Esophageal Varices

Definition and Pathophysiology

• Normal HVPG: 1-5 mm Hg
• Varices form at HVPG > 10 mm Hg
• Risk of bleeding is virtually absent when HVPG < 12 mm Hg
• HVPG > 20 mm Hg is a predictor of treatment failure and death

Epidemiology and Natural History

• Esophageal varices are present in ~40% of all cirrhotic patients, and up to 60% of those with cirrhosis + ascites
• In cirrhotic patients without varices at initial endoscopy, new varices develop at ~5% per year
• Progression from small to large varices: ~10% per year, related to degree of liver dysfunction
• Alcohol abstinence can lead to decrease or even disappearance of varices

• Up to 25% of patients with newly diagnosed varices will bleed within 2 years
• Varices < 5 mm: 7% bleeding risk at 2 years
• Varices > 5 mm: 30% bleeding risk at 2 years
• Once bleeding occurs, initial treatment controls bleeding in 80-90% of cases
• ~50% stop bleeding spontaneously (hypovolemia → splanchnic vasoconstriction → ↓ portal pressure)
• ~1/3 of patients who stopped bleeding will rebleed within 6 weeks
• Mortality: 5-8% at 1 week; ~20% at 6 weeks

Classification (Grading)

• Cherry-red spots
• Red wale signs
• Hematocystic spots

Management Framework

1. Primary Prophylaxis (Prevention of First Bleed)

• Non-selective beta-blockers (propranolol, nadolol, carvedilol) are first-line for large varices
• Starting dose: long-acting propranolol 60 mg once daily or nadolol 20 mg once daily (evening dosing preferred - bleeding risk is greatest at night)
• Titrate every 3-5 days to target heart rate 55-60 bpm or 25% below baseline, as long as systolic BP stays > 90 mm Hg
• Carvedilol (initial 6.25 mg/day, max 25 mg/day) preferred in patients with hypertension or coronary artery disease
• Goal: HVPG reduction to < 12 mm Hg or ≥ 20% decrease
• Only 30-40% of patients respond to beta-blockers; patients with better liver function respond best

• Endoscopic variceal ligation (EVL/band ligation) is used when beta-blockers are contraindicated, not tolerated, or HVPG target is not reached
• Repeat EGD every 1-2 weeks until variceal obliteration, then surveillance every 3-6 months
• Note: Prophylactic sclerotherapy cannot be recommended due to higher complication rates

2. Acute Variceal Bleeding - Emergency Management

• Two large-bore IV lines immediately
• Restrictive transfusion strategy: transfuse packed RBCs only when Hgb < 7 g/dL (associated with improved survival vs. transfusing at < 9 g/dL in Child-Pugh A/B)
• Target hematocrit ~25% - avoid excessive transfusions (increase risk of hypocoagulability and portal pressure rebound)
• Normal saline until blood products available
• Airway protection: endotracheal intubation for active bleeders
• Correct coagulopathy as needed

• Norfloxacin 400 mg PO twice daily × 7 days (preferred)
• If unavailable (e.g., USA): ciprofloxacin 500 mg PO twice daily × 7 days
• If oral intake not possible: IV ceftriaxone 1 g every 24 hours × 7 days, or IV ciprofloxacin 400 mg every 12 hours
• Failure to control infection significantly increases mortality and rebleeding risk

• Octreotide - most common in the USA (reduces splanchnic blood flow)
• Terlipressin - preferred in many countries; only agent associated with improved survival
• Somatostatin or vapreotide - alternatives
• Continue vasoactive agents for up to 5 days to prevent early rebleeding
• Combination of endoscopic + vasoactive therapy is superior to either alone

• Perform as soon as patient is hemodynamically stabilized
• Endoscopic variceal ligation (EVL) is the preferred treatment at time of initial endoscopy
• Variceal bleeding confirmed if: active spurting/oozing from varix, white fibrin plug or red clot over varix, risk signs (cherry-red spot, hematocystic spot, red wale sign), or varices without any other bleeding source

• Balloon tamponade (Sengstaken-Blakemore tube): temporizing measure when endoscopy fails or is unavailable - gastric balloon inflates first to occlude the gastroesophageal junction, then esophageal balloon if needed
• TIPS (Transjugular Intrahepatic Portosystemic Shunt): preferred definitive rescue procedure; as effective as distal splenorenal shunt for Child-Pugh A cirrhosis
• Surgical portosystemic shunt: reserved for centers without TIPS expertise

3. Secondary Prophylaxis (Prevention of Rebleeding)

• Standard of care: combination of non-selective beta-blocker + EVL (superior to either alone)
• Beta-blocker + EVL reduces rebleeding in Child-Pugh A patients; reduces mortality in Child-Pugh B and C
• If recurrent bleeding despite optimal pharmacologic + endoscopic therapy → TIPS or portosystemic shunt
• Patients with rebleeding, MELD > 18, > 4 units pRBC transfusion, or renal failure have highest mortality risk

Predictors of Poor Outcome

Gastric Varices (Sarin Classification)

• Gastric varices bleed less often but with greater severity
• Preferred treatment for bleeding gastric varices: cyanoacrylate glue injection (not banding)