OBJECTIVES: While esophageal varices (EVs) are typically treated endoscopically, other options such as interventional radiology or surgical treatment are considered when endoscopic treatment is challenging. Pipeline EVs are difficult to treat endoscopically due to their large diameter, and currently, no specific treatment guidelines have been established. METHODS: We reviewed cases of pipeline EVs treated at our hospital and analyzed previously reported cases to collect evidence for the formulation of treatment guidelines. Additionally, we created EV simple models to evaluate the safety margin of endoscopic variceal ligation for varices. RESULTS: Our analysis included 14 cases of pipeline EVs (four cases treated at our hospital from 2013 to 2024 and 10 previously reported cases from 1990 to 2024). Endoscopic treatment alone was insufficient in six cases (42.9%), and five cases (35.7%) required interventional radiology or surgical intervention. Using EV simple models with varying diameters, EVL was inadequate for varices with diameters of 20 mm or larger. CONCLUSIONS: There are few reported cases of pipeline EVs, making it difficult to determine a treatment algorithm. In our study using an EV simple model, it was suggested that endoscopic variceal ligation is effective in blocking blood flow for EVs with a diameter of 15 mm or less. It is important that we understand there are EVs, such as pipeline EVs, for which there are limitations to safely occluding blood flow with endoscopic variceal ligation, and it may be necessary to develop treatment strategies that include methods other than endoscopic therapy.