In a 55-year-old man with alcoholic cirrhosis, hepatic encephalopathy, recent melena, severe anemia, and endoscopy showing grade 2 esophageal varices with red‑wale signs and portal gastropathy, what is the next step in management?

Management of Grade 2 Esophageal Varices with Red Wale Signs After Recent Bleeding

The next step is variceal ligation (Option D), followed immediately by initiation of nonselective beta-blockers for combined secondary prophylaxis. 1

Immediate Management Rationale

This patient has already bled (melena one week ago) from high-risk varices (grade 2 with red wale signs), making this a case requiring secondary prophylaxis, not primary prevention. 1

Why Variceal Ligation Now

• Endoscopy has already been performed and confirmed grade 2 varices with red wale signs—the diagnostic step is complete 1
• EVL should be performed in the same session as diagnostic endoscopy when varices are identified as the bleeding source 1
• The patient had melena one week ago with severe anemia (Hb 4.6 g/dL), indicating recent variceal hemorrhage requiring endoscopic treatment 1
• EVL achieves hemostasis and begins the variceal eradication process that requires repeated sessions every 2-8 weeks 1

Why Nonselective Beta-Blockers Must Follow Immediately

• Combination therapy (EVL + NSBBs) is superior to either alone for secondary prophylaxis, with the strongest guideline recommendation (A1) 1, 2
• NSBBs should be initiated after the acute bleeding episode is controlled, which appears to be the case here (patient is asymptomatic, hemodynamically stable) 2, 3
• The combination reduces rebleeding rates to 14-23% versus 38-47% with EVL alone 3
• Beta-blockers provide systemic portal pressure reduction that EVL cannot achieve, preventing complications beyond just variceal bleeding 1

Why Other Options Are Incorrect

Option B (NSBBs Alone) - Inadequate

• NSBBs alone without EVL is inferior to combination therapy for secondary prophylaxis 1, 2
• The endoscopy has already been performed—not performing EVL wastes this opportunity 1
• While NSBBs are essential, they must be combined with EVL in this post-bleeding scenario 1, 2

Option C (TIPS) - Premature and Excessive

• TIPS is reserved for rescue therapy when combined pharmacological and endoscopic therapy fails 1
• TIPS increases hepatic encephalopathy risk (35% vs 14% with combination therapy), particularly problematic since this patient already has baseline hepatic encephalopathy 1
• Early TIPS is only considered in high-risk patients (Child-Pugh C or B with active bleeding at endoscopy)—this patient is hemodynamically stable 1

Option A (BRTO) - Wrong Indication

• BRTO is indicated for gastric varices (GOV2, IGV1), not esophageal varices 1, 4
• This patient has esophageal varices and portal gastropathy, not the gastric varices that BRTO treats 1

Complete Management Algorithm

Step 1: Immediate (During Current Endoscopy)

• Perform EVL on the grade 2 varices with red wale signs 1
• Achieve initial variceal reduction or eradication 1

Step 2: Post-Procedure (Within Days)

• Initiate nonselective beta-blocker (propranolol, nadolol, or carvedilol) 1, 2
• Titrate to maximal tolerated dose, targeting heart rate 55-60 bpm 1, 3
• Critical: Do not target blood pressure below 90 mmHg 1

Step 3: Short-Term Follow-Up

• Repeat EVL every 2-8 weeks until variceal eradication (varices too small to ligate) 1
• Typically requires 4-6 sessions total 1
• Continue NSBBs throughout this period 2

Step 4: Long-Term Surveillance

• First surveillance endoscopy 1-6 months after variceal eradication 1, 2
• Subsequent endoscopy every 6-12 months to detect recurrence 1
• Never discontinue NSBBs even after variceal eradication—they provide ongoing portal pressure reduction 2

Critical Pitfalls to Avoid

• Do not delay EVL when endoscopy has already identified high-risk varices in a patient with recent bleeding 1
• Do not use EVL alone without adding NSBBs—combination therapy is the standard of care 1, 2
• Do not use TIPS as first-line therapy—it is rescue therapy only 1
• Do not stop beta-blockers after variceal obliteration—varices recur and NSBBs provide systemic benefits 2
• Do not transfuse to "normal" hemoglobin—restrictive transfusion (target 7-9 g/dL) reduces rebleeding risk and mortality 1

Addressing the Severe Anemia

While not the primary question, this patient's Hb of 4.6 g/dL requires restrictive transfusion with target 7-9 g/dL 1. Excessive transfusion increases portal pressure and worsens variceal bleeding 1. The patient being asymptomatic with HR 65 and BP 100/60 suggests adequate compensation despite severe anemia.