What is the management of esophageal varices?

Management of Esophageal Varices

The management of esophageal varices requires a combination of non-selective beta-blockers (NSBBs) plus endoscopic variceal ligation (EVL) as the best approach for preventing rebleeding, with specific treatment strategies for acute bleeding episodes including immediate vasoactive drugs, antibiotics, and endoscopic therapy. 1

Risk Assessment and Classification

• Patients with clinically significant portal hypertension (hepatic venous pressure gradient ≥10 mmHg) are at risk for developing esophageal varices 1
• Management strategies differ based on clinical scenario:
  • Primary prophylaxis (preventing first bleed)
  • Acute variceal hemorrhage
  • Secondary prophylaxis (preventing rebleeding)

Primary Prophylaxis

• For medium/large varices that have not bled but have high risk of hemorrhage (Child B/C or red wale markings):
  • NSBBs (propranolol or nadolol) or EVL 2
• For medium/large varices without high-risk features (Child A patients without red signs):
  • NSBBs are preferred
  • EVL should be considered only if patient has contraindications, intolerance, or non-compliance to beta-blockers 2
• If using NSBBs:
  • Adjust to maximal tolerated dose
  • No follow-up surveillance endoscopy needed 2
• If using EVL:
  • Repeat every 1-2 weeks until obliteration
  • First surveillance EGD 1-3 months after obliteration
  • Then every 6-12 months to check for recurrence 2, 1

Management of Acute Variceal Hemorrhage

Initial Resuscitation

• Admit to intensive care unit
• Maintain hemoglobin around 8 g/dL (avoid overtransfusion which can increase portal pressure) 2
• Avoid vigorous saline resuscitation which can worsen ascites 2
• Consider airway protection, especially in patients with hepatic encephalopathy 2

Pharmacological Therapy

• Start vasoactive drugs immediately when variceal bleeding is suspected, even before endoscopy 1
  • Terlipressin: Initial dose 2 mg IV every 4 hours, can be titrated down to 1 mg IV every 4 hours once bleeding is controlled 2
  • Somatostatin: 250 µg IV bolus followed by infusion of 250 µg/hour 2
  • Octreotide (available in US): 50 µg IV bolus followed by continuous infusion of 50 µg/hour 2
  • Continue for 3-5 days after diagnosis confirmation 2

Antibiotic Prophylaxis

• Short-term (maximum 7 days) antibiotic prophylaxis is essential 2, 1
  • Oral norfloxacin (400 mg BID) or
  • IV ciprofloxacin (if oral administration not possible)
  • IV ceftriaxone (1 g/day) may be preferable in advanced cirrhosis or centers with high quinolone resistance 2

Endoscopic Management

• Perform EGD within 12 hours of presentation 2
• EVL is the preferred endoscopic method (superior to sclerotherapy) 2, 1
• For fundal varices, endoscopic variceal obturation with tissue adhesives (e.g., N-butyl-cyanoacrylate) is more effective than EVL 2

Rescue Therapies for Uncontrolled Bleeding

• For bleeding that cannot be controlled or recurs despite therapy (10-20% of cases):
  • TIPS (Transjugular Intrahepatic Portosystemic Shunt) is indicated 2, 1
  • Early TIPS (within 24-72 hours) should be considered for high-risk patients:
    • Child-Pugh class B with active bleeding or
    • Child-Pugh class C with MELD <14 points 1
  • Balloon tamponade as a temporizing measure (maximum 24 hours) while awaiting definitive therapy 2
  • Self-expanding covered metallic esophageal stent can be used for refractory bleeding 3

Secondary Prophylaxis

• Combination of NSBBs plus EVL is the best option 2, 1, 4
• NSBBs should be adjusted to maximal tolerated dose 2
• EVL schedule:
  • Repeat every 1-2 weeks until obliteration
  • First surveillance EGD 1-3 months after obliteration
  • Then every 6-12 months to check for recurrence 2
• For recurrent bleeding despite combination therapy:
  • TIPS should be considered in Child A or B patients 2, 1
  • Surgical shunt can be considered in Child A patients at centers with expertise 2, 1
• Liver transplantation should be considered for eligible patients 1

Special Considerations

• Gastric varices (GOV1) extending along lesser curvature: manage like esophageal varices 2
• Fundal varices: endoscopic variceal obturation with tissue adhesives is preferred 2
• Avoid combining EVL with sclerotherapy as it increases complications without improving outcomes 1
• TIPS may be particularly effective for gastric varices with large gastrorenal shunts 1
• Patients with high MELD scores (>19) have poor outcomes with TIPS 1

By following these evidence-based approaches to managing esophageal varices, clinicians can significantly reduce morbidity and mortality associated with this serious complication of portal hypertension.