ESOPHAGEAL/GASTRIC VARICES

Background:

• Present in 50% of cirrhotics

• Correlates with the severity of the liver disease

  • 40% of Child’s A patients have varices

  • 85% of Child’s C patients have varices

• (Portal vein pressure — hepatic vein pressure)

  • Gradient required to induce varices is 10-12mm/Hg

    • If TIPS is performed, the goal is to achieve a gradient < 12 mm/Hg

• Once varices develop, their size/diameter is related to risk of bleeding

• Mortality associated with variceal bleed ranges from 30-50%

• Most death occurs after early re-bleeding (within first week after bleed)

Treatment:

• Acute:

  • Stabilize patient hemodynamically

  • Transfuse (but avoid over-transfusing to Hg > 10 as re-bleeding will occur)

  • Consider early use of Somatostain/Octreotide (50 mcg/hr IV)

  • Therapeutic upper endoscopy with Banding and/or sclerotherapy

  • Use IV antibiotics to minimize risk of sepsis/SBP

  • Blakemore tube if Banding/sclerotherapy not beneficial to temporize/control bleed

    • Can not be used for greater than 24 hours

  • TIPS if bleeding not controlled

  • Consider shunt surgery (mesocaval/spleno-renal) if TIPS is unsuccessful

• Prevention of first variceal bleed/ “prophylactic therapy”

  • Preventing the initial bleed and decreased mortality has been reported in patients with large varices (greater than grade II) treated pharmacologically

    • Non-selective Beta Blockers (Propranolol 10-20 mg po BID or Nadolol 20 mg po qd) to achieve a 25% reduction in resting heart rate

    • Consider adding Isosorbide mononitrate (Ismo 20 mg bid or Imdur 30 mg po) as portal pressures will be more effectively decreased

      • Caution: evidence in the literature exists which both support and invalidate the combination of Beta-Blockers and Isosorbide mononitrate as prophylaxis to prevent first variceal bleed

  • Prophylactic shunt surgery

    • Decreased risk of bleed but increased mortality due to encephalopathy

    • Prophylactic TIPS prior to first bleed is being investigated

  • Sclerotherapy verus Banding (endoscopic variceal ligation / EVL) of varices

    • EVL decreases rate of first bleeding > sclerotherapy

    • EVL may decrease rate of first bleed > Beta blockers but needs to be further studied

• Pharmacologic agents undergoing investigation:

  • Carvedilol- a non-selective beta blocker with anti alpha 1 adrenergic activity

  • Losartan- angiotensin receptor blocker

    • Both medications significantly reduce portal pressures

    • Large studies are pending

• Prevention of recurrent variceal hemorrhage

  • Variceal bleeding will re-occur in 80% of untreated patients within 2 years of first variceal bleed

  • Pharmacologic therapy and sclerotherapy or EVL associated with decreased incidence of rebleeding and mortality

    • Beta Blockers (see above for doses)

    • Beta Blockers plus Isosorbide mononitrate has been shown to decrease recurrent bleed, but some studies indicate a higher mortality in patients on combination therapy versus Beta blockers alone

    • EVL more effective than sclerotherapy in decreasing rebleeding and:

    • Beta Blockers plus EVL decreases bleeding and mortality > Beta blockers plus sclerotherapy due to increased risk of sclerotherapy associated complications

  • If pharmacologic therapy with or without EVL/Sclerotherapy are ineffective consider:

    • Mesocaval/splenorenal shunt decrease recurrent bleeding but increase mortality due to encephalopathy

    • TIPS as a bridge to transplant

    • Transplant