Acute variceal
hemorrhage is the most lethal complication of
cirrhosis. The reported mortality rate from a first episode of variceal
hemorrhage is 17% to 57%. Management of
varices can be categorized into three phases: 1) prevention of initial
bleeding, 2) management of acute
bleeding, and 3) prevention of rebleeding. Modalities for treatment include pharmacologic, endoscopic, and shunt
therapy. For the prevention of first variceal
hemorrhage, cirrhotic patients should undergo endoscopy to identify patients with large
varices. Priority for screening for
varices should be given to patients with low platelet count,
splenomegaly, and advanced
cirrhosis. Once large
varices are identified, patients should be started on beta-blocker
therapy, which reduces the risk of
bleeding by 50%. If pharmacologic
therapy is not tolerated or contraindicated, endoscopic band
ligation should be performed, and surveillance of
varices should be performed every 6 months thereafter. Shunt procedures are not indicated due to their higher rates of complications compared with medical
therapy. For the management of acute variceal
hemorrhage, patients should be started on prophylactic intravenous
antibiotics and intravenous
octreotide. Endoscopy should be performed to diagnose and treat variceal
hemorrhage. Band
ligation appears to be as effective as
sclerotherapy, but with less complications. If hemostasis is not achieved, balloon tamponade can be used as a bridge to definitive
therapy, which in this case would be a transjugular intrahepatic
portosystemic shunt (
TIPS). If
TIPS is unavailable, a surgical shunt is indicated. Once an episode of acute
bleeding has been controlled, variceal eradication is best accomplished with repeat band
ligation every 10 to 14 days until
varices are obliterated. Prevention of recurrent
bleeding can be achieved with beta-blocker
therapy. The addition of
isosorbide mononitrate further reduces recurrent
bleeding. This combination pharmacologic
therapy has been shown to be superior to
sclerotherapy and may be superior to band
ligation. However, side effects of combination pharmacologic
therapy may limit its effectiveness. Band
ligation is preferred to
sclerotherapy when considering endoscopic
therapy due to less complications and lower cost. Surgical shunts should be used for prevention of rebleeding in patients who do not tolerate or are noncompliant with medical
therapy and who have relatively preserved liver function.
TIPS should be reserved for patients who have poor liver function and who have failed medical
therapy.