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 combination of endoscopic variceal ligation (EVL) plus non-selective beta-blockers (NSBBs) being the preferred approach for acute variceal hemorrhage, as recommended by the most recent guidelines 1. The management strategy should prioritize reducing portal pressure, which is the underlying cause of variceal formation and rupture in patients with portal hypertension due to liver cirrhosis.
- For primary prophylaxis in patients with medium to large varices, non-selective beta-blockers (NSBBs) like propranolol (20-40mg twice daily) or nadolol (20-40mg daily) are first-line therapy, titrated to reduce resting heart rate by 25% or to 55-60 beats per minute, as supported by earlier guidelines 1.
- Endoscopic variceal ligation (EVL) is an alternative for those who cannot tolerate NSBBs.
- For acute variceal bleeding, immediate resuscitation with blood products to maintain hemoglobin around 7-8 g/dL is crucial, along with vasoactive drugs like octreotide (50μg IV bolus followed by 50μg/hour infusion for 3-5 days) or terlipressin (2mg IV every 4 hours for 48 hours, then 1mg every 4 hours), and antibiotic prophylaxis with ceftriaxone 1g IV daily for 5-7 days should be initiated, as recommended by recent guidelines 1.
- Urgent endoscopy within 12 hours with EVL is the preferred hemostatic method.
- For refractory bleeding, balloon tamponade or transjugular intrahepatic portosystemic shunt (TIPS) may be necessary, with TIPS being considered as a rescue therapy if primary treatment fails, as suggested by recent studies 1.
- Secondary prophylaxis combines NSBBs with EVL sessions every 2-4 weeks until varices are eradicated, then surveillance endoscopy every 3-6 months. The choice of treatment should be individualized based on the patient's condition, the severity of the varices, and the presence of any complications, always prioritizing the reduction of morbidity, mortality, and improvement of quality of life.
From the Research
Management of Esophageal Varices
The management of esophageal varices involves several strategies, including:
- Primary prophylaxis to prevent the development of variceal bleeding
- Secondary prophylaxis to prevent recurrent variceal bleeding
- Treatment of acute variceal bleeding
Primary Prophylaxis
Primary prophylaxis is aimed at preventing the development of variceal bleeding in patients with esophageal varices. The following strategies are recommended:
- Non-selective beta blockers (NSBBs) such as carvedilol or propranolol 2, 3, 4, 5
- Endoscopic band ligation (EBL) 2, 6, 3, 4
- Combination of NSBBs and EBL 5
Secondary Prophylaxis
Secondary prophylaxis is aimed at preventing recurrent variceal bleeding in patients who have already experienced a variceal bleed. The following strategies are recommended:
- Combination of NSBBs and EBL 2, 5
- Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) in high-risk patients 2, 5
Treatment of Acute Variceal Bleeding
The treatment of acute variceal bleeding involves:
- Vasoactive agents such as terlipressin, octreotide, or somatostatin 2
- Antibiotic prophylaxis 2, 3, 5
- Endoscopic therapy such as EBL or cyanoacrylate injection 2, 6, 3
- Transjugular intrahepatic portosystemic shunt (TIPS) in patients who fail endoscopic therapy 2, 5
Key Recommendations
The following key recommendations are made:
- Patients with compensated advanced chronic liver disease and clinically significant portal hypertension should receive NSBB therapy to prevent the development of variceal bleeding 2
- EBL is the endoscopic prophylactic treatment of choice for patients with high-risk esophageal varices who are unable to receive NSBB therapy 2
- A combination of NSBBs and EBL should be used for secondary prophylaxis in patients with esophageal varices who have experienced a variceal bleed 5