What is the treatment for preventing esophageal varices?

Treatment for Esophageal Varix Prevention

Non-selective beta-blockers (NSBBs) are the first-line treatment for preventing esophageal variceal bleeding in patients with cirrhosis, with endoscopic variceal ligation (EVL) as an alternative for those who cannot tolerate beta-blockers. 1, 2

Initial Assessment and Risk Stratification

1. Screening and Diagnosis:

   • All patients with cirrhosis should undergo endoscopic screening at diagnosis 2
   • Classify varices as:
     • Small (<5mm)
     • Medium/Large (>5mm)
   • Note presence of high-risk features:
     • Red wale marks or red spots
     • Child-Pugh B/C cirrhosis

2. Risk-based Treatment Approach:

For Patients with No Varices:

• Surveillance EGD every 2-3 years in compensated cirrhosis
• Annual EGD in decompensated cirrhosis 1

For Patients with Small Varices:

• High-risk small varices (Child B/C or red wale marks):
  • Initiate non-selective beta-blockers 1, 2
• Low-risk small varices:
  • Beta-blockers can be used but long-term benefit not established
  • If no beta-blockers, repeat EGD in 1-2 years 1

For Patients with Medium/Large Varices:

• First choice: Non-selective beta-blockers 1, 2
• Alternative: Endoscopic variceal ligation (EVL) if beta-blockers contraindicated or not tolerated 1, 2

Specific Treatment Protocols

Non-selective Beta-Blockers:

1. Medication options:

   • Propranolol: Start at 40mg twice daily, titrate to maximum tolerated dose 1, 2
   • Nadolol: Start at 40mg once daily 1
   • Carvedilol: Alternative for propranolol non-responders (6.25-50mg/day) 2, 3
     • Provides additional α-adrenergic blockade
     • Avoid in decompensated patients due to vasodilatory effects 2

2. Dosing targets:

   • Reduce heart rate by 25% from baseline or to 55-60 bpm 2
   • Continue indefinitely as risk of bleeding recurs when treatment is stopped 1

3. Efficacy:

   • Meta-analyses show NSBBs reduce first variceal bleeding risk from 30% to 14% 1, 2
   • One bleeding episode avoided for every 10 patients treated 1
   • Mortality is also reduced with beta-blockers 1

Endoscopic Variceal Ligation (EVL):

1. Protocol:

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

2. Efficacy:

   • Equivalent to nadolol or propranolol in preventing first variceal hemorrhage 1
   • Decision between EVL and NSBBs should be based on patient characteristics, preferences, and local expertise 1

Important Cautions and Contraindications

1. Avoid these treatments:

   • Selective beta-blockers (atenolol, metoprolol) - ineffective for portal hypertension 1, 2
   • Nitrates alone - may increase mortality, especially in patients >50 years 1
   • Sclerotherapy for primary prophylaxis - may increase mortality 1, 2
   • Shunt therapy (TIPS or surgical) - increases encephalopathy and mortality 1

2. Use NSBBs with caution in:

   • Refractory ascites
   • Systolic BP <90 mmHg
   • Serum creatinine >1.5 mg/dl
   • Hyponatremia <130 mmol/L 2

3. Combination therapies:

   • Beta-blocker + isosorbide mononitrate: Not recommended (more side effects without proven additional benefit) 1
   • Beta-blocker + EVL: Not recommended for primary prophylaxis 1
   • Beta-blocker + spironolactone: Not recommended (no increased efficacy) 1

Follow-up Protocol

1. For patients on beta-blockers:

   • Follow-up EGD not necessary 1, 2
   • Monitor for side effects and medication adherence

2. For patients treated with EVL:

   • Repeat EGD every 1-2 weeks until obliteration
   • Surveillance at 1-3 months after obliteration
   • Then every 6-12 months thereafter 1, 2

3. For patients not on prophylaxis:

   • Small varices: EGD every 2 years
   • If hepatic decompensation occurs: EGD at that time and annually thereafter 1