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Management of varices in patients with cirrhosis

Abstract

Variceal bleeding remains a life-threatening condition with a 6-week mortality rate of 20%. Prevention of variceal bleeding can be achieved using nonselective β-blockers (NSBBs) or endoscopic band ligation (EBL), with NSBBs as the first-line treatment. EBL should be reserved for cases of intolerance or contraindications to NSBBs. Although NSBBs cannot be used to prevent varices, if the hepatic venous pressure gradient (HVPG) is ≤10 mmHg, prognosis is excellent. Survival after acute variceal bleeding has improved over the past three decades, but patients with Child–Pugh grade C cirrhosis remain at greatest risk. Vasoactive drugs combined with endoscopic therapy and antibiotics are the best therapeutic strategy for these patients. Transjugular intrahepatic portosystemic shunts (TIPS) should be used in patients with uncontrolled bleeding or those who are likely to have difficult-to-control bleeding. Rebleeding from varices occurs in 60% of patients 1–2 years after the initial bleeding episode, with a mortality rate of 30%. Secondary prophylaxis should start at day 6 after initial bleeding using a combination of NSBBs and EBL. TIPS with polytetrafluoroethylene-covered stents are the preferred option in patients who fail combined treatment with NSBBs and EBL. Despite the improvement in patient survival, further studies are needed to direct the management of patients with gastro-oesophageal varices and variceal bleeding.

Key Points

  • Endoscopy is the most accurate approach for variceal screening

  • Primary prophylaxis of varices using nonselective β-blockers (NSBBs) or endoscopic band ligation (EBL) reduces the risk of first bleeding

  • Management of acute bleeding should include vasoactive drugs, antibiotics and endoscopic therapy; in cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunts (TIPS) should be recommended

  • Early TIPS placement after standard therapy in Child–Pugh grade C cirrhosis (<14 points) and grade B with active bleeding increases survival and improves control of bleeding more than standard therapy alone

  • Prophylaxis of rebleeding is best carried out using a combination of EBL and NSBBs

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All authors researched data for the article, wrote the article and reviewed and/or edited the manuscript before submission. A. K. Burroughs and J. O'Brien also substantially contributed to the discussion of content.

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O'Brien, J., Triantos, C. & Burroughs, A. Management of varices in patients with cirrhosis. Nat Rev Gastroenterol Hepatol 10, 402–412 (2013). https://doi.org/10.1038/nrgastro.2013.51

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