Answer:

Portal pressure and variceal size. The portal to hepatic vein pressure gradient must be > 12 mmHg (normal = 3-6 mmHg) for varices to develop. Beyond this level, there is poor correlation between portal pressure and likelihood of bleeding. The best predictor of impending variceal hemorrhage is size. When varices reach a large size (> 5 mm in diameter), they are more likely to rupture and bleed. At any given pressure, the wall of a large varix is under greater tension than that of a small varix and must be thicker to withstand the pressure.

Reference: Sleisenger MH, Fordtran JS (eds): Gastrointestinal Disease: Pathophysiology, Diagnosis, and Management, 7th ed. Philadelphia, W.B. Saunders, 2003.

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