How can the incidence of variceal bleed in portal hypertension be reduced?

Reducing the Incidence of Variceal Bleeding in Portal Hypertension

The incidence of variceal bleeding in portal hypertension can be significantly reduced through a combination of pharmacological therapy with vasoactive agents and endoscopic variceal ligation (EVL), with transjugular intrahepatic portosystemic shunt (TIPS) reserved for treatment failures or high-risk patients. 1

Primary Prevention Strategies

Pharmacological Management

• Non-selective beta-blockers (NSBBs) are the cornerstone of medical therapy for preventing initial variceal bleeding by decreasing hepatic venous pressure gradient 2
• Patients with clinically significant portal hypertension (HVPG ≥10 mmHg) are at risk for developing esophageal varices and potential bleeding 3
• A reduction of HVPG by >20% from baseline or to <12 mmHg correlates with considerable reduction in variceal bleeding risk during treatment with NSBBs 3

Endoscopic Management

• For high-risk esophageal varices, endoscopic variceal ligation (EVL) is the preferred endoscopic treatment 1
• EVL is more effective than endoscopic sclerotherapy (ES) in decreasing the risk of bleeding with fewer complications 3
• EVL requires fewer sessions than ES to achieve variceal eradication (2.91 vs 4.73 sessions) 3

Acute Bleeding Management

Immediate Interventions

1. Vasoactive drugs should be initiated as the first step in stopping acute variceal bleeding, even before endoscopy 3

   • Options include terlipressin, somatostatin, or octreotide 3
   • Early administration facilitates endoscopy, improves early hemostasis, and lowers rebleeding rates 3

2. Prophylactic antibiotics are essential in patients with cirrhosis and acute gastrointestinal bleeding 3

   • Reduces mortality (RR: 0.79), bacterial infections (RR: 0.35), and rebleeding (RR: 0.53) 3

3. Endoscopic therapy should be performed after initial resuscitation 3

   • Combination of vasoactive drugs and endoscopy is the favored treatment algorithm, achieving 85-90% rates of initial bleeding control 3
   • EVL is recommended over ES for acute bleeding esophageal varices 3

Secondary Prevention (After First Bleeding Episode)

• Combination of NSBBs plus EVL is the best option for secondary prophylaxis 1
• After variceal eradication with EVL, perform surveillance endoscopy at 1-3 months and then every 6-12 months 1
• For patients with recurrent variceal hemorrhage despite combination therapy:
  • TIPS should be considered in Child-Pugh A or B patients 1
  • Surgical shunts can be considered for Child-Pugh A patients in centers with expertise 1

Special Considerations

High-Risk Patients

• Early TIPS with expanded polytetrafluoroethylene (ePTFE)-covered stents within 72 hours (ideally <24 hours) should be considered in patients at high risk of treatment failure 3:
  • Child-Pugh class B with active bleeding
  • Child-Pugh class C with MELD <14 points

Gastric Varices

• For isolated gastric varices (IGV1) and gastroesophageal varices type 2 (GOV2), injection of cyanoacrylate glue is considered the endotherapy of choice 2
• TIPS may be particularly effective for gastric varices with large gastrorenal shunts 3

Common Pitfalls to Avoid

• Combining EVL with sclerotherapy increases complications without improving outcomes 1
• Overuse of TIPS increases encephalopathy risk and should be reserved for treatment failures or high-risk patients 1
• Delayed antibiotic administration in acute bleeding can increase mortality and rebleeding rates 3
• High MELD scores (>19) predict poor outcomes with TIPS 1

By implementing these evidence-based strategies, the incidence of variceal bleeding in portal hypertension can be significantly reduced, improving patient morbidity, mortality, and quality of life.