Primary Prophylaxis of Variceal Bleeding

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Key points

  • Primary prophylaxis of esophageal varices is recommended for patients at high risk for bleeding (large esophageal varices, and small varices in patients with Child-Turcotte-Pugh class B/C and/or red wale markings).

  • Preprimary prophylaxis of varices with nonselective β-blockers is ineffective, and therefore is not recommended.

  • Carvedilol, a nonselective β-blocker with anti–α1-adrenergic activity, significantly reduces portal pressure and the risk of first variceal hemorrhage.

  • Nonselective

Risk for esophageal variceal bleeding

The appearance of varices in patients with compensated cirrhosis is associated with an increased risk of death (1.0%–3.4% per year), and the occurrence of variceal bleed significantly increases this risk, with 1-year mortality rate as high as 57%. Approximately 20% of deaths occur in the first 6 weeks of a bleeding episode.2

Recommendations for primary prophylaxis for esophageal varices differ according to the associated risk of bleeding. One of the most important risk factors for variceal

Preprimary prophylaxis

Nonselective β-adrenergic blockers have been shown to significantly reduce portal pressure, as measured by HVPG, and this reduction seems to be greater in patients without varices than in those with varices.12 Also, studies in animal models of portal hypertension have suggested a potential role for nonselective β-blockers in preventing the development of portosystemic collaterals or shunts.13, 14 These observations prompted evaluation of nonselective β-blockers for preventing the formation of

Prevention of variceal growth

Prevention of growth of small esophageal varices has been explored in 2 randomized trials with conflicting results. The first trial, mentioned earlier, showed a significantly higher rate of development of large varices in the propranolol group compared with the placebo group.15 In contrast, a second multicenter, randomized, placebo-controlled trial showed that nadolol significantly reduced the progression from small to large esophageal varices at 3 years (11% vs 37%).17 No difference in

Pharmacologic prophylaxis of variceal bleeding

The goal of primary prophylaxis is to prevent the first bleeding episode and consequently improve survival through decreasing bleeding-related death. Nonselective β-blockers reduce portal pressure through blockade of β1- and β2-adrenergic receptors. Blockade of these receptors results in a decrease in the cardiac output and unopposed splanchnic vasoconstriction, respectively, which in turn leads to a reduction of the portal inflow. In contrast, β1-selective agents lack the splanchnic

Endoscopic prophylaxis

Variceal band ligation (VBL) has become the preferred method for endoscopic prevention of variceal bleeding because it has been associated with fewer complications than endoscopic sclerotherapy.38 A meta-analysis of 5 randomized clinical trials comparing VBL with no treatment showed a significant decrease in the risk of first variceal bleeding and lower mortality rates in the VBL group.39 VBL is repeated every 2 to 4 weeks until the varices have been eradicated, which typically requires 2 to 4

Summary

In summary, primary prophylaxis of variceal bleeding is recommended for all patients with large esophageal varices, independently of the severity of liver disease or the presence of risk factors. Either nonselective β-blockers or VBL could be used, and the choice of treatment depends on local resources, expertise, and patient preference. Primary prophylaxis is also recommended for patients with small varices at high risk of bleeding (Child-Turcotte-Pugh class B/C or presence of red wales on

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    The authors have nothing to disclose.

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