OBJECTIVE The objective of this study was to evaluate the performance of 320-row multi-detector CT (MDCT) in the detection and grading of esophageal varices and to evaluate the ability of MDCT in predicting the risk of hemorrhage in comparison with upper endoscopy in patients with portal hypertension. METHODS A total of 69 patients, with clinically confirmed portal hypertension, underwent epigastric triphasic enhancement scans using 320-row MDCT 1 weeks or less before upper endoscopies were performed. Two blinded abdominal imagers retrospectively interpreted all CT images to detect the presence of esophageal varices and divided EV into large EV (≥ 5 mm) and small EV (< 5 mm). The correlation between CT measurements and endoscopic grading was assessed by kappa values. With endoscopy as standard, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of the two radiologists in detection of EV were calculated. Correlations between CT measurements of varix size and red color sign were assessed by correlation analysis. RESULTS Of the total of 69 patients, 56 patients had esophageal varices, 41 had large EV, and 15 had small EV according to the endoscopic findings. MDCT showed an excellent interobserver reliability with regard to the diagnosis of the EV (k = 0.94). Agreement between CT and endoscopy with regard to the grading of EV were excellent (k = 0.77). The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of radiologist 1 in the detection of EV was 95%, 69%, 87%, 93% and 75% respectively; the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of radiologist 2 in the detection of EV was 93%, 77%, 87%, 95% and 71%, respectively. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of the two radiologists in the detection of large EV was 95%, 100%, 97%, 100% and 93%, respectively. CT variceal grading showed a strong correlation with endoscopic grading for both observers (P < 0.01). Correlations between CT measurements of varix size and red color sign were significant in both radiologists with a correlation coefficient r of 0.731 for radiologist 1 (P < 0.01) and 0.718 for radiologist 2 (P < 0.01). CONCLUSIONS 320-row MDCT is useful for the detection and grading of EV, and it is useful in evaluation of EV for predicting a risk of hemorrhage.