Gastroesophageal varices and UGIB-cirrhosis

See: gastrointestinal bleeding

• Presence of varices correlates w/ severity of liver dis (40% of Child A Pts → 85% Child C)

• ↑ varix size, child B/C, & red wale marks assoc w/ ↑ risk of bleeding

• UGIB 1° prevention: screen at time of dx w/ EGD; data best for Pts w/ med-large varices

Nonselective β-blockers: ~50% ↓ risk of bleeding & ↓ mortality if med-large varices. Nadolol, propranolol, or carvedilol; latter ↓ MAP & HVPG more than propranolol; delays progression of varices (Gut 2017;66:1838); may use in Pts w/ HTN. Titrate to max tolerated dose; EGD not req. to document improvement. Hold for criteria listed above.

Endoscopic variceal ligation (EVL): superior to βB in ↓ risk of 1st bleed but no diff in mortality (Ann Hep 2012;11:369); risk of serious complications (esoph perf, ulcers). Repeat q1–4wk until varices gone, w/ f/u EGD at 3 mo then q6–12mo.

βB vs. EVL: choice based on Pt/physician preference; βB often 1st for small varices; larger varices may benefit more from EVL; both for 1° Ppx currently not recommended

• 2° prevention: for all Pts after 1st bleed, given ~50% risk of rebleed & ~30% mortality; βB + EVL >either alone; TIPS if refractory, or consider in child B/C w/in 72 h of admission for EV bleed (↓ rebleeding, ↑ enceph., Ø Δ mort.) (Hepatology 2017;65:310)