After viewing this presentation the participant will be able to discuss:
- The natural history of esophageal varices
- The rationale for treating the pathophysiology of portal hypertension
- Prevention of the first variceal bleeding
- Prevention of recurrent variceal bleeding
- Treatment of the acute variceal bleeding episode
Portal hypertension is a clinical syndrome characterized by a pathological increase in hepatic vein pressure gradient (HVPG) above 5 mmHg.
When the HVPG increases over 10mmHg this is considered as clinically significant, leading to the formation of varices and occurrence of variceal bleeding. Treatment strategies are targeted towards the pathophysiology, and also include local procedures at the varices. HVPG responders are known to have better prognosis among patients with cirrhosis (1).
In the presence of medium or large size varices, both non-selective beta-blockers and endoscopic band ligation (EBL) were shown to prevent first variceal bleeding (2). In patients with small varices, the risk of bleeding increases with degree of liver dysfunction and the presence of severe red colour signs, according to the NIEC data (NEJM 88). Patients with small varices can also be treated, says Dr. Garcia-Pagan.
For the prevention of variceal rebleeding, the long-term follow-up study by Lo et al. found that combination therapy with nadolol plus isosorbide-5-mononitrate had inferior efficacy compared to band ligation, but was associated with better survival (3). Further data from Dr Garcia-Pagans group suggested better efficacy by addition of EBL to nadalol and nitrate, however more studies are needed (4).
Turning to the treatment of acute variceal bleeding, Dr. Garcia-Pagan highlights the importance of careful replacement of volemia, showing some preliminary data suggesting that the hemoglobin should be maintained between 7-8 g/dL (restricted transfusion). The second important issue is the prophylactic use of antibiotics, which is known to reduce the infection and mortality rates in these patients. Dr. Garcia-Pagan discusses a management plan involving drugs with or without EBL, TIPS, and appropriate use of balloon tamponade. Finally, in high risk patients, the early use of covered TIPS may be a better alternative compared to drugs and EBL, as seen in terms of being free of failure to control bleeding, prevention of rebleeding, and improved survival (Garcia-Pagan et al. EASL 2008).
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1) Juan G. Abraldes et al.Hemodynamic response to pharmacological treatment of portal hypertension and long-term prognosis of cirrhosis Hepatology. 2003 Apr;37(4):902-8.
2) Gluud LL et al. Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials. Am J Gastroenterol. 2007 Dec;102(12):2842-8; quiz 2841, 2849.
3) Gin-Ho Lo et al. Improved survival in patients receiving medical therapy as compared with banding ligation for the prevention of esophageal variceal rebleeding. Hepatology
Volume 48 Issue 2, Pages 580 - 587.
4) García-Pagán JC. Nadolol plus isosorbide mononitrate alone or associated with band ligation in the prevention of recurrent bleeding: a multicentre randomised controlled trial. Gut. 2009 Aug;58(8):1144-50.
