What are the treatment options for managing varices, including esophageal varices and varicose veins?

Management of Varices

The management of varices requires a combination of pharmacological therapy, endoscopic interventions, and in some cases radiological or surgical approaches, with the specific treatment strategy determined by the type of varices and whether it is for prevention or active bleeding. 1, 2

Types of Varices and Diagnostic Approach

• Esophageal varices develop when hepatic venous pressure gradient (HVPG) exceeds 10 mmHg, with bleeding risk significantly increasing when HVPG rises above 12 mmHg 3
• Screening esophagogastroduodenoscopy (EGD) is recommended when cirrhosis is diagnosed to identify varices 1
• Varices should be graded as small or large (>5 mm), with presence of red signs (red wale marks or red spots) noted as they indicate higher bleeding risk 1, 4
• For patients with no varices on initial EGD, repeat endoscopy should be performed every 2-3 years in compensated cirrhosis and yearly in decompensated cirrhosis 1
• For patients with small varices, repeat endoscopy should be performed every 1-2 years 1

Management of Acute Variceal Bleeding

Immediate Measures

• Start vasoactive drugs (terlipressin, somatostatin, or octreotide) as soon as variceal bleeding is suspected, even before endoscopy 5
• Initiate resuscitation with intravascular volume support, maintaining hemoglobin at approximately 8 g/dL 2
• Administer prophylactic antibiotics to reduce infection risk, bacterial infections, and rebleeding 1, 5
• Do not use beta-blockers during acute bleeding episodes as they decrease blood pressure and blunt physiologic heart rate response 6, 5

Endoscopic Management

• Perform emergency endoscopy within 12 hours for diagnosis and treatment 2
• Endoscopic variceal ligation (EVL) is the preferred endoscopic treatment for esophageal varices 1, 2
• For gastric varices, tissue adhesives such as N-butyl-cyanoacrylate are more effective than EVL 2
• Combination of vasoactive drugs and endoscopic therapy is superior to endoscopic treatment alone, with 5-day hemostasis rates of 77% vs. 58% 1, 5

Rescue Therapy

• Consider transjugular intrahepatic portosystemic shunt (TIPS) for patients who fail medical and endoscopic therapy 5
• TIPS is particularly beneficial for Child-Pugh class B patients with active bleeding or Child-Pugh class C patients with MELD <14 points 5

Primary Prevention of Variceal Bleeding

• Non-selective beta-blockers (propranolol, nadolol) are the gold standard for preventing first variceal hemorrhage in patients with medium/large varices 6, 2, 7
• Beta-blockers should be titrated to the maximal tolerated dose rather than targeting a specific heart rate reduction 2
• Beta-blockers are indicated for patients with small varices who have high bleeding risk (Child B/C cirrhosis or red wale marks) 2
• EVL is an alternative for patients who have contraindications or intolerance to beta-blockers 3, 8
• The combination of beta-blockers and EVL for primary prophylaxis has not shown clear superiority over either therapy alone 8

Secondary Prevention of Variceal Bleeding

• The combination of non-selective beta-blockers plus EVL is the most effective approach for preventing rebleeding, with rebleeding rates of 14-23% for combination therapy versus 38-47% for EVL alone 2
• Beta-blockers should be started once the patient has recovered from the acute bleeding episode and before discharge from hospital 6
• HVPG response to beta-blockers is the best predictor of clinical efficacy, with patients having a reduction to <12 mmHg or by >20% from baseline having the lowest rebleeding risk (approximately 10%) 2, 3
• After variceal eradication with EVL, endoscopy should be performed every 3-6 months to evaluate for variceal recurrence 2
• TIPS is more effective than endoscopic treatment in reducing variceal rebleeding but does not improve survival and is associated with more encephalopathy 1

Management of Gastric Varices

• Gastric variceal obturation with tissue adhesives, such as N-butyl-cyanoacrylate, is more effective than EVL for gastric variceal bleeding 2
• Endoscopic injection of bovine thrombin has shown promise for bleeding from gastric varices in small studies 1
• TIPS should be considered for refractory gastric variceal bleeding 1, 5

Important Considerations and Pitfalls

• Recognize contraindications to beta-blockers, including asthma, severe COPD, heart block, significant bradycardia, hypotension, and decompensated heart failure 6, 2
• Beta-blockers reduce portal pressure through β1-receptor blockade (decreasing cardiac output) and β2-receptor blockade (causing splanchnic vasoconstriction) 6
• Carvedilol, a newer non-selective beta-blocker with anti-alpha1-adrenergic activity, may have a better impact on reducing HVPG than propranolol 9
• Capsule endoscopy may play a future role in screening for esophageal varices, though its sensitivity remains to be established 1