The Clinical Management of Gastroesophageal Varices: Primary Prophylaxis for Variceal Hemorrhage

For patients with medium-to-large esophageal varices (> 5 mm in diameter), nonselective beta-blocker prophylaxis will reduce the risk for bleeding.Although beta-blocker therapy will not prevent varices from forming, it can reduce the likelihood of gastrointestinal hemorrhage by 40%  through a reduction of portal pressure flow from reduced splanchnic arterial vasodilation and cardiac output. Nonselective beta-blockers such as propranolol, nadolol, or carvedilol should be used. Side effects including fatigue, dyspnea, lightheadedness, and bradycardia can develop. Carvedilol has been directly compared with band ligation, and achieved a lower rate of first bleed. No difference in bleeding-related or overall mortality was observed. The goal of beta-blocker therapy is a reduction of pulse rate by 25% or a rate of 55 beats per minute. Potential contraindications to beta-blocker therapy include asthma, heart block, obstructive pulmonary disease, aortic outflow tract disorders, or resulting severe side effects. Beta-blocker therapy should be continued indefinitely because the risk for bleeding is increased when the drug is stopped. Up to one third of patients may not achieve sufficient reduction of portal pressure to prevent bleeding. Varices < 5 mm in diameter with red wale signs in patients with decompensated cirrhosis may also benefit from beta-blocker therapy. Addition of isosorbide has been studied, but the data are insufficient to recommend its use with beta-blockers.
Band ligation of esophageal varices at upper endoscopy for moderate-to-large esophageal varices will also reduce the likelihood of first bleeding.  Meta-analyses suggest that banding is either more effective or equally effective as beta-blockers. Although banding has a reduced daily side effect profile when compared with beta-blockers, some complications can be severe, including bleeding from superficial ulceration or esophageal perforation. For that reason, initial therapy should be with beta-blockers reserving primary use of band ligation for those with contraindications or intolerance to beta-blockers.The simultaneous use of band ligation and beta-blockers for primary prophylaxis is unnecessary.
Gastric varices tend to have a lower risk for bleeding than esophageal varices, although bleeding can be more severe. Varices in the fundus of the stomach are more likely to bleed then varices at other gastric locations. Beta-blocker therapy should be used as primary prophylaxis for gastric varices. Intravariceal injection of glue (cyanoacrylate) as primary prophylaxis does not lead to a greater reduction of subsequent mortality than beta-blockers.
Sclerotherapy of esophageal varices is not recommended for primary prophylaxis due to the frequency of associated complications.Surgical shunts or TIPS are not recommended due to operative mortality and/or the development of postprocedure hepatic encephalopathy.