From the Guidelines
Esophageal varices are abnormally enlarged veins in the esophagus, typically diagnosed through upper endoscopy (EGD) when a patient presents with upper gastrointestinal bleeding or during screening for patients with cirrhosis.
Diagnosis and Treatment
Treatment focuses on both acute management of bleeding and prevention of future bleeds.
- For acute bleeding, immediate interventions include:
- Hemodynamic stabilization with IV fluids or blood transfusions
- Vasoactive medications like octreotide (50-100 mcg IV bolus followed by 25-50 mcg/hour infusion) or terlipressin
- Endoscopic therapy (band ligation or sclerotherapy)
- Balloon tamponade with Sengstaken-Blakemore or Minnesota tubes may be used as a temporary bridge in severe cases.
Prevention of Recurrent Bleeding
- Non-selective beta-blockers such as propranolol (20-40 mg twice daily) or nadolol (20-40 mg daily) are prescribed, with doses titrated to reduce resting heart rate by 25% 1.
- Endoscopic band ligation is performed every 2-4 weeks until varices are obliterated.
- In cases refractory to these measures, transjugular intrahepatic portosystemic shunt (TIPS) may be considered.
Primary Prophylaxis
Primary prophylaxis with beta-blockers or band ligation is recommended for high-risk varices in cirrhotic patients 1. These treatments are effective because they either physically obliterate the varices or reduce portal pressure, addressing the underlying pathophysiology of portal hypertension that causes varices to form and bleed. According to the most recent study 1, combination therapy with vasoactive drugs and endoscopy has become the favored treatment algorithm in managing acute bleeding from esophageal varices.
From the Research
Definition and Diagnosis of Esophageal Varices
- Esophageal varices are a life-threatening complication of portal hypertension, commonly due to liver cirrhosis 2, 3, 4.
- Approximately 40% to 80% of patients surviving the first bleeding suffer from a recurrence of variceal bleeding within one year 2.
- Diagnosis of esophageal varices involves endoscopic examination to visualize the varices and assess their size and risk of bleeding 3, 4.
Treatment of Esophageal Varices
- Primary prophylaxis of variceal bleeding can be achieved through the use of non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL) 3, 4.
- Beta-blockers, such as propranolol, reduce portal pressure by decreasing cardiac output and thereby reducing blood flow to the varices 2, 4.
- Endoscopic variceal ligation (EVL) is an effective treatment for preventing initial bleeding episodes and for secondary prophylaxis to prevent rebleeding 3, 5, 4.
- In cases of acute variceal bleeding, initial management includes hemodynamic stabilization followed by pharmacological therapy with vasoactive drugs and endoscopic intervention 3, 4.
- Transjugular intrahepatic portosystemic shunt (TIPS) may be considered in cases where bleeding is refractory to endoscopic treatment 3, 6, 4.
Secondary Prophylaxis of Esophageal Varices
- Combination therapy with beta-blockers and EVL is the standard prophylaxis of esophageal variceal rebleeding in cirrhosis 5.
- Beta-blockers are the backbone of combination therapy, since their benefit extends to other complications of portal hypertension 5.
- TIPS is the rescue treatment, but it could be considered as first choice in patients that first bleed while on beta-blockers, those with contraindications to beta-blockers or with refractory ascites, and those with fundal varices 5, 6.