What is the recommended treatment for esophageal varices in patients with cirrhosis?

Treatment of Esophageal Varices in Cirrhosis

All patients with cirrhosis should undergo screening esophagogastroduodenoscopy (EGD) at diagnosis to identify and grade varices, followed by risk-stratified prophylactic treatment with nonselective beta-blockers or endoscopic variceal ligation to prevent life-threatening hemorrhage. 1

Initial Screening and Surveillance

• Perform screening EGD when cirrhosis is first diagnosed to identify the presence and size of varices 1
• Grade varices as small (≤5 mm) or large (>5 mm), and document the presence or absence of red color signs (red wale marks or red spots) 1, 2
• For patients with no varices: repeat EGD every 2-3 years if compensated, annually if decompensated 1, 3
• For patients with small varices: repeat EGD every 1-2 years if not on beta-blockers 1, 3

Treatment Algorithm Based on Variceal Size and Risk Factors

Small Varices with High-Risk Features

High-risk features include Child-Pugh class B/C or presence of red wale marks on varices 1

• Initiate nonselective beta-blockers (propranolol or nadolol) for primary prophylaxis 1, 2
• Start nadolol at 40 mg once daily or propranolol at 40 mg once daily 1
• Titrate to maximum tolerated dose, aiming for heart rate reduction of 25% from baseline or target of 55-60 beats per minute 1, 2
• Continue beta-blocker therapy indefinitely once started, as discontinuation leads to recurrent bleeding risk 1
• Follow-up EGD is not necessary in patients receiving beta-blockers 1

Small Varices Without High-Risk Features

• Beta-blockers may be used but long-term benefit is not well established 1
• If beta-blockers are declined, perform surveillance EGD every 2 years (annually if decompensated) 1, 3

Medium or Large Varices

For medium/large varices, both nonselective beta-blockers and endoscopic variceal ligation (EVL) are effective primary prophylaxis options 1, 3

Preferred Treatment Approach:

• Nonselective beta-blockers (propranolol or nadolol) are the first-line treatment 1

  • Reduce first variceal bleeding from 30% to 14% (1 bleeding episode prevented per 10 patients treated) 1
  • Also reduce mortality compared to no treatment 1
  • Most cost-effective prophylactic therapy 1

• EVL is recommended for patients with contraindications, intolerance, or non-compliance to beta-blockers 1, 3

  • If EVL is chosen, repeat every 1-2 weeks until variceal obliteration 1
  • First surveillance EGD at 1-3 months after obliteration, then every 6-12 months to check for recurrence 1, 2

• For highest-risk patients (Child B/C or red wale markings), either beta-blockers or EVL may be used 1

Carvedilol Consideration:

• Carvedilol (a nonselective beta-blocker with alpha-1 blocking effects) reduces hepatic venous pressure gradient more than traditional beta-blockers but has not demonstrated superior clinical outcomes in preventing bleeding or mortality 4
• Traditional nonselective beta-blockers (propranolol, nadolol) remain the standard of care 1

Contraindications to Beta-Blockers

Do not use beta-blockers in patients with: 5

• Hypotension
• Severe bradycardia or high-degree heart block
• Asthma or severe reactive airway disease
• Active variceal bleeding (as they decrease blood pressure and blunt compensatory tachycardia) 5

Therapies to Avoid

• Nitrates alone or in combination with beta-blockers should not be used for primary prophylaxis 1
• Sclerotherapy should not be used for primary prophylaxis due to increased mortality 1
• Shunt therapy (TIPS or surgical shunts) should not be used for primary prevention 1

Critical Prognostic Considerations

• Patients with decompensated cirrhosis (ascites, encephalopathy) and varices have 5-year mortality exceeding 80%, compared to 20% for isolated variceal findings 3
• Untreated variceal hemorrhage carries 60% rebleeding rate within 1-2 years and 33% mortality 3
• All patients with Child-Pugh score ≥7 or MELD ≥15 who survive variceal hemorrhage should be referred for liver transplantation evaluation 3
• Large varices have 15% yearly bleeding risk, which increases to 80% with red color signs 3, 2

Common Pitfalls to Avoid

• Do not use selective beta-blockers (atenolol, metoprolol) as they are less effective than nonselective agents 1
• Approximately 11% of patients on beta-blockers experience adverse events requiring withdrawal, compared to 1% on placebo 1
• Heart rate reduction does not correlate with hepatic venous pressure gradient reduction, so titrate to maximum tolerated dose rather than relying solely on heart rate 1
• Beta-blockers do not prevent the development of new varices, so screening EGD cannot be replaced by empiric beta-blocker therapy 1