Management of oesophageal and gastric varices

Timing of endoscopy

• endoscopy should be offered to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation
• endoscopy should be offered within 24 hours of admission to all other patients with upper gastrointestinal bleeding

Management of variceal bleeding

• terlipressin should be offered to patients with suspected variceal bleeding at presentation. Stop treatment after definitive haemostasis has been achieved, or after 5 days, unless there is another indication for its use
• prophylactic antibiotic therapy should be offered at presentation to patients with suspected or confirmed variceal bleeding

Oesophageal varices

• band ligation should be employed in patients with upper gastrointestinal bleeding from oesophageal varices
• consider transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from oesophageal varices is not controlled by band ligation

Gastric varices

• endoscopic injection of N-butyl-2-cyanoacrylate should be offered to patients with upper gastrointestinal bleeding from gastric varices
• offer TIPS if bleeding from gastric varices is not controlled by endoscopic injection of N-butyl-2-cyanoacrylate

Notes:

• SIGN also suggest (2):
  • balloon tamponade should be considered as a temporary salvage treatment for uncontrolled variceal haemorrhage
  • variceal band ligation combined with a beta blocker is recommended as secondary prevention for oesophageal variceal haemorrhage
  • in patients unsuitable for variceal band ligation combination of non-selective beta blocker and nitrate is recommended as secondary prevention for oesophageal variceal haemorrhage
• there is trial evidence that nonselective beta-blockers are ineffective in preventing varices in unselected patients with cirrhosis and portal hypertension and are associated with an increased number of adverse events (3)
• combination therapy with drug therapy and endoscopic therapy (4)
  • combination of endoscopic and drug therapy reduces overall and variceal rebleeding in cirrhosis more than either therapy alone
    
    
• NICE suggest with respect to liver cirrhosis and complications (5):
  • consider simultaneous endoscopic variceal band ligation if medium or large varices are detected during upper gastrointestinal endoscopy
  • for people with medium or large oesophageal varices, offer:
    • carvedilol or propranolol or
    • endoscopic variceal band ligation, if either carvedilol or propranolol are not tolerated or contraindicated, or the person cannot take tablets regularly because of their circumstances
  • offer prophylactic intravenous antibiotics for people with cirrhosis who have upper gastrointestinal bleeding
    
• a systematic review concluded (4):
  • beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates may decrease the death rate compared to no treatment in people with high-risk oesophageal varices in people with cirrhosis and no history of bleeding
  • variceal band ligation may result in a higher number of serious side effects than beta-blockers
  • evidence indicates considerable uncertainty about the effect of beta-blockers versus variceal band ligation on variceal bleeding

Reference:

1. NICE (June 2012). Acute Upper GI bleeding.
2. SIGN (2008). Management of acute upper and lower gastrointestinal bleeding
3. Groszmann RJ et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. NEJM 2005; 353:2254-61.
4. Gonzalez R et al. Meta-analysis: Combination endoscopic and drug therapy to prevent variceal rebleeding in cirrhosis.Ann Intern Med. 2008 Jul 15;149(2):109-22
5. NICE (September 2023).Cirrhosis in over 16s: assessment and management
6. Roccarina D, Best LMJ, Freeman SC, Roberts D, Cooper NJ, Sutton AJ, Benmassaoud A, Plaz Torres MCorina, Iogna Prat L, Csenar M, Arunan S, Begum T, Milne EJ, Tapp M, Pavlov CS, Davidson BR, Tsochatzis E, Williams NR, Gurusamy KS. Primary prevention of variceal bleeding in people with oesophageal varices due to liver cirrhosis: a network meta-analysis. Cochrane Database of Systematic Reviews 2021, Issue 4. Art. No.: CD013121. DOI: 10.1002/14651858.CD013121.pub2. Accessed 29 August 2021.