From the Guidelines
The most effective treatment for esophageal varices is a combination of endoscopic variceal ligation (EVL) and non-selective beta-blockers (NSBBs), which has been shown to reduce the risk of variceal rebleeding and improve survival rates 1.
Treatment Options
The treatment options for esophageal varices can be divided into preventive measures and active bleeding management.
- For primary prevention in patients with high-risk varices, non-selective beta-blockers (propranolol 20-40mg twice daily or nadolol 20-40mg daily) are first-line therapy to reduce portal pressure.
- Endoscopic variceal ligation (EVL) is an alternative for those who cannot tolerate beta-blockers.
- 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 2-5 days) or terlipressin (2mg IV every 4 hours).
- Urgent endoscopic therapy with band ligation is the preferred intervention to control active bleeding.
- Antibiotics (ceftriaxone 1g daily for 5-7 days) are given to prevent infection.
Secondary Prevention
For refractory bleeding, transjugular intrahepatic portosystemic shunt (TIPS) may be necessary.
- Secondary prevention after a bleeding episode involves combination therapy with beta-blockers and EVL.
- These treatments work by reducing portal pressure, physically obliterating varices, or creating alternative blood flow pathways to decompress the portal system.
- The underlying liver disease should also be managed to prevent progression of portal hypertension.
Evidence-Based Recommendations
The combination of EVL and NSBBs has been shown to be the most effective treatment for preventing esophageal variceal rebleeding, with a lower overall rebleeding rate and improved survival rates compared to EVL alone or NSBBs alone 1.
- A recent meta-analysis demonstrated that the rebleeding rate decreased (RR, 0.44; 95% CI, 0.28–0.69) and the mortality rate during follow-up tended to decrease with the combination of EVL plus a NSBBs (RR, 0.58; 95% CI, 0.33–1.03) compared with EVL alone 1.
- The use of carvedilol to prevent EV rebleeding can be considered, but no studies have compared the combination of EVL plus carvedilol with the combination of EVL plus an NSBBs, which is currently considered to be the primary treatment to prevent rebleeding 1.
From the Research
Treatment Options for Esophageal Varices
The treatment options for esophageal varices include:
- Non-selective beta-blockers (NSBBs) such as propranolol or nadolol, which should be titrated to a heart rate of 55 beats per minute or adverse effects 2, 3, 4, 5, 6
- Endoscopic variceal ligation (EVL) or banding therapy, which is recommended for patients with medium-to-large esophageal varices 2, 3, 4, 5
- Vasoactive drugs, such as octreotide, which should be administered to patients with acute variceal bleeding 2, 3, 4
- Transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents, which is recommended for patients with uncontrolled bleeding or those who fail endoscopic and pharmacologic treatment 2, 3, 4
- Combination therapy, which includes NSBBs and EVL, and is recommended for secondary prophylaxis 2, 3, 4, 6
Primary Prophylaxis
Primary prophylaxis is recommended for patients with medium and large-sized varices, and includes:
- NSBBs 2, 3, 4, 5, 6
- EVL or banding therapy 2, 3, 4, 5
- The choice of treatment should be based on local resources and expertise, patient preference and characteristics, side-effects and contra-indications 5
Secondary Prophylaxis
Secondary prophylaxis is recommended for patients who have experienced variceal bleeding, and includes: