What is the management of esophageal varices?

From the Guidelines

Management of esophageal varices requires a comprehensive approach including prevention of first bleeding, acute bleeding management, and prevention of rebleeding, with the primary goal of reducing morbidity, mortality, and improving quality of life.

Overview of Esophageal Varices

Esophageal varices are collateral vessels that form in the esophagus as a result of portal hypertension, typically from cirrhosis, which can rupture under pressure and lead to severe bleeding.

Primary Prophylaxis

For primary prophylaxis in patients with medium to large varices, non-selective beta-blockers (propranolol 20-40mg twice daily or nadolol 20-40mg daily, titrated to reduce resting heart rate by 25% or to 55-60 beats per minute) are first-line therapy 1. Endoscopic variceal ligation (EVL) is an alternative for those who cannot tolerate beta-blockers.

Acute Variceal Bleeding Management

For acute variceal bleeding, immediate resuscitation with blood products to maintain hemoglobin around 7-8 g/dL is crucial, along with vasoactive medications (terlipressin 2mg IV every 4 hours, octreotide 50mcg IV bolus followed by 50mcg/hour infusion, or somatostatin 250mcg IV bolus followed by 250mcg/hour infusion) for 3-5 days 1. Antibiotic prophylaxis with ceftriaxone 1g IV daily for 5-7 days prevents infection. Urgent endoscopy within 12 hours with EVL or sclerotherapy is essential.

Refractory Bleeding and Secondary Prophylaxis

For refractory bleeding, balloon tamponade, transjugular intrahepatic portosystemic shunt (TIPS), or surgical shunts may be necessary 1. Secondary prophylaxis combines beta-blockers with EVL sessions every 2-4 weeks until varices are eradicated. The underlying pathophysiology involves portal hypertension (typically from cirrhosis), causing collateral vessels to form in the esophagus, which can rupture under pressure. Treatment aims to reduce portal pressure, physically obliterate varices, or create alternative pathways for blood flow.

Some key points to consider in the management of esophageal varices include:

• The importance of early endoscopy in patients with suspected esophageal variceal bleeding 1
• The use of vasoactive agents as soon as possible after admission in patients with acute esophageal variceal bleeding 1
• The consideration of TIPS placement in patients at high risk of rebleeding or as a rescue therapy for patients in whom bleeding control fails despite combined pharmacological and endoscopic therapy 1

From the Research

Definition of Esophageal Varices

Esophageal varices are a life-threatening complication of portal hypertension, which can occur in patients with liver cirrhosis 2.

Management of Esophageal Varices

The management of esophageal varices involves several strategies, including:

• Primary prophylaxis of variceal bleeding using non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL) for patients with medium- or large-sized varices 2
• Combination therapy with beta-blockers and endoscopic band ligation (EBL) for secondary prophylaxis of esophageal variceal rebleeding in cirrhosis 3
• Vasoactive drugs, combined with endoscopic therapy and antibiotics, for patients with acute variceal bleeding 2
• Transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents for cases of uncontrolled bleeding 2

Treatment Options

Various treatment options are available, including:

• Endoscopic sclerotherapy
• Variceal band ligation
• Beta-blockers
• TIPS
• Surgical portocaval shunts
• Somatostatin analogues
• Vasopressin analogues
• Balloon tamponade 4, 5

Comparison of Treatment Options

Network meta-analyses have compared the benefits and harms of different initial treatments for variceal bleeding from oesophageal varices in adults with decompensated liver cirrhosis 4, 5. The results show:

• Variceal band ligation may result in fewer serious adverse events than sclerotherapy 4
• TIPS may result in a large decrease in symptomatic rebleed than variceal band ligation 4
• Sclerotherapy probably results in fewer 'any' variceal rebleeding than no active intervention 4
• Beta-blockers plus sclerotherapy and TIPS probably result in fewer 'any' variceal rebleeding than sclerotherapy 4
• Somatostatin analogues alone and vasopressin analogues alone probably result in increased mortality, compared to endoscopic sclerotherapy 5
• Vasopressin analogues alone and band ligation alone probably result in fewer adverse events compared to endoscopic sclerotherapy 5