor who did the endoscopy, your hepatologist and your oncologist are the people who can put those together.
Who this page does not apply to
If you have been told you have varices in the stomach only, or bleeding from the stomach lining rather than from veins, the grading here does not fit you well. If you have already had a bleed, the plan is different again, and our page on preventing a second bleed is the better place to start.
It cannot replace an emergency call
No reading can stand in for an ambulance when someone is vomiting blood. Keep the warning signs where the whole family can see them, and make sure everyone at home knows which hospital to go to.
If you are holding a report and are unsure what it says, call the helpline. A CION team member can arrange for it to be reviewed.Questions we are asked
Common questions about grades of varices
Is grade 2 varices dangerous?
Medium varices carry a real chance of bleeding, and many doctors treat them like large ones. That usually means a tablet to lower the pressure, banding, or both. It is not an emergency on its own, but it does need a clear prevention plan agreed with your doctors soon.
Can varices go back to a lower grade?
Yes, sometimes. Banding can close large veins, and lowering the pressure in the liver can shrink them. If the liver disease or the tumour pressure gets worse, they can also grow again. That is why the grade is checked at each repeat endoscopy rather than once.
How often will I need another endoscopy?
It depends on the grade, whether you have bled before, and whether your liver disease is stable. People with small veins are rechecked less often than people having banding. Your hepatologist will set the timing, so ask them to write the next date on your report.
Do varices cause any symptoms before they bleed?
Usually none at all. Most people only find out because a doctor arranged an endoscopy to look for them. This is why people with cirrhosis or liver cancer are often checked even when they feel well, and why waiting for symptoms is not a safe plan.
Does the grade change my cancer treatment?
It can. Some cancer medicines, including bevacizumab, can raise the chance of bleeding. Before starting them, your oncologist will usually want large veins treated first. The tumour board considers the endoscopy result when it agrees your plan.
What do red signs on the report mean?
Red wale marks and cherry red spots show that the vein wall is thin and under strain. They raise the chance of a bleed even when the veins are small. If your report mentions them, ask your doctor whether prevention should start now rather than waiting.
Can food or drink make varices bleed?
Ordinary food does not cause a bleed. Alcohol makes liver disease worse and raises pressure over time, so stopping helps. Some painkillers bought over the counter raise bleeding risk, so check any new medicine with your doctor before taking it.
Where do I start if I have just been given this report?
Bring the report and your latest blood tests to your oncologist or hepatologist and ask what the grade means for your plan. Put the warning signs on the fridge for the family. Call the CION helpline if you need help arranging a review.
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)
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Sources
- Cleveland Clinic — Esophageal Varices: Symptoms, Causes & Treatment
- MedlinePlus — Bleeding esophageal varices
- Merck Manual Consumer Version — Portal Hypertension
- Liver UK (formerly British Liver Trust) — Cirrhosis
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.
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