From the Research
Introduction to Esophageal Varices Treatment
Esophageal varices are a serious complication of cirrhosis, characterized by enlarged veins in the esophagus that can bleed easily. The treatment of esophageal varices aims to prevent bleeding, manage acute bleeding, and prevent recurrence.
Primary Prevention of Esophageal Variceal Bleeding
For primary prevention of esophageal variceal bleeding, non-selective beta-blockers (NSBB) are considered the first-line treatment 1. NSBB monotherapy or in combination with variceal band ligation (VBL) or isosorbide-mononitrate (ISMN) has been shown to decrease mortality and prevent variceal bleeding in patients with cirrhosis and large esophageal varices.
Treatment Options for Esophageal Varices
The following treatment options are available for esophageal varices:
- Non-selective beta-blockers (NSBB): propranolol or nadolol, typically started at a dose of 20-40 mg twice daily and titrated to achieve a heart rate of 50-60 beats per minute
- Variceal band ligation (VBL)
- Isosorbide-mononitrate (ISMN)
- Sclerotherapy
- Terlipressin: a vasoconstrictive drug used to treat acute variceal bleeding, typically administered at a dose of 1-2 mg every 4-6 hours
- Somatostatin or octreotide: vasoactive drugs used to treat acute variceal bleeding
Acute Variceal Bleeding Management
For acute variceal bleeding, the following steps are recommended:
- Fluid resuscitation
- Vasoactive drugs such as terlipressin, somatostatin, or octreotide
- Endoscopic treatment with VBL or sclerotherapy
- Consideration of transjugular intrahepatic portosystemic shunt (TIPS) or liver transplantation if bleeding is uncontrolled
Prevention of Recurrent Bleeding
To prevent recurrent bleeding, the following measures are recommended:
- Continued use of NSBB
- Regular endoscopic surveillance and treatment of varices
- Consideration of TIPS or liver transplantation in patients with recurrent bleeding
Caveats and Differentials
It is essential to note that the treatment of esophageal varices should be individualized based on the patient's underlying condition, medical history, and response to treatment. Patients with certain medical conditions, such as asthma or chronic obstructive pulmonary disease, may not be suitable for NSBB therapy. Additionally, the use of vasoactive drugs such as terlipressin, somatostatin, or octreotide requires careful monitoring of the patient's hemodynamic status 2, 3, 4, 5.