Journal List > Korean J Gastroenterol > v.56(3) > 1006708

Lee: Prevention of Esophageal Variceal Bleeding

Abstract

Esophageal varices(EV) are present in 40% and 60% of Child-Pugh A and C patients, respectively when cirrhosis is diagnosed. EV bleeding is a life-threatening complication of liver cirrhosis with a high probability of recurrence. Treatment to prevent first EV bleeding or rebleeding is mandatory. In small EV with high risk of bleeding, nonselective β-blockers should be used for the prevention of first variceal bleeding. For medium to large EV, nonselective β-blockers or endoscopic variceal ligation (EVL) may be recommended to high risk varices. But, nonselective β-blockers are the first treatment option to non-high risk varices and EVL is an alter-native when nonselective β-blockers are contraindicated or not tolerated. For the prevention of rebleeding, a combination of nonselective β-blockers and EVL may be the best option. A great improvement in the prevention of variceal bleeding has emerged over the last years. However, further therapeutic options that combine higher efficacy, better tolerance and fewer side effects are needed.

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Fig. 1.
Recommendation of follow up endoscopy for screening of esophageal varices in liver cirrhosis.
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Fig. 2.
Primary prophylaxis for small esophageal varices.
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Fig. 3.
Primary prophylaxis for large esophageal varices.
kjg-56-155f3.tif
Table 1.
Likelihood (%) of Bleeding of Untreated Varices within 23 Months in the North Italian Endoscopic Club study (adopted from NEJM 1988;319:983)
Status of red wale markings Child A Child B Child C
S M L S M L S M L
Absent 6 10 15 10 16 26 20 30 42
Mild 8 2 19 15 23 33 28 38 54
Moderate 12 16 24 20 30 42 36 48 64
Severe 16 23 34 28 40 52 44 60 76

  S, M, L, small, medium, and large variceal size, respectively.

Table 2.
Comparision of EVL and Non-selective β-blocker for Primary Prophylaxis for Esophageal Variceal Bleeding
EVL β-blocker
First bleeding No difference
Mortality No difference
Cost effectiveness Less More
Varix recur Yes (22-29%) No
f/u Endoscopy 6-12 months No
All adverse effects No difference
Severe adverse effects Yes (EVL ulcer bleeding) No
Effects on portal hypertension No Yes

  EVL, endoscopic variceal ligation; f/u, follow-up.

Table 3.
Meta-Analysis Results of EVL plus β-blockers Compared with EVL for the Prevention of Recurrent Esophageal Variceal Bleeding (25 Trials, 2,159 subjects)
Variable RR (95% CI) p-value
All cause mortality 0.787 (0.587-1.054) 0.11
Death due to rebleeding 0.786 (0.445-1.387) 0.41
Rebleeding 0.623 (0.523-0.741) <0.001
Rebleeding varices 0.601 (0.440-0.820) <0.001

  EVL, endoscopic variceal ligation.

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