Objective To investigate the risk factors of thrombus head shedding and bleeding during endoscopic treatment of patients with esophageal varices veins, and build a risk prediction model.Methods 209 cases of esophageal varices with thrombus head found by endoscopy from February 2009 to July 2024 were retrospectively analyzed, and divided into non-shedding group (n = 186) and shedding group (n = 23) according to whether thrombus head shedding bleeding occurred during endoscopic treatment. Clinical and endoscopic data of the two groups were compared. Statistically significant factors were included in multivariate Logistic regression analysis and their independent risk factors were explored. A nomogram risk prediction model was constructed by R software, and its prediction efficiency was evaluated.Results Multivariate Logistic regression analysis showed that red thrombus head (OR＾ = 6.231, 95%CI: 1.748~22.208), thrombus head diameter ≥ 3 mm (OR＾ = 4.355, 95%CI: 1.341 ~ 14.144), conical thrombus head (OR＾ = 8.555, 95%CI: 2.427 ~ 30.154), and the presence of hematoma in the stomach (OR＾ = 7.079, 95%CI: 1.665 ~ 30.103) were risk factors for bleeding after thrombus head shedding during endoscopic diagnosis and treatment. A nomogram prediction model was constructed with a sensitivity of 0.870 (95%CI: 0.732 ~ 1.000) and a specificity of 0.887 (95%CI: 0.842 ~ 0.933).Conclusion The thrombus head being red, conical in shape, with a diameter of ≥ 3 mm and the presence of hematoma in the stomach are independent risk factors for thrombus head shedding and bleeding during endoscopic diagnosis and treatment. Timely intervention should be made for the above factors to benefit patients.