Preventing a first episode of esophageal variceal hemorrhage
Cleveland Clinic Journal of Medicine. 2008 March;75(3):235-244
March 1, 2008|Cleveland Clinic Journal of Medicine
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ABSTRACTIn patients with esophageal varices, hemorrhage is common and often lethal, so we need to take a proactive approach to preventing a first episode of bleeding. All patients with cirrhosis should undergo endoscopy to look for varices. Depending on the size and appearance of the varices and the patient’s Child-Pugh grade, prophylactic treatment may be indicated.
KEY POINTS
- The hepatic vein pressure gradient (HVPG) correlates well with the portal pressure and is easier to measure. However, whether it is cost-effective to measure the HVPG in clinical practice is controversial.
- Nonselective beta-blockers are the mainstay of treatment; selective beta-blockers do not reduce portal pressure to the same degree and are not recommended for preventing variceal bleeding.
- Endoscopic variceal ligation is an acceptable alternative to beta-blocker therapy for patients who cannot tolerate these drugs and for patients with varices at high risk of bleeding.
- Nitrates are no longer used as monotherapy for preventing variceal hemorrhage, and their use in combination with beta-blockers is controversial. Surgical portal decompression, transjugular intrahepatic portosystemic shunting, and endoscopic sclerotherapy are not recommended.
RECOMMENDATIONS FOR SCREENING AND PROPHYLAXIS
Based on Garcia-Tsao G, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46:922–938.
- All patients with cirrhosis should be screened for varices at the time of diagnosis.
- The size of the varices, including small (≤ 5 mm) and large (> 5 mm), and the presence of red wale marks on the varices should be recorded.
- Patients who have no varices on screening endoscopy should be rescreened every 3 years if their liver function is stable or every year if their liver function deteriorates. (Varices grow at a rate proportional to the severity of the liver disease.)
- Patients with portal hypertension but without varices do not need treatment with nonselective beta-blockers. Endoscopy should be performed at the intervals suggested above.
- Those who are found to have small varices on screening endoscopy but who have well-compensated liver disease (Child-Pugh class A) and no red wale marks should be rescreened every other year because the development of large varices is greater in patients with small varices on initial endoscopy than in patients with no varices. Emerging data support the use of beta-blockers to prevent varices from increasing in size.
- Patients who have small varices with red wale signs or who are in Child-Pugh class B or C have an increased risk of bleeding and should be treated with beta-blockers. If beta-blockers are not used, endoscopy should be done every year to look for an increase in variceal size.
- Patients who have large varices without red wale signs or who are in Child-Pugh class B or C should be treated with nonselective beta-blockers. The dose should be adjusted to achieve maximal tolerable decrease in heart rate to a minimum of 55 beats per minute, and treatment should be continued indefinitely.
- Endoscopic variceal ligation is an acceptable alternative to beta-blocker treatment as first-line therapy in those who cannot tolerate beta-blockers or who have contraindications to their use, or in those who have red wale marking or who are in Child-Pugh class B or C.
