1)
Emergency treatment. The best treatment remains endoscopic
sclerotherapy, which controls the
bleeding in 90% of the cases. Pharmacologic management stops the variceal
hemorrhage in 80% of the cases and is indicated before endoscopic treatment can be performed. Intravenous
somatostatin administration may be prolonged for 5 days, even more, and may thus prevent early rebleeding, which is not achieved neither by
vasopressin nor by
glypressin, which administration is restricted to 24 hours. Esophageal tamponade is useful to arrest a massive variceal
bleeding, if vasoactive drugs are not available or not efficient, before endoscopic management. If the
bleeding persists after 2
sclerotherapy sessions, an alternative treatment is mandatory: the patient should be sent to the surgeon for a
portosystemic shunt if the operative risk is acceptable (child A and B) or should become a candidate for a transjugular intrahepatic
stent shunt, especially if
transplantation is considered afterwards. 2) Prevention of recurrent
hemorrhage. A) Early (within 5 days after the initial
bleeding).
Somatostatin probably prevents early rebleeding, as do
sclerotherapy. B) Late. B blockade (+
nitrates) or long-term
sclerotherapy have the same efficacy. Their association may improve their results. 3) Prevention of the first
bleeding episode.
Propranolol decrease the risk of variceal
rupture from 20% to 9% during the first year after the diagnosis of
esophageal varices and is the only treatment which may be proposed to cirrhotics who did not yet bled form their
varices.