What is the treatment for esophageal varices?

Treatment of Esophageal Varices

The treatment of esophageal varices requires a combination of pharmacological therapy with vasoactive agents and endoscopic band ligation, with transjugular intrahepatic portosystemic shunt (TIPS) reserved for treatment failures. 1, 2

Acute Variceal Bleeding Management

Initial Management

1. Resuscitation and Medical Therapy

   • Initiate vasoactive agents immediately upon suspicion of variceal bleeding (terlipressin, octreotide, or somatostatin) and continue for up to 5 days 2
   • Use restrictive blood transfusion strategy (hemoglobin threshold ≤70 g/L) 2
   • Administer prophylactic antibiotics (ceftriaxone 1g/day for up to 7 days) 2
   • Consider IV erythromycin 250mg 30-120 minutes before endoscopy 2

2. Endoscopic Management

   • Perform endoscopy within 12 hours of presentation after hemodynamic stabilization 2
   • Endoscopic variceal ligation (EVL) is the preferred first-line endoscopic treatment for acute esophageal variceal bleeding 1, 2
   • For gastric varices:
     • GOV1 (gastroesophageal varices type 1): EVL or cyanoacrylate injection 2
     • GOV2/IGV1 (isolated gastric varices): Cyanoacrylate injection 2

3. Management of Treatment Failure

   • For persistent bleeding despite pharmacological and endoscopic therapy, urgent rescue TIPS should be considered 2
   • Self-expanding metal stents or balloon tamponade can be used as bridge therapy when TIPS is not immediately available 1, 3

Prevention of Recurrent Bleeding (Secondary Prophylaxis)

1. Combination Therapy

   • Combination of non-selective beta-blockers (NSBBs) plus EVL is the best option for secondary prophylaxis 1, 2
   • Adjust beta-blocker to maximal tolerated dose 1
   • Carvedilol or propranolol are recommended NSBBs 2

2. Endoscopic Follow-up

   • Repeat EVL every 1-4 weeks until variceal eradication 1, 2
   • After eradication, perform surveillance endoscopy at 1-3 months and then every 6-12 months to check for recurrence 1

3. Rescue Therapy for Rebleeding

   • TIPS should be considered in Child-Pugh A or B patients who experience recurrent variceal hemorrhage despite combination therapy 1
   • In centers with expertise, surgical shunts can be considered for Child-Pugh A patients 1

Pre-emptive TIPS

For high-risk patients (Child-Pugh C ≤13 or Child-Pugh B >7 with active bleeding at endoscopy despite vasoactive agents), pre-emptive TIPS within 72 hours (preferably within 24 hours) should be considered 2

Special Considerations

Portal Vein Thrombosis

• Portal vein thrombosis may complicate management and negatively impact survival 1
• TIPS may still be feasible in selected cases with portal vein thrombosis 1

Advanced Liver Disease

• Patients with high MELD scores (>19) have poor outcomes with TIPS 1
• Liver transplantation should be considered for eligible patients 1

Common Pitfalls to Avoid

1. Delayed endoscopy - Perform endoscopy within 12 hours of presentation after hemodynamic stabilization
2. Inadequate pharmacological therapy - Continue vasoactive drugs for up to 5 days
3. Combining EVL with sclerotherapy - This increases complications without improving outcomes 1
4. Insufficient follow-up - Regular endoscopic surveillance is essential to detect and treat recurrent varices
5. Overuse of TIPS - Reserve for treatment failures or high-risk patients, as it increases encephalopathy risk 1

The management of esophageal varices has significantly improved over the past decades, with combination pharmacological and endoscopic therapy providing effective control of bleeding and reducing mortality in most patients.