From the Guidelines
Esophageal varices are a life-threatening condition that requires immediate medical attention, and the primary symptoms include vomiting blood, black tarry stools, and abdominal pain.
Symptoms of Esophageal Varices
- Vomiting blood or coffee ground-like material
- Black, tarry stools
- Abdominal pain or tenderness
- Fatigue or weakness
Treatment Options for Esophageal Varices
- Endoscopic variceal ligation (EVL): a highly efficacious treatment option that achieves 85% to 90% rates of initial control of bleeding 1
- Endoscopic sclerotherapy (ES): an alternative treatment option that is equally efficient regarding variceal eradication and recurrence during short interval follow-up, but requires more sessions than EVL 1
- Vasoactive agents: such as terlipressin, somatostatin, or octreotide, which reduce splanchnic blood flow and portal pressure, and are used to control bleeding and prevent variceal rebleeding 1
- Combination therapy: with vasoactive drugs and endoscopy, which has become the favored treatment algorithm in managing acute bleeding from esophageal varices 1
- Transjugular intrahepatic portosystemic shunt (TIPS): a possible rescue treatment for patients in whom bleeding control fails despite combined pharmacological and endoscopic therapy 1
- Balloon tamponade: a bridge therapy for patients who fail to achieve hemostasis after endoscopic treatment 1
The goal of treatment is to reduce portal pressure, control bleeding, and prevent rebleeding, and the choice of treatment depends on the severity of the condition, the presence of other complications, and the patient's overall health.
- Restrictive PRBC transfusion is recommended with the goal of maintaining a hemoglobin level of 7–9 g/dL 1
- Short-term antibiotic prophylaxis should be instituted in patients with acute esophageal variceal bleeding 1
- Early TIPS placement can be considered in patients at high risk of rebleeding 1
From the Research
Symptoms of Esophageal Varices
- Patients with esophageal varices without previous bleeding have a risk of 25-30% for the development of a bleeding episode within two years 2
- The mortality rate is high, with 30-40% of patients dying within six weeks after a bleeding episode 2
Treatment Options for Esophageal Varices
- Treatment with a non-selective betablocker possibly combined with isosorbidnitrate should be initiated if an upper endoscopy shows the presence of medium- or large-sized oesophageal varices 2
- Sclerotherapy or ligation initiated within a short time after start of an acute bleeding episode reduces mortality and risk of bleeding 2
- Pharmacological treatment may have effect on the acute episode, and most data advocate for Terlipressin to be the first choice 2
- Endoscopic band ligation is the first-line endoscopic treatment of esophageal variceal hemorrhage 3
- Vasoactive agents such as somatostatin analog and terlipressin are both safe and effective pharmacologic treatments of esophageal variceal hemorrhage 3
- Transjugular intrahepatic portosystemic shunt (TIPS) should be reserved as rescue therapy for failure of medical and endoscopic treatments 3
Endoscopic Management of Esophageal Varices
- Endoscopic therapies for varices aim to reduce variceal wall tension by obliteration of the varix 4
- The two principal methods available for esophageal varices are endoscopic sclerotherapy (EST) and band ligation (EBL) 4
- Endoscopic variceal ligation obliterates varices by causing mechanical strangulation with rubber bands 4
New Methods for the Management of Esophageal Varices
- Combining IVR with endoscopic treatment or EIS with EVL can improve survival 5
- Proper management of recurrent EVs can significantly improve patients' quality of life 5
- Performing EVL at 2-mo (bi-monthly) intervals can result in a higher rate of total eradication and lower rates of recurrence and additional treatment 5
Therapeutic Options for Bleeding Esophageal Varices
- Emergency endoscopy plays the most important role in diagnosis and treatment of patients with esophageal variceal bleeding 6
- Endoscopic sclerotherapy (EST), placement of esophageal band ligatures (EVL), medicamentous treatment using somatostatin and its derivatives, and balloon tamponade are the methods most frequently applied in treatment of the bleeding esophageal varices 6
- The efficacy of modern endoscopic therapy in the form of sclerotherapy and band ligature placement, as well as application of vasoactive substances, reaches up to 90% 6