What are the causes and treatments of esophageal varices (enlarged veins in the esophagus)?

From the Guidelines

Esophageal varices are best managed with a combination of non-selective beta-blockers (NSBBs) and endoscopic variceal ligation (EVL) for primary and secondary prevention of bleeding, with transjugular intrahepatic portosystemic shunt (TIPS) considered for patients with recurrent bleeding despite medical therapy. The causes of esophageal varices are primarily related to portal hypertension, most commonly due to cirrhosis, which leads to the formation of these abnormally enlarged veins in the lower esophagus as blood seeks alternative routes back to the heart. Management strategies include:

• Primary prevention in patients with medium to large varices using NSBBs like propranolol (20-40mg twice daily) or nadolol (20-40mg daily), with dosage titrated to reduce resting heart rate by 25% or to 55-60 beats per minute 1.
• Endoscopic band ligation as an alternative for those who cannot tolerate beta-blockers, with the goal of variceal eradication 1.
• For acute bleeding, immediate resuscitation with IV fluids and blood products is essential, followed by vasoactive medications like octreotide (50mcg IV bolus, then 50mcg/hour infusion) or terlipressin (2mg IV every 4 hours) 1.
• Urgent endoscopic band ligation should be performed within 12 hours, with EVL being the endoscopic treatment of choice for patients with acute bleeding from esophageal varices 1.
• Antibiotic prophylaxis with ceftriaxone 1g daily for 5-7 days is recommended to prevent infection 1.
• Secondary prevention after a bleeding episode requires combination therapy with both beta-blockers and endoscopic band ligation, with TIPS considered for patients with recurrent bleeding despite medical therapy 1. The most recent and highest quality study 1 supports the combination of EVL plus NSBBs as the primary treatment for esophageal variceal bleeding, with TIPS placement as a rescue therapy if primary treatment fails. Liver transplantation may also be considered in patients with recurrent variceal rebleeding 1.

Key points to consider in management include:

• The importance of prompt endoscopic evaluation and treatment for acute variceal bleeding 1.
• The role of vasoactive medications in controlling acute bleeding and preventing rebleeding 1.
• The consideration of TIPS for patients with recurrent bleeding, despite its potential risks such as hepatic encephalopathy 1.
• The need for individualized treatment approaches based on patient-specific factors, including the severity of liver disease and the presence of complications like hepatic encephalopathy 1.

Overall, the management of esophageal varices requires a multifaceted approach that incorporates medical, endoscopic, and radiologic interventions to prevent bleeding, manage acute hemorrhage, and improve patient outcomes.

From the Research

Causes of Esophageal Varices

• Esophageal varices are caused by portal hypertension, which is often a result of liver cirrhosis 2, 3
• Portal hypertension leads to the formation of varices, which are enlarged veins in the esophagus that can bleed easily 2, 3

Treatments for Esophageal Varices

• Primary prophylaxis:
  • Non-selective beta-blockers (NSBBs) such as propranolol or nadolol can be used to reduce the risk of first variceal bleeding 4, 2, 5, 6
  • Endoscopic variceal ligation (EVL) is also effective in preventing first variceal bleeding 2, 3
• Secondary prophylaxis:
  • Combination of NSBBs and EVL is recommended to prevent rebleeding 4, 2, 3
  • Transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents can be used in patients who fail endoscopic and pharmacologic treatment 2, 3
• Acute variceal bleeding:
  • Vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy 3
  • EVL is the endoscopic procedure of choice for acute variceal bleeding 3

Hemodynamic Response to Treatment

• A hemodynamic response to treatment, defined as a decrease in the hepatic venous pressure gradient (HVPG) of more than 20% or to less than 12 mm Hg, is associated with a better long-term prognosis 4, 5
• Carvedilol can lead to a significantly greater decrease in HVPG than propranolol, and can be used in patients who do not respond to propranolol 5