What is the best management approach for a patient with esophageal varices and underlying liver disease to prevent bleeding and manage complications?

Management of Esophageal Varices in Liver Disease

All patients with newly diagnosed cirrhosis should undergo screening endoscopy to detect varices, and management should be stratified based on varix size and bleeding risk, with non-selective beta-blockers or endoscopic variceal ligation as first-line prevention for medium-to-large varices. 1

Screening and Surveillance

• Perform screening endoscopy at the time of cirrhosis diagnosis to identify the presence and size of esophageal varices 1
• For patients without varices on initial screening, repeat endoscopy every 2-3 years 1
• For patients with small varices, repeat endoscopy every 1-2 years to monitor for progression 1
• Patients on non-selective beta-blockers for primary prophylaxis do not require serial endoscopic monitoring 1

Primary Prophylaxis (Prevention of First Bleeding)

For Medium or Large Varices

Either non-selective beta-blockers (propranolol, nadolol, carvedilol) OR endoscopic variceal ligation should be used—choice depends on patient characteristics and contraindications, not patient preference alone. 1, 2

Non-Selective Beta-Blocker Dosing:

• Propranolol: Start 20-40 mg orally twice daily, titrate every 2-3 days to target heart rate 55-60 bpm; maximum 320 mg/day without ascites, 160 mg/day with ascites 1
• Nadolol: Start 20-40 mg orally once daily, titrate to same heart rate target; maximum 160 mg/day without ascites, 80 mg/day with ascites 1
• Carvedilol: Start 6.25 mg once daily, increase after 3 days to 6.25 mg twice daily; maximum 12.5 mg/day 1
• Maintain systolic blood pressure ≥90 mmHg with all beta-blockers 1

Endoscopic Variceal Ligation Protocol:

• Repeat EVL every 2-8 weeks until complete variceal eradication 1, 2
• First surveillance endoscopy 3-6 months after eradication, then every 6-12 months to detect recurrence 1, 2

Combination therapy (beta-blockers plus EVL) is NOT recommended for primary prophylaxis 1

For Small Varices at High Risk

• Use non-selective beta-blockers if small varices have red wale marks or occur in decompensated cirrhosis (Child-Pugh B/C) 1
• EVL is not indicated for small varices 2

Acute Variceal Bleeding Management

Immediate Resuscitation (Within Minutes of Presentation)

Start vasoactive agents immediately upon suspicion of variceal bleeding, even before endoscopy is performed—this is a critical time-sensitive intervention that reduces mortality. 1, 3

• Restrictive transfusion strategy: Target hemoglobin 7-9 g/dL (over-transfusion increases portal pressure and rebleeding risk) 1, 3
• Initiate broad-spectrum antibiotics immediately (reduces infection and mortality; grade A1 recommendation) 1, 3
• Start vasoactive drugs (octreotide, terlipressin, or somatostatin) before endoscopy 1, 3

Urgent Endoscopy (Within 12-24 Hours)

• Perform endoscopy once hemodynamically stable to confirm diagnosis and provide therapeutic intervention 1
• Endoscopic variceal ligation is the treatment of choice for acute esophageal variceal bleeding 1, 2
• Continue vasoactive agents for 2-5 days after endoscopic treatment 1

Rescue Therapy for Failed Initial Treatment

If bleeding continues despite combined pharmacological and endoscopic therapy, TIPS is the definitive rescue treatment (achieves hemostasis in 90% of cases). 1, 3

• Balloon tamponade can serve as bridge therapy (80-90% hemostasis rate) but must not exceed 24 hours due to risk of esophageal rupture and aspiration pneumonia 1, 3
• Self-expandable esophageal metal stents show better bleeding control (85% vs 47%) and fewer serious adverse events (15% vs 47%) compared to balloon tamponade 1

Early TIPS for High-Risk Patients

Consider early TIPS placement (within 72 hours) for Child-Pugh C patients with scores 10-13 or Child-Pugh B patients with active bleeding despite vasoactive agents—this reduces treatment failure and mortality in this specific high-risk population. 1, 3

Secondary Prophylaxis (Prevention of Rebleeding)

The combination of endoscopic variceal ligation PLUS non-selective beta-blockers is the gold standard for preventing rebleeding—this combination is superior to either therapy alone. 1, 2

• Repeat EVL every 2-8 weeks until variceal eradication 1, 2
• Continue non-selective beta-blockers indefinitely at doses used for primary prophylaxis 1
• First surveillance endoscopy 1-3 months after eradication, then every 6-12 months 1, 2
• Mortality is lower with combination therapy compared to EVL alone (RR 1.25 for EVL alone) 1

Alternative for Combination Therapy Failure

• If rebleeding occurs despite combination therapy, consider TIPS placement 1

Critical Pitfalls to Avoid

• Do not delay vasoactive agents waiting for endoscopy—start immediately on clinical suspicion 1, 3
• Do not over-transfuse—targeting hemoglobin >9 g/dL increases portal pressure and rebleeding 1, 3
• Do not omit antibiotic prophylaxis—bacterial infections occur in 20-50% of cirrhotic patients with GI bleeding and significantly worsen outcomes 1, 3
• Do not use combination beta-blockers plus EVL for primary prophylaxis—no mortality benefit and increased side effects 1
• Do not use TIPS for primary prophylaxis—it is not indicated for prevention of first bleeding 1
• Do not continue balloon tamponade beyond 24 hours—high risk of esophageal rupture, ulceration, and aspiration pneumonia 1