From the Guidelines
Esophageal varices should be managed with a combination of non-selective beta-blockers and endoscopic variceal ligation (EVL) for primary prophylaxis in patients with medium to large varices, as this approach has been shown to reduce the risk of bleeding and improve outcomes 1.
Primary Prophylaxis
For patients with medium to large varices, non-selective beta-blockers (propranolol 20-40mg twice daily or nadolol 20-40mg daily) are first-line therapy, with dose adjustments to reduce resting heart rate by 25% 1. EVL is an alternative for those who cannot tolerate beta-blockers. The frequency of surveillance endoscopies in patients with no or small varices depends on their natural history, with EGD recommended every 2-3 years for patients with compensated cirrhosis and no varices, and every 1-2 years for those with small varices 1.
Acute Bleeding
For acute bleeding, immediate resuscitation with IV fluids and blood products is essential, followed by vasoactive medications like octreotide (50mcg IV bolus, then 50mcg/hour for 3-5 days) or terlipressin (2mg IV every 4 hours for 48 hours, then 1mg every 4 hours) 1. Urgent endoscopic therapy with band ligation is the definitive treatment for active bleeding. Antibiotic prophylaxis with ceftriaxone 1g daily for 5-7 days is recommended during acute bleeding episodes to prevent bacterial infections.
Secondary Prophylaxis
Secondary prophylaxis after a bleeding episode requires combination therapy with both beta-blockers and EVL 1. For refractory cases, transjugular intrahepatic portosystemic shunt (TIPS) may be considered. The underlying mechanism involves portal hypertension causing blood to seek alternative routes through esophageal veins, which become distended and prone to rupture, potentially leading to life-threatening hemorrhage.
Some key points to consider in the management of esophageal varices include:
- The size classification of varices, with large varices being those greater than 5 mm in diameter 1
- The use of non-invasive markers, such as platelet count and spleen size, to predict the presence of high-risk varices, although these markers have limited predictive accuracy 1
- The role of capsule endoscopy as a potential alternative to EGD for screening and diagnosis of esophageal varices, although its sensitivity and specificity are still being evaluated 1
- The importance of antibiotic prophylaxis during acute bleeding episodes to prevent bacterial infections 1
From the Research
Esophageal Varices Overview
- Esophageal varices are a common complication of liver cirrhosis, resulting from portal hypertension (PH) 2
- The development of esophageal varices can lead to significant upper gastrointestinal bleeding, with mortality rates up to 20% despite state-of-the-art treatment 2
Primary Prophylaxis of Variceal Bleeding
- Non-selective beta blockers (NSBBs) or endoscopic band ligation (EBL) are effective for primary prophylaxis of variceal bleeding 2, 3
- NSBB monotherapy may decrease all-cause mortality and the risk of first variceal bleeding in patients with cirrhosis with large esophageal varices 3
- Carvedilol, a NSBB with additional alpha-adrenergic blocking effect, may also be effective in primary prophylaxis of variceal bleeding 3, 4
Secondary Prophylaxis of Variceal Bleeding
- A combination of NSBB + EBL should be routinely used in secondary prophylaxis 2
- Endoscopic variceal ligation (EVL) may be superior to pharmacological therapy regarding the prevention of the first bleeding episode, but NSBBs or carvedilol may play a more prominent role in mortality reduction 4
Endoscopic Treatment of Esophageal Varices
- Endoscopic variceal banding is the recommended endoscopic therapy for acute variceal bleeding 5
- Sclerotherapy may have a role in the treatment of esophageal varices, although banding is the first-choice treatment 5
- Treatment with Sengstaken-Blakemore tube or self-expanding covered metallic esophageal stent can be used for acute variceal bleeding refractory to standard pharmacologic and endoscopic therapy 5