What is the treatment for esophageal varices?

Treatment for Esophageal Varices

The optimal treatment for esophageal varices depends on whether you are managing acute bleeding, preventing first bleeding (primary prophylaxis), or preventing rebleeding (secondary prophylaxis), with combination therapy of non-selective beta-blockers plus endoscopic variceal ligation being the gold standard for secondary prophylaxis. 1, 2

Acute Variceal Bleeding Management

Start vasoactive drugs immediately when variceal bleeding is suspected, even before endoscopy is performed. 1, 3, 2

Immediate Resuscitation and Medical Therapy

• Initiate vasoactive drugs (terlipressin, octreotide, or somatostatin) as soon as bleeding is suspected and continue for 3-5 days 1, 2
• Terlipressin is the preferred vasoactive agent based on the most convincing evidence for controlling acute bleeding, with longer half-life and fewer adverse effects than vasopressin 1, 4
• Octreotide is an effective alternative with a good safety profile, particularly when terlipressin is unavailable 1, 4
• Resuscitate with intravascular volume support targeting hemoglobin at approximately 8 g/dL to avoid overtransfusion 3, 2
• Administer prophylactic antibiotics (oral norfloxacin or IV ciprofloxacin) to all cirrhotic patients with variceal bleeding, as this reduces mortality, bacterial infections, and rebleeding 1, 2

Critical Pitfall to Avoid

• Do NOT use beta-blockers during acute bleeding episodes - they decrease blood pressure and blunt the physiologic heart rate response needed during hemorrhage 3, 2
• Temporarily suspend beta-blockers if systolic blood pressure is below 90 mmHg 1, 4

Endoscopic Management

• Perform emergency endoscopy within 12 hours for diagnosis and treatment 3, 2
• Endoscopic variceal ligation (EVL) is the preferred endoscopic treatment for esophageal varices, achieving 85-90% initial control of bleeding 1, 3
• Endoscopic sclerotherapy is an alternative if EVL is not available 1

Primary Prophylaxis (Preventing First Bleeding)

Non-selective beta-blockers are the gold standard for preventing first variceal hemorrhage in patients with medium/large varices. 1, 3, 2

Pharmacological Approach

• Propranolol: Start 20-40 mg orally twice daily, adjust every 2-3 days until target heart rate of 55-60 beats per minute is achieved, with maximum daily dose of 320 mg/day in patients without ascites and 160 mg/day in patients with ascites 4
• Nadolol: Start 20-40 mg orally once daily, adjust every 2-3 days until target heart rate of 55-60 beats per minute is achieved, with maximum daily dose of 160 mg/day in patients without ascites and 80 mg/day in patients with ascites 4
• Carvedilol may be superior to propranolol in achieving hemodynamic response, with 56% of propranolol non-responders achieving response with carvedilol 5
• NSBBs reduce first bleeding risk from 30% to 14% in patients with medium/large varices 4

Alternative to Pharmacological Therapy

• Endoscopic variceal ligation is an alternative to beta-blockers for primary prophylaxis, with choice based on local expertise, patient preference, and contraindications 1, 3

Indications for Treatment

• Treat all patients with medium/large varices 1, 3
• Treat patients with small varices who have high bleeding risk (Child B/C cirrhosis or red wale marks on endoscopy) 2

Contraindications to Beta-Blockers

• Asthma or severe COPD 3, 2
• Heart block or significant bradycardia 3, 2
• Hypotension 3, 2
• Decompensated heart failure 3, 2

Secondary Prophylaxis (Preventing Rebleeding)

The combination of non-selective beta-blockers plus endoscopic variceal ligation is superior to either therapy alone and is the recommended treatment for preventing rebleeding. 1, 3, 2

Combination Therapy Protocol

• Combination therapy reduces rebleeding rates to 14-23% compared to 38-47% with EVL alone 3, 2
• Start beta-blockers once the patient has recovered from acute bleeding and before hospital discharge 3
• Titrate beta-blockers to maximal tolerated dose rather than targeting a specific heart rate reduction 3, 2
• Perform EVL every 1-2 weeks until variceal obliteration 1
• After variceal eradication, perform surveillance endoscopy at 1-3 months, then every 6-12 months to check for recurrence 1, 2

Hemodynamic Response Monitoring

• HVPG reduction to <12 mmHg or by ≥20% from baseline is associated with the lowest rebleeding rate of approximately 10% 1, 2
• HVPG-based medical therapy is useful when measurement is available, though it is invasive and not widely practiced 1

Rescue Therapy for Treatment Failures

• TIPS (transjugular intrahepatic portosystemic shunt) should be considered in patients with recurrent bleeding despite combination therapy, particularly in Child A or B patients 1
• Pre-emptive TIPS should be used in all Child C10-C13 patients experiencing variceal bleeding, and potentially in Child B patients with active bleeding at endoscopy 6
• TIPS reduces rebleeding more effectively than medical therapy (0-7% vs 26-29%) but increases hepatic encephalopathy risk (35% vs 14%) without improving survival 1
• Liver transplantation should be considered in patients with recurrent variceal rebleeding 1

Special Considerations for Gastric Varices

Gastric varices require different management than esophageal varices, with tissue adhesives being more effective than EVL. 3, 2

• For GOV1 (gastroesophageal varices along lesser curvature), follow esophageal variceal guidelines 1
• For GOV2 and IGV1 (fundal varices), use tissue adhesives such as N-butyl-cyanoacrylate, which are more effective than EVL 3, 2
• TIPS should be considered for refractory gastric variceal bleeding 3