What is the bleeding risk with grade 3 esophageal varices?

Bleeding Risk with Grade 3 Esophageal Varices

Patients with grade 3 esophageal varices have a very high risk of bleeding, with approximately 15% annual risk of first hemorrhage, which carries a mortality rate of at least 20% at 6 weeks. 1

Risk Stratification

The bleeding risk for grade 3 esophageal varices is determined by several factors:

Variceal Characteristics

• Grade 3 varices (large enough to occlude the lumen) represent the highest risk category 1
• Presence of red wale marks (longitudinal dilated venules on the variceal surface) significantly increases bleeding risk 1

Liver Function

Child-Pugh classification strongly correlates with bleeding risk and mortality:

• Child A: 5% mortality from variceal hemorrhage over one year
• Child B: 25% mortality from variceal hemorrhage over one year
• Child C: 50% mortality from variceal hemorrhage over one year 1

Hemodynamic Factors

• Hepatic venous pressure gradient (HVPG) >20 mmHg (measured within 24 hours of variceal hemorrhage) indicates higher risk for:
  • Early rebleeding (83% vs. 29%)
  • One-year mortality (64% vs. 20%) 1

Natural History Without Treatment

Without prophylactic treatment, grade 3 varices have:

• 15% annual risk of first hemorrhage 1
• 60% risk of rebleeding within 1-2 years after initial hemorrhage 1
• 30-50% of patients with portal hypertension will bleed from varices 1
• Approximately 50% mortality from effects of first bleed 1

Prophylactic Management

For patients with grade 3 varices that have not yet bled:

1. First-line therapy: Nonselective beta-blockers (propranolol or nadolol)

   • Reduces risk of first variceal bleeding from 30% to 14% 1, 2
   • Propranolol typically started at 40mg once daily, titrated to maximum tolerated dose 1
   • Nadolol can be used at 40mg once daily as an alternative 2

2. Alternative therapy: Endoscopic variceal band ligation (EVL)

   • Recommended when beta-blockers are contraindicated, not tolerated, or patient is non-compliant 1, 3
   • Should be repeated every 1-2 weeks until obliteration 1

3. Combination therapy: Not routinely recommended for primary prophylaxis

Important Considerations

• Beta-blockers should be continued indefinitely as the risk of bleeding recurs when treatment is stopped 1, 2
• Patients on beta-blockers do not require follow-up endoscopy for surveillance 1
• Patients treated with EVL should have surveillance endoscopy 1-3 months after obliteration and then every 6-12 months 1
• Sclerotherapy is not recommended for primary prophylaxis due to inconsistent results and potential complications 1, 2
• Shunt therapy (surgical or TIPS) should not be used for primary prophylaxis due to increased risk of encephalopathy and mortality 1

Management of Acute Bleeding

If bleeding occurs from grade 3 varices:

• Immediate resuscitation with careful volume replacement (target hemoglobin ~8 g/dL)
• Vasoactive drugs (terlipressin, somatostatin, or octreotide) should be started immediately
• Endoscopic therapy within 12 hours of presentation
• Consider pre-emptive TIPS within 72 hours for high-risk patients (Child-Pugh C ≤13 or Child-Pugh B >7 with active bleeding) 3

Pitfalls to Avoid

1. Overly aggressive blood volume resuscitation can increase portal pressure and precipitate rebleeding 1
2. Using selective beta-blockers (atenolol, metoprolol) which are less effective than nonselective ones 1, 2
3. Discontinuing beta-blockers after initial response, as this increases rebleeding risk 2
4. Relying on sclerotherapy for primary prophylaxis, which has been shown to be ineffective and potentially harmful 1

By properly assessing and managing patients with grade 3 esophageal varices, the significant morbidity and mortality associated with variceal bleeding can be substantially reduced.