DDSEP® 8 Quick Quiz

August 2018 Question 2

A 56-year-old man with hepatitis C cirrhosis presents for variceal screening. He has mild ascites and grade 1-2 encephalopathy, both controlled with pharmacologic treatment. Recent blood work reveals a total bilirubin of 2.1 mg/dL, albumin of 3.1 g/dL, and an INR of 1.8. Endoscopy reveals small varices.

Which is the next best step in management?

DDSEP® 8 Quick Quiz - August 2018 Question 2

A. Nadolol

B. Metoprolol

C. Nitroglycerin

D. Cardizem

E. Observation, no treatment indicated

Rationale
For patients who have small varices with either red wale signs or the presence of severe liver disease (Child Pugh class C), the risk of first hemorrhage is as high as for patients with large varices. Because these small varices are difficult to ligate, therapy with a nonselective beta-blocker such as nadolol is recommended. Nonselective beta-adrenergic blockers (propranolol, nadolol) reduce portal pressure by reducing portal venous inflow through both a beta-1 (reduction in cardiac output) and a beta-2 (splanchnic vasoconstriction). A decrease in HVPG greater than 20% in patients treated with nonselective beta-blockers has been associated with a lower rate of first variceal hemorrhage, ascites, and death. Clinical targets include a heart rate below 60 bpm or a 25% reduction from baseline heart rate. Metoprolol is a selective beta-blocker and is not effective in reducing portal pressure. Nitrates alone are not effective in preventing first variceal hemorrhage and are associated with increased long-term mortality in patients over the age of 50. Diltiazem is a calcium channel blocker, which has not been shown to be effective in the treatment of esophageal varices. Observation is not an appropriate option given the high risk of bleeding for these varices, which should be addressed.

References
1. Garcia-Tsao G., Sanyal A.J., Grace N.D., et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.
2. de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV Consensus Workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2005;43:167-76.

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