The Clinical Management of Gastroesophageal Varices: Summary

Esophageal varices develop in 5%-10% of patients with cirrhosis annually. Esophageal varices are more likely to bleed than gastric varices, although gastric variceal hemorrhage may be more severe. All patients with cirrhosis should be screened for gastroesophageal varices, and patients with medium-to-large varices should receive prophylaxis with beta-blockers to reduce the risk for bleeding. In patients who are intolerant to or who have contraindications to beta-blockers, band ligation of esophageal varices is effective in reducing the risk for esophageal hemorrhage. Once variceal hemorrhage occurs, band ligation of esophageal varices or cyanoacrylate injection of gastric varices can be used. For poorly controlled patients with continuing bleeding, placement of a TIPS or surgical shunt may be required.

Key Points All patients with compensated cirrhosis should be screened for gastroesophageal varices every 2 years. Upper endoscopy is the screening method of choice. Patients with decompensated cirrhosis should have more frequent endoscopic screening. Patients with esophageal varices > 5 mm in diameter should receive noncardioselective beta-blocker prophylaxis with propranolol, nadolol, or carvedilol. For those intolerant to or with contraindications for beta-blockers, obliteration of esophageal varices with band ligation is an alternative method of prophylaxis.

Key Points All patients with compensated cirrhosis should be screened for gastroesophageal varices every 2 years. Upper endoscopy is the screening method of choice. Patients with decompensated cirrhosis should have more frequent endoscopic screening. Patients with esophageal varices > 5 mm in diameter should receive noncardioselective beta-blocker prophylaxis with propranolol, nadolol, or carvedilol. For those intolerant to or with contraindications for beta-blockers, obliteration of esophageal varices with band ligation is an alternative method of prophylaxis.

Preferred examination

Endoscopy is the criterion standard for evaluating esophageal varices and assessing the bleeding risk.^{[1, 2, 5, 9, 10]} This procedure is performed by a surgeon or a gastroenterologist with the patient under light sedation. The procedure involves using a flexible endoscope inserted into the patient's mouth and through the esophagus to inspect the mucosal surface.
When esophageal varices are discovered, they are graded according to their size, as follows:

• Grade 1 – Small, straight esophageal varices
• Grade 2 – Enlarged, tortuous esophageal varices occupying less than one third of the lumen
• Grade 3 – Large, coil-shaped esophageal varices occupying more than one third of the lumen

The esophageal varices are also inspected for red wheals, which are dilated intra-epithelial veins under tension and which carry a significant risk for bleeding. The grading of esophageal varices and identification of red wheals by endoscopy predict a patient's bleeding risk, on which treatment is based.