What is the role of steroids in the management of esophageal varices and portal gastropathy?

From the Guidelines

Corticosteroids are not recommended for the management of esophageal varices or portal gastropathy, as they may worsen portal hypertension and increase the risk of infection and impaired wound healing. The primary treatments for esophageal varices include non-selective beta-blockers (such as propranolol 20-40mg twice daily or nadolol 20-40mg once daily), endoscopic band ligation for primary and secondary prophylaxis, and vasoactive drugs (terlipressin 2mg IV every 4-6 hours or octreotide 50mcg IV bolus followed by 50mcg/hour infusion) plus endoscopic therapy for acute bleeding, as supported by recent studies 1. For portal hypertensive gastropathy, non-selective beta-blockers are the mainstay of treatment, with propranolol typically started at 20mg twice daily and titrated to heart rate or maximum tolerated dose, as recommended by recent guidelines 1.

Some key points to consider in the management of esophageal varices and portal gastropathy include:

• The use of transjugular intrahepatic portosystemic shunts (TIPS) as a treatment option for patients with recurrent esophageal variceal hemorrhage, as shown to be effective in reducing rebleeding and improving survival in high-risk patients 1.
• The importance of addressing underlying cirrhosis and portal hypertension in the management of iron deficiency anemia (IDA) in patients with portal hypertensive gastropathy, with interventions to reduce portal pressure such as nonselective beta-blockers and TIPS 1.
• The role of iron therapy in the management of IDA in patients with PHG, which may be oral or IV, depending on the severity of iron depletion 1.

Overall, the goal of therapy is to reduce portal pressure, which can be achieved through a combination of pharmacological and endoscopic treatments, as well as interventions such as TIPS, but steroids are not a recommended treatment option due to their potential to worsen portal hypertension and increase the risk of complications.

From the Research

Role of Steroids in Esophageal Varices and Portal Gastropathy

• There is no direct evidence in the provided studies regarding the role of steroids in the management of esophageal varices and portal gastropathy.
• The studies primarily focus on the use of beta-blockers, such as propranolol, and endoscopic treatments for the management of esophageal varices and portal hypertensive gastropathy 2, 3, 4.
• The use of beta-blockers, like propranolol, has been shown to reduce the incidence of first variceal bleeding and re-bleeding in patients with esophageal varices 3, 4.
• Endoscopic treatments, such as band ligation, are also effective in reducing the risk of re-bleeding, but may accentuate portal hypertensive gastropathy, which can be partly relieved by propranolol 3.
• The management of gastric varices is outlined in one study, which suggests an algorithm based on the etiology of the gastric varices, severity of the underlying liver disease, and local availability and expertise 5.
• Another study found that propranolol did not prevent the development of large esophageal varices in patients with cirrhosis 6.