What is the primary management for non-alcoholic varices?

Management of Non-Alcoholic Varices

Non-selective beta-blockers (NSBBs) such as propranolol or nadolol are the first-line therapy for primary prophylaxis of bleeding from non-alcoholic varices in patients with medium to large varices or those at high risk of hemorrhage. 1, 2

Risk Assessment and Screening

• All patients with cirrhosis should undergo endoscopic screening at diagnosis to assess for varices
• Risk factors for bleeding include:
  • Size of varices (medium/large varices have higher risk)
  • Child-Pugh classification (Class B/C indicates higher risk)
  • Presence of red wale marks on varices
  • Advanced liver disease

Primary Prophylaxis Algorithm

For Medium/Large Varices:

1. First-line: Non-selective beta-blockers (NSBBs)

   • Propranolol: Start at 40mg twice daily, titrate to maximum tolerated dose
   • Nadolol: Start at 40mg once daily, titrate as needed
   • Goal: Reduce heart rate by 25% from baseline or to 55-60 bpm

2. Alternative if NSBB contraindicated/not tolerated: Endoscopic Variceal Ligation (EVL)

   • Schedule EVL every 1-2 weeks until varices are obliterated
   • First surveillance EGD 1-3 months after obliteration
   • Then every 6-12 months to check for recurrence 1

For Small Varices with Red Wale Marks or Child-Pugh C:

• NSBBs are recommended 1
• No need for surveillance endoscopy if patient is on adequate NSBB therapy

Contraindications and Special Considerations

• Use NSBBs with caution in patients with:

  • Refractory ascites
  • Systolic blood pressure <90 mmHg
  • Serum creatinine >1.5 mg/dl
  • Hyponatremia <130 mmol/L 1

• Consider dose reduction or temporary discontinuation of NSBBs in:

  • Acute intercurrent conditions (bleeding, sepsis, SBP, AKI)
  • Progressive hypotension
  • Worsening renal function 1

• Avoid high doses of NSBBs (>160 mg/day of propranolol) as they may increase mortality in patients with advanced cirrhosis 1

• Avoid carvedilol in decompensated patients due to its additional vasodilatory effects that may cause systemic hemodynamic depression 1

Acute Variceal Bleeding Management

1. Immediate resuscitation

   • Maintain hemodynamic stability
   • Target hemoglobin ~8 g/dL
   • Avoid excessive volume expansion which can increase portal pressure 1

2. Pharmacological therapy

   • Vasoactive drugs (terlipressin, somatostatin, octreotide) for 3-5 days
   • Prophylactic antibiotics to prevent infection

3. Endoscopic therapy

   • Perform within 12 hours of presentation
   • EVL is preferred over sclerotherapy

4. Rescue therapy

   • TIPS (Transjugular Intrahepatic Portosystemic Shunt) for uncontrollable bleeding or early rebleeding

Secondary Prophylaxis

• Combination therapy is recommended:
  • NSBBs plus EVL is more effective than either treatment alone 1
  • NSBBs are the cornerstone of combined therapy and improve survival 1

Common Pitfalls to Avoid

1. Using selective beta-blockers (atenolol, metoprolol) which are ineffective for portal hypertension

2. Using nitrates alone which can increase mortality, especially in patients over 50 years 1

3. Using sclerotherapy for primary prophylaxis which may increase mortality compared to no treatment 1

4. Using shunt therapy (TIPS or surgical) for primary prophylaxis, which increases encephalopathy and mortality 1

5. Abruptly discontinuing NSBBs - if needed, taper gradually and consider restarting after resolution of acute issues

6. Overtransfusion during acute bleeding, which can increase portal pressure and rebleeding risk

By following this evidence-based approach to managing non-alcoholic varices, clinicians can significantly reduce the risk of first variceal hemorrhage from approximately 30% to 14% in high-risk patients 2, thereby improving morbidity, mortality, and quality of life.