From the Guidelines
The treatment of esophageal varices should focus on preventing and managing bleeding episodes, with the combination of endoscopic variceal ligation (EVL) plus non-selective beta-blockers (NSBBs) being the primary treatment for esophageal variceal bleeding, as recommended by the most recent guidelines 1. The management of esophageal varices involves several key strategies, including:
- Initial management with endoscopic therapy, specifically band ligation, which is preferred over sclerotherapy due to fewer complications and better outcomes
- Use of vasoactive medications like octreotide or terlipressin for patients with acute bleeding, as supported by recent studies 1
- Antibiotic prophylaxis with ceftriaxone to prevent bacterial infections
- Primary prophylaxis with non-selective beta-blockers like propranolol or nadolol for patients with high-risk varices
- Secondary prophylaxis after a bleeding episode, combining endoscopic band ligation with beta-blockers
- Consideration of transjugular intrahepatic portosystemic shunt (TIPS) in cases of refractory bleeding, as discussed in recent studies 1 It is essential to address the underlying cause of portal hypertension, typically liver cirrhosis, through alcohol abstinence, viral hepatitis treatment, or management of other liver diseases to prevent progression and reduce portal pressure. Regular endoscopic surveillance is necessary to monitor varices and assess treatment effectiveness. Patients should avoid NSAIDs and other medications that increase bleeding risk. Key considerations in the management of esophageal varices include:
- The importance of early administration of vasoactive agents to facilitate endoscopy and improve early hemostasis, as supported by recent studies 1
- The role of TIPS in managing refractory bleeding, with recent studies highlighting its effectiveness in reducing variceal bleeding, although with a higher risk of hepatic encephalopathy 1
- The need for individualized treatment approaches, taking into account the patient's specific clinical context and underlying liver disease.
From the Research
Treatment Options for Esophageal Varices
The treatment for esophageal varices typically involves a combination of medical and endoscopic therapies. The primary goal of treatment is to prevent bleeding and reduce the risk of complications.
- Primary Prophylaxis: Patients with medium- or large-sized varices can be treated with non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL) to prevent initial variceal bleeding 2, 3, 4, 5.
- Acute Variceal Bleeding: Patients with acute variceal bleeding are treated with vasoactive drugs, combined with endoscopic therapy and antibiotics. EVL is the preferred endoscopic procedure, and transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents may be recommended in cases of uncontrolled bleeding 2, 3, 5.
- Secondary Prophylaxis: After an initial bleeding episode, patients are at high risk of rebleeding. The combination of NSBBs and EVL is the recommended management, while TIPS with PTFE-covered stents may be considered in patients who fail endoscopic and pharmacologic treatment 2, 3, 4, 5.
Endoscopic Procedures
Several endoscopic procedures are available for the treatment of esophageal varices, including:
- Endoscopic Variceal Ligation (EVL): A widely used and effective procedure for treating esophageal varices 2, 3, 4, 5.
- Sclerotherapy: A procedure that involves injecting a sclerosing agent into the varices to stop bleeding and prevent rebleeding 3, 4, 6.
- Tissue Adhesives: A procedure that involves using a tissue adhesive to occlude the varices 6.
- Endoloops: A procedure that involves using an endoloop to ligate the varices 2.
- Argon Plasma Coagulation: A procedure that involves using argon plasma coagulation to treat esophageal varices 2.
Pharmacological Management
Pharmacological management of esophageal varices includes the use of: