How should esophageal varices be screened and managed—including primary prophylaxis, acute bleed treatment, and secondary prophylaxis—in an adult with cirrhosis?

Management of Esophageal Varices in Cirrhosis

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

Screening Protocol

Initial Screening

• Perform EGD at the time of cirrhosis diagnosis to detect and classify varices as small (≤5 mm) or large (>5 mm), documenting red color signs (red wale marks or red spots). 1, 2
• EGD remains the gold standard with sensitivity and specificity approaching 100%, superior to all non-invasive methods. 2

Surveillance Intervals

• No varices on initial EGD:

  • Repeat every 2-3 years if compensated cirrhosis 1, 2
  • Repeat annually if decompensated cirrhosis 1, 2

• Small varices present:

  • Repeat every 1-2 years in compensated cirrhosis 2
  • Repeat annually in decompensated cirrhosis 2
  • Small varices progress to large varices in 12% at 1 year, increasing to 22% in Child B/C cirrhosis 2

Important caveat: Non-invasive methods like transient elastography (cutoff 19.5 kPa) have inadequate accuracy (sensitivity 0.89, specificity 0.56) and can misclassify 2.2% of high-risk patients, potentially exposing them to variceal hemorrhage risk. 2

Primary Prophylaxis

Risk Stratification

High-risk features requiring treatment include: 1

• Large varices (>5 mm)
• Medium varices with Child-Pugh class B/C
• Any varices with red wale marks

Treatment Options

First-line: Nonselective beta-blockers (NSBBs) 1

• Propranolol or nadolol are preferred agents
• Reduces first variceal bleeding from 30% to 14% (1 bleeding prevented per 10 patients treated) 1
• Also reduces mortality compared to no treatment 1
• Large varices carry 15% yearly bleeding risk, increasing to 80% with red color signs 1

Alternative: Endoscopic variceal ligation (EVL) 1

• Reserved for patients with contraindications, intolerance, or non-compliance to beta-blockers
• Repeat EVL every 1-2 weeks until variceal obliteration 1
• Follow-up endoscopy at 1-6 months after eradication, then every 6-12 months 3

Beta-Blocker Contraindications

Do not use NSBBs in: 1

• Hypotension
• Severe bradycardia or high-degree heart block
• Asthma or severe reactive airway disease
• Active variceal bleeding

Acute Variceal Bleeding Management

Treat acute bleeding with the triad of: 4

• Vasoactive drugs (octreotide or terlipressin)
• Endoscopic band ligation
• Prophylactic antibiotics

This approach applies to standard cirrhosis; the same principles can be followed even in specialized populations. 4

Secondary Prophylaxis

After surviving variceal hemorrhage, implement combination therapy: 4

• NSBBs (propranolol or nadolol) PLUS
• Endoscopic variceal ligation

Critical point: Untreated variceal hemorrhage carries a 60% rebleeding rate within 1-2 years and 33% mortality. 1

Transplant Evaluation Triggers

Refer for liver transplantation evaluation if: 1

• Child-Pugh score ≥7, OR
• MELD score ≥15, AND
• Patient survives variceal hemorrhage

This is non-negotiable given that decompensated cirrhosis with varices carries >80% 5-year mortality compared to 20% for isolated variceal findings. 1

Common Pitfalls to Avoid

• Do not rely on non-invasive tests alone for variceal screening—they miss high-risk patients. 2
• Do not delay screening endoscopy in decompensated cirrhosis regardless of other test results. 2
• Do not use NSBBs during active bleeding—they are contraindicated in this setting. 1
• Do not forget prophylactic antibiotics during acute bleeding episodes—they are part of the standard triad. 4
• Monitor heart rate targets in patients on beta-blockers to ensure adequate dosing and tolerance. 3