What is the management of esophageal varices?

Management of Esophageal Varices

The combination of nonselective beta-blockers plus endoscopic variceal ligation (EVL) is the most effective approach for managing esophageal varices, particularly for secondary prophylaxis after a bleeding episode. 1, 2

Acute Variceal Bleeding Management

• Immediate resuscitation with intravascular volume support and blood transfusions should be initiated, maintaining hemoglobin at approximately 8 g/dL 1
• Vasoactive drugs (somatostatin, octreotide, terlipressin) should be started as soon as variceal bleeding is suspected, even before diagnostic endoscopy, and continued for 3-5 days 1, 3
• Short-term antibiotic prophylaxis (maximum 7 days) is essential in all cirrhotic patients with GI hemorrhage - oral norfloxacin (400 mg BID) or IV ciprofloxacin is recommended; IV ceftriaxone (1 g/day) may be preferred in advanced cirrhosis 1, 3
• Emergency endoscopy should be performed within 12 hours to diagnose and treat variceal hemorrhage with EVL or sclerotherapy 1
• Balloon tamponade should only be used as a temporary measure (maximum 24 hours) in uncontrollable bleeding while awaiting definitive therapy 1
• Beta-blockers should NOT be used during acute bleeding episodes as they can decrease blood pressure and blunt physiologic heart rate response 2, 3

Primary Prophylaxis

• Nonselective beta-blockers are the gold standard for preventing first variceal hemorrhage in patients with medium/large varices 1, 4
• Beta-blockers are indicated for patients with small varices who have high bleeding risk (Child B/C cirrhosis or red wale marks) 4
• Beta-blockers can slow progression from small to large varices, reducing progression from 37% to 11% at 3 years 4
• EVL is an alternative to beta-blockers for primary prophylaxis in patients with contraindications or intolerance to beta-blockers 1, 5

Secondary Prophylaxis

• Combination of nonselective beta-blockers plus EVL is superior to either therapy alone for preventing rebleeding, with rebleeding rates of 14-23% for combination therapy versus 38-47% for EVL alone 1, 2
• Beta-blockers should be titrated to the maximal tolerated dose rather than targeting a specific heart rate reduction 1, 4
• EVL should be repeated every 1-2 weeks until obliteration, with first surveillance endoscopy 1-3 months after obliteration, then every 6-12 months to check for recurrence 1
• TIPS (transjugular intrahepatic portosystemic shunt) should be considered in Child A or B patients who experience recurrent bleeding despite combination therapy 1
• Surgical shunts can be considered in Child A patients at centers with appropriate expertise 1
• Patients who are transplant candidates should be referred to a transplant center 1

Endoscopic Variceal Ligation (EVL) Technique

• EVL is superior to sclerotherapy for preventing variceal rebleeding (pooled odds ratio 0.46) with fewer complications 1
• EVL sessions are typically repeated at 7-14 day intervals until variceal obliteration, usually requiring 2-4 sessions 1, 6
• Common complications include transient dysphagia, chest discomfort, and shallow ulcers at ligation sites 1
• Proton pump inhibitors may be beneficial after EVL to reduce ulcer size and potentially decrease post-EVL bleeding risk 1

Special Considerations for Gastric Varices

• For gastric variceal bleeding, gastric variceal obturation with tissue adhesives like N-butyl-cyanoacrylate is more effective than EVL, with significantly lower rebleeding rates (23% vs 47%) 1
• 2-octyl cyanoacrylate has shown promise for achieving hemostasis and preventing rebleeding from fundal varices 1

Monitoring and Follow-up

• HVPG (hepatic venous pressure gradient) response to beta-blockers is the best predictor of clinical efficacy - patients with reduction to <12 mmHg or by >20% from baseline have the lowest rebleeding rate of approximately 10% 1, 2, 5
• After variceal eradication with EVL, endoscopy should be performed every 3-6 months to evaluate for variceal recurrence 1
• Beta-blockers should be continued indefinitely once started, as discontinuation increases bleeding risk 2, 4

Pitfalls to Avoid

• Never combine EVL with sclerotherapy, as this increases complications without improving outcomes 1
• Avoid using beta-blockers during acute bleeding episodes 2, 3
• Recognize contraindications to beta-blockers including asthma, severe COPD, heart block, significant bradycardia, hypotension, and decompensated heart failure 2, 4
• Don't delay antibiotic prophylaxis in acute variceal bleeding, as it significantly reduces infection risk and improves survival 1, 3