Materiały źródłowe

• #1 Management of Esophageal Varices

  https://pmc.ncbi.nlm.nih.gov/articles/PMC5345213/

  Esophageal varices are caused by portal hypertension most commonly due to cirrhosis or to portal vein thrombosis. […] In cirrhotic patients who have never bled before, screening for esophageal varices is recommended at least once every 3 years. If large varices are identified in these patients, they may undergo either prophylactic band ligation therapy, administration of -blockers, or both. […] If a patient presents with gastrointestinal bleeding and cirrhosis, they need to undergo urgent or emergent endoscopy and the source of the bleed needs to be identified. If the cause is esophageal varices, band ligation is the first-line treatment that should be applied. Patients who fail band ligation therapy and have continued bleeding are candidates for transjugular hepatic portosystemic shunting (TIPS) therapy.

• #2 Esophageal varices – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/esophageal-varices/symptoms-causes/syc-20351538

  Esophageal varices form when regular blood flow to the liver is blocked by a clot or scar tissue in the liver. To go around the blockages, blood flows into smaller blood vessels that aren’t designed to carry large volumes of blood. The vessels can leak blood or even burst, causing life-threatening bleeding. […] A few medicines and medical procedures are available to help prevent or stop bleeding from esophageal varices. […] Currently, no treatment can prevent the development of esophageal varices in people with cirrhosis. While beta blocker drugs are effective in preventing bleeding in many people who have esophageal varices, they don’t stop esophageal varices from forming.

• #3 Esophageal varices – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/esophageal-varices/diagnosis-treatment/drc-20351544

  During an upper endoscopy, a healthcare professional inserts a thin, flexible tube equipped with a light and camera down the throat and into the esophagus. […] The primary aim in treating esophageal varices is to prevent bleeding. Bleeding esophageal varices are life-threatening. If bleeding happens, treatments are available to try to stop the bleeding. […] Treatments to lower blood pressure in the portal vein may reduce the risk of bleeding esophageal varices. Treatments may include: […] A type of blood pressure drug called a beta blocker may help reduce blood pressure in the portal vein. This can decrease the likelihood of bleeding. […] If the esophageal varices appear to have a high risk of bleeding, or if the varices have bled before, a healthcare professional might recommend a procedure called endoscopic band ligation.

• #4 Esophageal Varices: Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/15429-esophageal-varices

  If youve already been treated for bleeding, or if your varices arent bleeding yet but are at risk, your healthcare provider will offer you preventive treatment. Prevention generally includes: Beta-blockers: These medications, which are commonly prescribed to treat high blood pressure, can reduce the risk of variceal bleeding by up to 50%. […] If the above treatments dont reduce your risk of variceal bleeding, or if youre having other complications from portal hypertension, your provider might recommend alternative procedures to reduce portal hypertension in the portal vein itself. […] Portal hypertension may improve by treating the cause in some cases. If the cause is a blood clot or an infection that can be cured, curing these might cure portal hypertension.

• #5 Patient education: Esophageal varices (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/esophageal-varices-beyond-the-basics

  If large varices are detected, a medication is prescribed to reduce the risk of bleeding (see 'Beta blockers’ below), and the endoscopy does not usually need to be repeated. […] Beta blockers, which are traditionally used to treat high blood pressure, are the most commonly recommended medication to prevent bleeding from varices. […] Variceal band ligation is a procedure that is done during endoscopy. A physician places small rubber bands around esophageal varices to prevent them from bleeding or stop active bleeding. […] Variceal band ligation is usually performed in people who have bled from esophageal varices. However, it can also be performed to prevent bleeding, especially in people whose varices are large and/or have other features that increase the risk of bleeding and who cannot tolerate beta blockers.

• #5 Patient education: Esophageal varices (Beyond the Basics) – UpToDate

  https://www.uptodate.com/contents/esophageal-varices-beyond-the-basics

  Patient education: Esophageal varices (Beyond the Basics) […] Varices are enlarged or dilated blood vessels (veins) in the esophagus, the tube that connects the mouth and stomach, or in the stomach itself. Esophageal or gastric varices are a common complication of advanced cirrhosis. […] Esophageal or gastric varices are a potentially serious complication of cirrhosis. Without treatment, varices may rupture and cause severe bleeding (hemorrhage) resulting in significant illness or even death. […] Bleeding varices require emergency medical treatment. […] People with cirrhosis who are at risk for having varices usually undergo a screening test to determine if varices are present. If varices are discovered, strategies to prevent bleeding may be recommended. […] The most common way to detect varices is with a procedure known as upper endoscopy.

• #6 Esophageal Varices – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK448078/

  With active bleeding, avoid beta-blockers, which decrease blood pressure and blunt the physiologic increase in heart rate during acute hemorrhage. […] Prevent recurrence of acute bleeding: […] Vasoconstrictors: terlipressin, octreotide (reduce portal pressure) […] Endoscopic band ligation (EBL): if bleeding recurs/portal pressure measurement shows portal pressure remains greater than 12 mmHg […] TIPS: Second-line therapy if the above methods fail; TIPS decreases portal pressure by creating communication between hepatic vein and an intrahepatic portal vein branch. […] Medications […] First-Line […] NSBB reduce portal pressure and decrease the risk of the first bleed from 25% to 15% in primary prophylaxis […] Carvedilol: 6.25 mg daily is more effective than NSBB (Propranolol and Nadolol) in dropping HVPG

• #7 Top Recommendations for the Diagnosis and Management of Esophagogastric Variceal Bleeding – Endoscopy Campus

  https://www.endoscopy-campus.com/en/ec-news/top-recommendations-for-the-diagnosis-and-management-of-esophagogastric-variceal-bleeding/

  If there are no contraindications, patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [body mass index 30kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient 10mmHg and/or liver stiffness by transient elastography 25 kPa) should be given nonselective beta-blocker (NSBB) therapy (preferably carvedilol) to prevent variceal bleeding. (Strong recommendation, moderate-quality evidence) […] Endoscopic band ligation (EBL) is the preferred endoscopic prophylactic treatment in patients unable to receive NSBB therapy for high-risk esophageal varices demonstrated by upper GI endoscopy screening. EBL should be repeated every 2 to 4 weeks until variceal eradication is achieved, followed by surveillance EGD performed every 3 to 6 months the first year after eradication. (Strong recommendation, moderate-quality evidence)

• #8 Endoscopic diagnosis and management of esophagogastric variceal hemorrhage | ESGE

  https://www.esge.com/endoscopic-diagnosis-and-management-of-esophagogastric-variceal-hemorrhage

  ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding. Strong recommendation, moderate quality evidence. […] ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2–4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3–6 months in the first year following eradication. Strong recommendation, moderate quality evidence.

• #9 Esophageal Varices Treatments | Northwestern Medicine

  https://www.nm.org/conditions-and-care-areas/gastroenterology/esophageal-varices/treatments

  Treatment for esophageal varices depends on the size and appearance of the veins and the risk for bleeding. Several treatments are performed during an endoscopy, in which a thin, flexible tube is inserted through your mouth and down your esophagus. Treatments include: […] Endoscopic ligation: During an endoscopy, small rubber bands are placed around the varices to stop active bleeding or the risk of bleeding. […] Endoscopic injections: During an endoscopy, your physician can inject dilated veins with alcohol or blood-clotting medication to shrink them. […] Tamponade: During an endoscopy, a balloon is inserted into your esophagus and filled with air to put pressure on a bleeding blood vessel and help stop bleeding. […] Shunt placement: A shunt is a small tube that provides a new path for blood to flow when a blood vessel is damaged. This method is often used to halt bleeding while waiting for a liver transplant.

• #10 Diagnosis and Management of Esophagogastric Varices

  https://www.mdpi.com/2075-4418/13/6/1031

  Endoscopic injection tissue adhesives (ETA) are another method of treating varices. […] Balloon tamponade was developed to control AVB and has been used to provide temporary hemostatic control until more definitive therapy can be administered. […] In high-risk patients who meet any of the following criteria, a transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene (PTFE)-covered stents is recommended as an early option: Child–Pugh class C or B greater than 7 with active bleeding at initial endoscopy. […] Emergency surgery has a limited role in the treatment of AVB. […] To prevent recurrent variceal bleeding, patients recovering from a first episode of variceal bleeding should be treated with a combination of NSBBs and EBL. […] The AASLD recommends 1-to-4-week intervals for EBL follow-up until eradication, with the first follow-up EGD performed 3 to 6 months after eradication and then every 6 to 12 months.

• #11 Combination Therapy as Primary Prophylaxis for High-Risk Esophageal Varices – American College of Gastroenterology

  https://gi.org/journals-publications/ebgi/schoenfeld_dec2024/

  Combination Therapy as Primary Prophylaxis for High-Risk Esophageal Varices […] This summary reviews Tevethia HV, Pande A, Vijayaraghavan R, et al. Combination of carvedilol with variceal band ligation in prevention of first variceal bleed in Child-Turcotte-Pugh B and C cirrhosis with high-risk oesophageal varices: The ‘CAVARLY Trial.’ Gut 2024; 73: 1844-53. […] Question: Is combination therapy with non-selective beta blockers plus variceal band ligation (VBL) superior to monotherapy with either treatment for preventing first variceal bleed in patients with decompensated cirrhosis (Child-Turcotte-Pugh B and C cirrhosis) and high-risk esophageal varices? […] In the ITT analysis, the overall incidence of first variceal bleed was significantly lower in the combination therapy group vs non-selective beta blocker monotherapy or VBL monotherapy: 11.8% vs 33.6% vs 25.5%, respectively, P < 0.002.

• #11 Combination Therapy as Primary Prophylaxis for High-Risk Esophageal Varices – American College of Gastroenterology

  https://gi.org/journals-publications/ebgi/schoenfeld_dec2024/

  Also, all-cause mortality at 1 year was significantly lower in the combination therapy group vs non-selective beta-blocker monotherapy or VBL monotherapy: 6.3% vs 20% vs 14.5%, respectively, P = 0.012. […] The 2024 guidelines from the American Association for the Study of Liver Diseases (AASLD) recommend “if high-risk varices are detected, non-selective beta blockers or endoscopic band ligation are recommended; preference is given to non-selective beta blockers (including carvedilol) because of benefits beyond prevention of variceal hemorrhage.” […] I focus on using non-selective beta blockers in patients with compensated and decompensated cirrhosis as primary prophylaxis against variceal bleeding since VBL is associated with more severe adverse events. […] Given the results of the current study, I expect to change my practice and routinely provide combination therapy for patients with decompensated cirrhosis and high-risk esophageal varices.

• #12 Esophageal varices – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/esophageal-varices/diagnosis-treatment/drc-20351544

  Bleeding esophageal varices are life-threatening, and immediate treatment is essential. Treatments used to stop bleeding and reverse the effects of blood loss include: […] A healthcare professional may wrap elastic bands around the esophageal varices during an endoscopy. […] Medicines such as octreotide (Sandostatin) and vasopressin (Vasostrict) slow the flow of blood to the portal vein. […] If medicine and endoscopy treatments don’t stop the bleeding, a care professional might recommend a procedure called transjugular intrahepatic portosystemic shunt (TIPS). […] If medicine and endoscopy treatments don’t work, a care professional may try to stop bleeding by applying pressure to the esophageal varices. […] A transfusion may be needed to replace lost blood, and a clotting factor may be given to stop bleeding.

• #13 Esophageal Varices: Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/15429-esophageal-varices

  Esophageal varices are swollen veins in the lining of your esophagus. Most treatment is aimed at damage control. […] Healthcare providers have several ways of treating varices to prevent and control bleeding. Most treatment is aimed at damage control. Varices usually dont reduce and go away, unless portal hypertension does. This may be possible in some cases, depending on the condition causing it. […] The goals of treatment are to: Control active bleeding. Prevent future bleeding. Reduce portal hypertension or prevent it from worsening, if possible. […] Bleeding from esophageal varices is an emergency that requires immediate treatment. Supportive care in the hospital may include: IV fluids. Blood transfusion. Mechanical ventilation. Antibiotics to prevent infections. […] When your condition is stable, youll have an emergency upper endoscopy to diagnose and treat the bleeding. Treatment during endoscopy will include: IV medications to reduce blood pressure and tighten veins in your portal venous system. Commonly used medications include octreotide, vasopressin and somatostatin. Variceal band ligation: An endoscopist will wrap tiny elastic bands around bleeding varices to cut off their blood flow.

• #14 Esophageal Varices – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK448078/

  TREATMENT / MANAGEMENT […] Treat underlying cirrhotic comorbidities. […] Hepatic encephalopathy and infection often complicate variceal bleeding. […] Active bleeding: […] Intravenous (IV) access, hemodynamic resuscitation […] Overtransfusion increases portal pressure and increases rebleeding risk […] Treat coagulopathy as necessary. Fresh frozen plasma may increase blood volume and increase rebleeding risk […] Monitor mental status. Avoid sedation, nephrotoxic drugs, and beta-blockers acutely. […] IV octreotide to lower portal venous pressure as adjuvant to endoscopic management. IV bolus of 50 micrograms followed by a drip of 50 micrograms/hr. […] Terlipressin (alternative): 2 mg q4h IV for 24 to 48 hours, then 1 mg q4h […] Erythromycin 250 mg IV 30 to 120 minutes before endoscopy

• #15 Diagnosis and Management of Esophagogastric Varices

  https://www.mdpi.com/2075-4418/13/6/1031

  The rupture of esophageal varices presents with severe hemorrhage, characterized by hematemesis and/or melena, severe anemia, and possible loss of consciousness. […] Baveno VII recommends that in cases of suspected variceal bleeding, vasoactive drugs (such as terlipressin and octreotide) be started as soon as possible and continued for 2–5 days. […] Antibiotic prophylaxis is an essential part of treatment for patients with ACLD who present with UGIB, according to Baveno VII guidelines, and should be started right away. […] Upper endoscopy should be performed on patients with suspected AVB within 12 h of presentation after hemodynamic resuscitation. […] Endoscopy has a key role in the management of EV bleeding. […] EBL is the preferred type of endoscopic therapy for AVB. […] In contrast to EBL, which is mechanical, the mechanism of EVS is chemical.

• #15 Diagnosis and Management of Esophagogastric Varices

  https://www.mdpi.com/2075-4418/13/6/1031

  Acute variceal bleeding (AVB) is a potentially fatal complication of clinically significant portal hypertension and is one of the most common causes of acute upper gastrointestinal bleeding. […] Patients with high-risk varices should receive primary prophylaxis with either nonselective beta-blockers or endoscopic band ligation. […] In cases of AVB, patients should receive upper endoscopy within 12 h after resuscitation and hemodynamic stability, whereas endoscopy should be performed as soon as possible if patients are unstable. […] In cases of suspected variceal bleeding, starting vasoactive therapy as soon as possible in combination with endoscopic treatment is recommended. […] On the other hand, in cases of uncontrolled bleeding, balloon tamponade or self-expandable metal stents can be used as a bridge to more definitive therapy such as transjugular intrahepatic portosystemic shunt.

• #16 Top Recommendations for the Diagnosis and Management of Esophagogastric Variceal Bleeding – Endoscopy Campus

  https://www.endoscopy-campus.com/en/ec-news/top-recommendations-for-the-diagnosis-and-management-of-esophagogastric-variceal-bleeding/

  Treatment with a vasoactive agent (terlipressin, octreotide, or somatostatin) should be initiated at the time of presentation in patients with suspected acute variceal bleeding and continued for up to 5 days. (Strong recommendation, high-quality evidence) […] Patients with ACLD presenting with acute esophageal variceal hemorrhage (EVH) should receive 1g daily of the antibiotic prophylaxis ceftriaxone for up to 7 days. Alternative antibiotics may also be used based on local antibiotic resistance and patient allergies. (Strong recommendation, high-quality evidence) […] Provided there are no contraindications, patients with suspected acute EVH should be given 250 mg of intravenous erythromycin 30 to 120 minutes before upper GI endoscopy. (Strong recommendation, high-quality evidence) […] Patients with suspected EVH should undergo endoscopic evaluation within 12 hours of presentation, as long as hemodynamic resuscitation has been performed. (Strong recommendation, moderate-quality evidence)

• #17 English | World Gastroenterology Organisation

  https://www.worldgastroenterology.org/guidelines/esophageal-varices/esophageal-varices-english

  Terlipressin reduces failure to control bleeding and mortality, and should be the first choice for pharmacological therapy when available. […] Long-term endoscopic control and banding or sclerotherapy of recurrent varices every 3-6 months. […] Portosystemic shunts are associated with lower rates of variceal rebleeding in comparison with sclerotherapy/banding, but they increase the incidence of hepatic encephalopathy. […] Liver transplantation should always be considered if the patient has Child-Pugh grades B or C.

• #17 English | World Gastroenterology Organisation

  https://www.worldgastroenterology.org/guidelines/esophageal-varices/esophageal-varices-english

  Esophagogastroduodenoscopy is the gold standard for the diagnosis of esophageal varices. […] The following treatment options are available in the management of esophageal varices and hemorrhage. […] The use of vasoactive drugs may be safe and effective whenever endoscopic therapy is not promptly available and is associated with less adverse events than emergency sclerotherapy. […] Endoscopic sclerotherapy and variceal band ligation are effective in stopping bleeding in up to 90% of patients. […] A transjugular intrahepatic portosystemic shunt (TIPS) is a good alternative when endoscopic treatment and pharmacotherapy fail. […] The use of balloon tamponade is decreasing, as there is a high risk of rebleeding after deflation and a risk of major complications. […] Combined endoscopic and pharmacologic treatment is shown to achieve better control of acute bleeding than endoscopic treatment alone.

• #18 Methods to achieve hemostasis in patients with acute variceal hemorrhage – UpToDate

  https://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage

  Methods to achieve hemostasis in patients with acute variceal hemorrhage […] The current treatment options for acute variceal hemorrhage include medications (vasopressin, somatostatin, and their analogs), endoscopy, transjugular intrahepatic portosystemic shunt placement, and surgery. […] This topic will review the pharmacologic, endoscopic, radiologic, and surgical methods used to achieve hemostasis in patients with acute variceal hemorrhage. […] The management of variceal hemorrhage is also discussed in a 2017 guideline from the American Association for the Study of Liver Diseases, a 2014 guideline from the American Society of Gastrointestinal Endoscopy, a 2015 international consensus statement (Baveno VI), and a 2015 guideline from the British Society of Gastroenterology.

• #19 Endoscopic diagnosis and management of esophagogastric variceal hemorrhage | ESGE

  https://www.esge.com/endoscopic-diagnosis-and-management-of-esophagogastric-variceal-hemorrhage

  ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH). Strong recommendation, high quality evidence. […] ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child–Pugh C ≤ 13 or Child–Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered. Strong recommendation, high quality evidence. […] ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available). Strong recommendation, moderate quality evidence.

• #20 Management of Esophageal Varices

  https://pmc.ncbi.nlm.nih.gov/articles/PMC5345213/

  After a patient has been through the initial band ligation to correct an active bleed, he or she requires repeated band ligation treatment in order to obliterate the varices altogether. […] In general, -blockers are effective in decreasing portal pressure and they are recommended for prophylactic prevention of recurrent bleeding. […] Band ligation therapy has been shown in studies to be easier to apply, with far fewer side effects, and is just as, if not more, effective than sclerotherapy (direct injection of a sclerosant agent into the variceal vessel).

• #21 Esophageal Varices – Harvard Health

  https://www.health.harvard.edu/a_to_z/esophageal-varices-a-to-z

  If you have esophageal varices, treatment may be able to prevent bleeding. This treatment includes endoscopic banding or sclerotherapy (described in the Treatment section) to shrink the varices. Drugs to reduce portal blood pressure such as propranolol (Inderal) or nadolol (Corgard) also can be used alone or in combination with endoscopic techniques. […] Emergency treatment for bleeding esophageal varices begins with blood and fluids given intravenously (into a vein) to compensate for blood loss. At the same time, intravenous drugs are usually given to decrease blood flow in the portal vein and help slow the rate of bleeding from the varices. Efforts are then made to stop the bleeding. […] Endoscopy is done to identify the site of the bleeding. If the bleeding is caused by ruptured esophageal varices, one of two endoscopic treatments are often used: Band ligation. A rubber band is used to tie off the bleeding portion of the vein. Sclerotherapy. A drug is injected into the bleeding vein, causing it to constrict (narrow). This slows the bleeding and allows a blood clot to form over the ruptured vessel.

• #22 Esophageal Varices – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK448078/

  Urgent upper GI endoscopy for diagnosis and treatment […] If no contraindication, start beta-blocker (nitrates are an alternative) […] Variceal band ligation is preferred to sclerotherapy for bleeding varices and for nonbleeding medium-to-large varices to decrease bleeding risk. Ligation has lower rates of rebleeding, fewer complications, more rapid cessation of bleeding and a higher rate of variceal eradication. […] Repeat ligation/sclerosant for rebleeding. […] If endoscopic treatment fails, consider self-expanding esophageal metal stents or peroral placement of Sengstaken-Blakemore-type tube up to 24 hours to stabilize the patient for TIPS. […] As many as two-thirds of patients with variceal bleeding develop an infection, most commonly spontaneous bacterial peritonitis, UTI, or pneumonia. Antibiotic prophylaxis with oral norfloxacin 400 mg or IV ceftriaxone, 1 g q24h for up to a week, is indicated.

• #23 Esophageal varices – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/esophageal-varices/diagnosis-treatment/drc-20351544

  There is a high risk that bleeding will recur in people who’ve had bleeding from esophageal varices. Beta blockers and endoscopic band ligation are the recommended treatments to help prevent rebleeding. […] Researchers are exploring an experimental emergency therapy to stop bleeding from esophageal varices that involves spraying an adhesive powder. […] Another possible way to stop bleeding when all other measures fail is to use self-expanding metal stents (SEMS).

• #24 Acute management of an oesophageal variceal bleed

  https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Acute_management_of_an_oesophageal_variceal_bleed/

  If bleeding is ongoing and uncontrollable, patient will require Balloon Tamponade (Foleys Catheter if child 15kg or Sengstaken Blakemore tube if child15kg). […] The Sengstaken-Blackmore tube (SSBT) was designed to stop hemorrhage by mechanically compressing esophageal and gastric varices. […] Re-bleeding has been reported in 33%-60% of patients. […] The paper recommends the following, regarding management of acute variceal bleeding: Monitor vital signs, obtain venous access, FBC, INR, LFTs, UECs, crossmatch. […] The use of non-selective beta-blockers to prevent variceal bleeding in adults is established and comparable to EVL. […] Sclerotherapy and EVL are highly effective in paediatric variceal bleed management.

• #24 Acute management of an oesophageal variceal bleed

  https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Acute_management_of_an_oesophageal_variceal_bleed/

  Oesophageal varices (and indeed any varices) are a rare but serious complication of portal hypertension. […] The aim of this guideline is to assist nurses and other health professionals in the management of infants and children with oesophageal varices to minimise risk of variceal bleeding. This guideline will also outline the management of an acute oesophageal variceal bleed. […] Patients should have routine surveillance gastroscopies to monitor status and progression of varices. Banding or sclerotherapy can be undertaken as required. Frequency of gastroscopies is dictated by treating gastroenterologist. […] Seek urgent medical/ ICU review/ MET (ext. 2222). […] Consider need to activate RCH Massive Haemorrhage and Critical Bleeding Procedure. […] Consider vasoactive therapy: Octreotide, IV bolus followed by IV infusion.

• #25 An update on the management of acute esophageal variceal bleeding | Gastroenterología y Hepatología

  https://www.elsevier.es/es-revista-gastroenterologia-hepatologia-14-articulo-an-update-on-management-acute-S0210570516000303

  Current evidence supports EBL as the endoscopic therapy of choice for the initial control of bleeding as it is associated with less adverse events and less mortality than sclerotherapy. […] If bleeding is mild and the patient has a good liver function a second endoscopic therapy might be attempted. […] Both TIPS and surgical shunts are extremely effective at controlling variceal bleeding (control rate approaches 95%), but due to worsening of liver function, encephalopathy and mortality remains high. […] Two randomized controlled trials have assessed the beneficial effects of an early TIPS placement (within 72h of admission) in preventing re-bleeding and mortality in patients with AVB at high risk of treatment failure. […] Altogether, these results suggest that the management of variceal bleeding should be stratified according to patient risk, and that high-risk patients might benefit from more aggressive therapies such as an early, preemptive-TIPS.

• #26 Esophageal Varices – Digestive Disorders – Merck Manual Consumer Version

  https://www.merckmanuals.com/home/digestive-disorders/gastrointestinal-bleeding/esophageal-varices

  If the person’s life is in immediate danger from severe bleeding while waiting for the shunt procedure, doctors may place a tube with balloons down the person’s esophagus. […] People who have cirrhosis and bleeding are at risk of bacterial infection and are given an antibiotic. […] Even after successful treatment, esophageal varices can bleed again, particularly if the person’s liver disease remains active. Doctors may give medications such as beta-blockers to help control portal hypertension, but people who continue to have problems may need liver transplantation.

• #27 Esophageal Varices – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK448078/

  Chronic prevention of rebleeding (secondary prevention): NSBBs and EBL reduce the rate of rebleeding to a similar extent, but beta-blockers reduce mortality, whereas ligation does not. […] Second-Line […] Obliterate varices with esophageal banding for patients not tolerant of medication prophylaxis. […] During ligation, proton pump inhibitors are used, such as lansoprazole 30 mg/day, until varices are obliterated. […] Management of Budd-Chiari syndrome: anticoagulation, angioplasty/thrombolysis, TIPS, and orthotopic liver transplantation […] Management of extrahepatic portal vein obstruction: anticoagulation; mesenteric-left portal vein bypass (Meso-Rex procedure). […] Refer for endoscopy, liver transplant, and interventional radiology for TIPS. […] Pneumococcal and hepatitis A/B (HAV/HBV) vaccine need to be considered.

• #28 Portal Hypertension Treatment & Management: Approach Considerations, Emergent Treatment, Primary Prophylaxis

  https://emedicine.medscape.com/article/182098-treatment

  Propranolol and nadolol significantly reduce the risk of rebleeding and are associated with prolongation of survival. […] Endoscopic variceal ligation (EVL) is considered the endoscopic treatment of choice in the prevention of rebleeding. […] Despite the contrasting findings above, combination of beta-blocker therapy with EVL is considered to the best option for secondary prophylaxis of variceal hemorrhage.

• #29 Top Recommendations for the Diagnosis and Management of Esophagogastric Variceal Bleeding – Endoscopy Campus

  https://www.endoscopy-campus.com/en/ec-news/top-recommendations-for-the-diagnosis-and-management-of-esophagogastric-variceal-bleeding/

  An endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage should be administered. (Strong recommendation, moderate-quality evidence) […] Patients who have undergone EBL for acute EVH should receive follow-up EBLs every 1 to 4 weeks until esophageal varices are eradicated (secondary prophylaxis). (Strong recommendation, moderate-quality evidence) […] Early endoscopy in patients with suspected variceal bleeding, use of antibiotics in those with cirrhosis, and consideration of beta blockers for primary prevention are all important strategies to improve patient outcomes.

• #30 Top 10 Clinical Tips for New Gastroenterology and Hepatology Fellows | AASLD

  https://www.aasld.org/liver-fellow-network/core-series/tools-trade/top-10-clinical-tips-new-gastroenterology-and

  After variceal hemorrhage, if there is no clear indication (i.e GERD, esophagitis, peptic ulcer disease) consider stopping PPI therapy or only continuing therapy for 10 days. If varices were banded, PPIs can reduce the size of post banding ulcers, but should not be used as a long-term treatment option. If non-selective beta blockers are started for esophageal varices, ensure heart rate is appropriate and titrate to resting heart rate. […] Always think about the possibility of TIPS for patients with cirrhosis, particularly in those with difficult to manage ascites, hepatic hydrothorax or recurrent or uncontrollable variceal bleeding.

• #31 Endoscopic diagnosis and management of esophagogastric variceal hemorrhage | ESGE

  https://www.esge.com/endoscopic-diagnosis-and-management-of-esophagogastric-variceal-hemorrhage

  ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage. Strong recommendation, high quality evidence. […] ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD. Strong recommendation, high quality evidence.

• #32 Esophageal varices – Knowledge @ AMBOSS

  https://www.amboss.com/us/knowledge/esophageal-varices/

  Medium or large esophageal varices: Provide either pharmacological prophylaxis or EVL. […] Nonselective beta blockers (recommended); Propranolol OR nadolol. […] Endoscopic variceal ligation (EVL): Repeat every 18 weeks until varices are eradicated. […] Esophageal variceal hemorrhage is a medical emergency. […] Vasoactive medication and antibiotic prophylaxis are indicated for all patients. […] Esophageal variceal bleeding is a consequence of portal hypertension, and therefore treatment focuses on reducing portal hypertension rather than the correction of coagulation abnormalities. […] Consider if pharmacological and endoscopic treatment are unsuccessful. […] The combination of EVL and nonselective beta blockers for the prevention of recurrent esophageal variceal hemorrhage is more effective than either therapy alone.

• #33 Quick Tips: Esophageal Varices | AASLD

  https://www.aasld.org/liver-fellow-network/core-series/tools-trade/quick-tips-esophageal-varices

  Now learn how to treat bleeding esophageal varices! […] meta-analysis showing that combined treatment (EVL + pharmacologic) is superior to EVL alone in acute variceal bleeding […] antibiotic prophylaxis in the setting of GI bleeding in cirrhosis reduces infections, re-bleeding, and mortality […] the addition of NSBB to EVL reduces re-bleeding after an acute esophageal variceal bleed.

• #34 Esophageal Varices Treatments | Northwestern Medicine

  https://www.nm.org/conditions-and-care-areas/gastroenterology/esophageal-varices/treatments

  Liver transplant: A healthy liver or part of a liver from a donor replaces your diseased liver. […] Blood transfusion: Blood from a donor replaces the blood you have lost. […] Medications: Beta blockers may reduce the pressure in your portal vein. Other medications may slow blood flow from your esophagus to your liver. Antibiotics are given to prevent a bacterial infection in the esophagus.

• #35

  https://link.springer.com/article/10.1007/s11938-003-0052-3

  Band ligation is preferred to sclerotherapy when considering endoscopic therapy due to less complications and lower cost. Surgical shunts should be used for prevention of rebleeding in patients who do not tolerate or are noncompliant with medical therapy and who have relatively preserved liver function. TIPS should be reserved for patients who have poor liver function and who have failed medical therapy.

• #36 Esophageal Varices – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK448078/

  Surgery/Other Procedure […] Esophageal transection: in rare cases of uncontrollable, exsanguinating bleeding […] Liver transplantation […] Portosystemic shunt […] Inpatient admission to the intensive care unit to stabilize acute bleeding and hemodynamic status, therapeutic endoscopy. […] Discharge criteria: bleeding cessation; hemodynamic stability and appropriate plan for treating comorbidities. […] Radiology […] Percutaneous transhepatic embolization has been used to stop variceal bleeding. However, its effectiveness remains questionable. It is generally reserved for patients who are not candidates for surgery. […] TIPS is a salvage procedure to stop acute variceal bleeding. However, the procedure is also associated with serious complications including encephalopathy and occlusion of the shunt within 12 months. TIPS may be a bridge to a liver transplant.

• #37 Esophageal varices | UM Health-Sparrow

  https://www.uofmhealthsparrow.org/departments-conditions/conditions/esophageal-varices

  Restoring blood volume. A transfusion may be needed to replace lost blood, and a clotting factor may be given to stop bleeding. […] Preventing infection. There is an increased risk of infection with bleeding, so an antibiotic may be prescribed to prevent infection. […] Rebleeding. There is a high risk that bleeding will recur in people who’ve had bleeding from esophageal varices. Beta blockers and endoscopic band ligation are the recommended treatments to help prevent rebleeding. […] Researchers are exploring an experimental emergency therapy to stop bleeding from esophageal varices that involves spraying an adhesive powder.

• #38 Variceal Banding: Procedure, Recovery Time, Outlook, and MoreHealthline

  https://www.healthline.com/health/variceal-banding

  Other treatment options for esophageal varices include: Beta-blockers: Beta-blockers such as nadolol (Corgard) and propranolol (Inderal) lower the blood pressure in your portal vein. […] Experts consider variceal banding the most effective procedure for preventing ruptures. It has a success rate of 85–94%. […] Variceal esophageal banding is a safe and effective way to prevent and treat bleeding varices. This is a complication of advanced liver conditions that can be fatal.

• #39 Esophageal Varices: Symptoms, Causes, Treatments

  https://resources.healthgrades.com/right-care/vascular-conditions/esophageal-varices

  Additional treatment options are available for esophageal varices that are resistant to endoscopic banding treatment. These include endoscopic injection of a sclerosing agent: This irritant substance causes a reaction that damages and destroys the bleeding vessel. […] Endoscopic stent placements: This procedure puts pressure on the area to stop bleeding. This off-label procedure may be used in emergency situations. […] Transjugular intrahepatic portosystemic shunt (TIPS): TIPS uses interventional radiology to reduce portal hypertension when endoscopic therapy is unsuccessful or not feasible. A doctor places a stent between the intrahepatic portal vein branch and the hepatic vein.

• #40 Portal Hypertension Treatment & Management: Approach Considerations, Emergent Treatment, Primary Prophylaxis

  https://emedicine.medscape.com/article/182098-treatment

  Following resuscitation, treatment of acute variceal bleeding includes control of bleeding (24 h without bleeding within the first 48 h following the start of therapy) and prevention of early recurrence. […] A short course of prophylactic antibiotics has been demonstrated to decrease both the rate of bacterial infections and mortality rates. […] Combination endoscopic and pharmacologic therapy minimizes the risk of complications, especially within the period when the risk of rebleeding is the greatest (ie, within 5 days of the initial episode). […] Octreotide is the pharmacologic agent of choice in acute variceal bleeding and is used in conjunction with endoscopic therapy. […] Endoscopic variceal ligation (EVL) is the preferred endoscopic therapy in acute esophageal variceal bleeding.

• #41 Oesophageal Varices :: East Lancashire Hospitals NHS Trust

  https://elht.nhs.uk/services/endoscopy/investigations/oesophageal-varices

  The main benefit is that the procedure is safe and the bands are easy to apply. […] It can be used to either prevent varices from rupturing or as treatment for already bleeding varices. […] More than one of these procedures is usually required to completely destroy the varices. The procedure will be repeated every 2 to 4 weeks, until there are no varices left for banding. […] Endoscopic treatment of oesophageal varices is safe but there are some risks, which are rare (less than 1 in 50 cases).

• #42 Understanding Esophageal Varices Ligation for Esophageal varices: A Comprehensive Patient Guide | Symptoms, Causes, Diagnosis and Treatment Options Explained – The Kingsley Clinic

  https://thekingsleyclinic.com/uncategorized/understanding-esophageal-varices-ligation-for-esophageal-varices-a-comprehensive-patient-guide-symptoms-causes-diagnosis-and-treatment-options-explained/

  Patients with certain risk factors such as advanced cirrhosis and large varices may benefit from prophylactic EVL to prevent a first bleeding episode. […] Esophageal Varices Ligation is a well-established, minimally invasive procedure with a high success rate in managing esophageal varices. It offers a non-surgical option to control bleeding, which can significantly improve a patient’s quality of life and overall health outcome. […] EVL is a highly effective treatment for esophageal varices. Studies show it can successfully control active bleeding in about 90% of patients, and it reduces the risk of future bleeding in about 70% of patients. […] While EVL is an effective tool in the management of esophageal varices, it’s important to remember that it is a part of a comprehensive treatment plan.

• #43 Understanding Esophageal Varices Ligation for Esophageal varices: A Comprehensive Patient Guide | Symptoms, Causes, Diagnosis and Treatment Options Explained – The Kingsley Clinic

  https://thekingsleyclinic.com/uncategorized/understanding-esophageal-varices-ligation-for-esophageal-varices-a-comprehensive-patient-guide-symptoms-causes-diagnosis-and-treatment-options-explained/

  Esophageal Varices Ligation (EVL) is generally a safe procedure, but like any medical intervention, it carries certain risks. […] Overall, the mortality rate associated directly with the procedure is less than 1%, making it a relatively safe procedure. […] While EVL is a common and effective treatment for esophageal varices, there are alternatives. […] Research and development are always ongoing in the field of gastroenterology. One of the promising experimental procedures for esophageal varices is the use of fully covered self-expandable metallic stents. These stents aim to control variceal bleeding when traditional methods are not effective or feasible.

• #44 Oesophageal varices – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-us/815?locale=fr

  Oesophageal varices are a direct consequence of portal hypertension as a progressive complication of cirrhosis. […] Non-selective beta-blockers and/or endoscopic ligation can prevent the development of variceal bleeding. […] Acute haemorrhage can be managed with resuscitation, terlipressin or a somatostatin analogue (e.g., octreotide), and endoscopic band ligation. Additional management includes prophylactic antibiotics and in some patients trans-jugular intrahepatic shunt therapy. […] Diagnosis and surveillance by endoscopy is an important aspect of management.

• #45 Diagnosis and Management of Esophagogastric Varices

  https://www.mdpi.com/2075-4418/13/6/1031

  The endoscopic management of EV can be divided into three scenarios: the role in preventing first variceal bleeding (primary prophylaxis), the treatment of AVB, and prophylaxis for re-bleeding after the first hemorrhaging event (secondary prophylaxis). […] Primary prophylaxis is especially important in compensated patients with CSPH and/or EV or GV because they are at high risk of decompensating. […] Both NSBB therapy and endoscopic band ligation (EBL) have been shown to significantly reduce the risk of the first episode of variceal bleeding. […] Baveno VII guidelines recently recommended endoscopic band ligation to prevent first variceal bleeding in compensated patients with high-risk varices who have contraindications or intolerance to NSBBs. […] Esophageal varices generally have an asymptomatic course until they leak or burst.

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