Prevention and management of gastroesophageal varices

Jang, Jae Young

Abstract

Gastroesophageal varices are the most common lethal complication of cirrhosis that result most directly from portal hypertension. Patients with cirrhosis and gastroesophageal varices have an hepatic venous pressure gradient (HVPG) of at least 10~12 mmHg. An increased portal pressure gradient results from both an increase in resistance to portal flow and an increase in portal blood inflow. Patients whose HVPG decreased to < 12 mmHg or at least 20% from baseline levels have a lower probability of developing recurrent variceal hemorrhage. Therefore, a reduction in HVPG is most important. Nonselective beta-blockers are the gold standard in the prevention of first variceal hemorrhage in pateints with medium/large varices. Endoscopic variceal ligation (EVL) has been established as an alternative to nonselective beta-blockers for the prevention of initial variceal hemorrhage. The combination of vasoconstrictive pharmacological therapy and variceal ligation is the preferred approach to the management of acute variceal hemorrhage. Prophylactic antibiotic therapy is considered standard of care as adjunctive treatment of the acute bleeding episode. Both combination pharmacological therapy and EVL have been proven effective for the prevention of recurrent variceal hemorrhage. For failures of medical therapy, TIPS or surgically created shunts are excellent salvage procedures.