Materiały źródłowe

• #1 KoreaMed Synapse

  https://synapse.koreamed.org/articles/1006708

  Esophageal varices (EV) are present in 40% and 60% of Child-Pugh A and C patients, respectively when cirrhosis is diagnosed. […] Treatment to prevent first EV bleeding or rebleeding is mandatory. In small EV with high risk of bleeding, nonselective beta-blockers should be used for the prevention of first variceal bleeding. For medium to large EV, nonselective beta-blockers or endoscopic variceal ligation (EVL) may be recommended to high risk varices. […] For the prevention of rebleeding, a combination of nonselective beta-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.

• #2 Prevention of Esophageal Variceal Bleeding

  https://www.kjg.or.kr/journal/view.html?pn=search&uid=4265

  Esophageal varices(EV) are present in 40% and 60% of Child-Pugh A and C patients, respectively when cirrhosis is diagnosed. […] Treatment to prevent first EV bleeding or rebleeding is mandatory. In small EV with high risk of bleeding, nonselective beta-blockers should be used for the prevention of first variceal bleeding. […] For medium to large EV, nonselective beta-blockers or endoscopic variceal ligation (EVL) may be recommended to high risk varices. […] But, nonselective beta-blockers are the first treatment option to non-high risk varices and EVL is an alternative when nonselective beta-blockers are contraindicated or not tolerated. […] For the prevention of rebleeding, a combination of nonselective beta-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.

• #3 Primary prophylaxis of variceal bleeding in patients with cirrhosis: A comparison of different strategies

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8716979/

  Patients with cirrhosis and esophageal varices bleed at a yearly rate of 5%-15%, and, when variceal hemorrhage develops, mortality reaches 20%. […] In order to avoid variceal bleeding and death, individuals with cirrhosis at high risk of bleeding must undergo primary prophylaxis, for which currently recommended strategies are the use of traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a NSBB with additional alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL). […] The Baveno VI consensus recommends that patients with cirrhosis and medium-large varices should be submitted to prophylaxis with either traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a beta-blocker with an alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL).

• #4 Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis

  https://www.wjgnet.com/1948-5182/full/v13/i7/731.htm

  Portal hypertension (PH), a common complication of liver cirrhosis, results in development of esophageal varices. When esophageal varices rupture, they cause significant upper gastrointestinal bleeding with mortality rates up to 20% despite state-of-the-art treatment. Thus, prophylactic measures are of utmost importance to improve outcomes of patients with PH. Several high-quality studies have demonstrated that non-selective beta blockers (NSBBs) or endoscopic band ligation (EBL) are effective for primary prophylaxis of variceal bleeding. […] In secondary prophylaxis, a combination of NSBB + EBL should be routinely used. Once esophageal varices develop and variceal bleeding occurs, standardized treatment algorithms should be followed to minimize bleeding-associated mortality. Special attention should be paid to avoidance of overtransfusion, early initiation of vasoconstrictive therapy, prophylactic antibiotics and early endoscopic therapy.

• #5 Esophageal Varices: Primary and Secondary Prophylaxis | Abdominal Key

  https://abdominalkey.com/esophageal-varices-primary-and-secondary-prophylaxis/

  Screening EGD should be performed at different intervals according cirrhosis status (compensated vs. decompensated) and on previous size of varices (small vs. large) (see Table 9.1 for recommended screening intervals [1012]). […] The management of esophageal varices includes prevention of varices formation (preprimary prophylaxis), prevention of the initial hemorrhage (primary prophylaxis), control of acute variceal bleeding (see Chap. 10), and prevention of rebleeding (secondary prophylaxis). […] The goal of preprimary prophylaxis is to prevent the development of varices in patients with portal hypertension. […] The use of NSBBs for primary prophylaxis reduces the incidence of variceal hemorrhage. […] The combination of NSBBs with EVL is the standard of care for secondary prophylaxis.

• #6 Primary prevention of bleeding from esophageal varices in patients with cirrhosis – UpToDate

  https://www.uptodate.com/contents/primary-prevention-of-bleeding-from-esophageal-varices-in-patients-with-cirrhosis

  Primary prevention of bleeding from esophageal varices in patients with cirrhosis […] Thus, strategies to prevent the first episode of variceal bleeding are important for patients with cirrhosis and portal hypertension. […] The rationale for screening for esophageal varices is to identify patients at risk for bleeding from esophageal varices so as to prevent bleeding and improve survival in such patients. […] Screening for esophageal varices is indicated for patients with CSPH and includes the following groups: All patients with decompensated cirrhosis […] Patients with compensated cirrhosis and either liver stiffness measurement (LSM) >20 kPa or platelet count <150,000/microL. [...] General measures to prevent the first episode of variceal bleeding include: Manage underlying liver disease – Patients with cirrhosis are evaluated for interventions that will slow or reverse the progression of liver disease

• #7 Primary prevention of bleeding from esophageal varices in patients with cirrhosis – UpToDate

  https://www.uptodate.com/contents/primary-prevention-of-bleeding-from-esophageal-varices-in-patients-with-cirrhosis

  Primary prevention of bleeding from esophageal varices in patients with cirrhosis […] Thus, strategies to prevent the first episode of variceal bleeding are important for patients with cirrhosis and portal hypertension. […] The rationale for screening for esophageal varices is to identify patients at risk for bleeding from esophageal varices so as to prevent bleeding and improve survival in such patients. […] Screening for esophageal varices is indicated for patients with CSPH and includes the following groups: All patients with decompensated cirrhosis […] Patients with compensated cirrhosis and either liver stiffness measurement (LSM) >20 kPa or platelet count <150,000/microL. [...] General measures to prevent the first episode of variceal bleeding include: Manage underlying liver disease – Patients with cirrhosis are evaluated for interventions that will slow or reverse the progression of liver disease

• #8 Management of Patients with Incidental Esophageal Varices | AAFP

  https://www.aafp.org/pubs/afp/issues/2005/0301/p980a.html

  In patients with cirrhosis, the presence of esophageal varices on upper endoscopy may be an indication of the development of portal hypertension. […] Because variceal bleeding is a major cause of mortality in cirrhotic patients, prevention of such bleeding is a high priority of management. […] Screening for esophageal varices may be worthwhile because useful prophylactic treatments exist. […] Universal prophylaxis in all cirrhotic patients with beta blockers has been recommended as the most cost-effective therapy. […] The author concludes that patients with medium or large esophageal varices noted on screening endoscopy should be treated prophylactically with beta blockers. […] Prophylactic therapies include drug treatment, surgical or radiologic shunt treatments, and endoscopic variceal obliteration techniques. […] Primary prophylaxis appears to have good results.

• #9 Primary prevention of bleeding from esophageal varices in patients with cirrhosis – UpToDate

  https://www.uptodate.com/contents/primary-prevention-of-bleeding-from-esophageal-varices-in-patients-with-cirrhosis

  Primary prevention of bleeding from esophageal varices in patients with cirrhosis […] Thus, strategies to prevent the first episode of variceal bleeding are important for patients with cirrhosis and portal hypertension. […] The rationale for screening for esophageal varices is to identify patients at risk for bleeding from esophageal varices so as to prevent bleeding and improve survival in such patients. […] Screening for esophageal varices is indicated for patients with CSPH and includes the following groups: All patients with decompensated cirrhosis […] Patients with compensated cirrhosis and either liver stiffness measurement (LSM) >20 kPa or platelet count <150,000/microL. [...] General measures to prevent the first episode of variceal bleeding include: Manage underlying liver disease – Patients with cirrhosis are evaluated for interventions that will slow or reverse the progression of liver disease

• #10 Primary prevention of bleeding from esophageal varices in patients with cirrhosis – UpToDate

  https://www.uptodate.com/contents/primary-prevention-of-bleeding-from-esophageal-varices-in-patients-with-cirrhosis

  Primary prevention of bleeding from esophageal varices in patients with cirrhosis […] Thus, strategies to prevent the first episode of variceal bleeding are important for patients with cirrhosis and portal hypertension. […] The rationale for screening for esophageal varices is to identify patients at risk for bleeding from esophageal varices so as to prevent bleeding and improve survival in such patients. […] Screening for esophageal varices is indicated for patients with CSPH and includes the following groups: All patients with decompensated cirrhosis […] Patients with compensated cirrhosis and either liver stiffness measurement (LSM) >20 kPa or platelet count <150,000/microL. [...] General measures to prevent the first episode of variceal bleeding include: Manage underlying liver disease – Patients with cirrhosis are evaluated for interventions that will slow or reverse the progression of liver disease

• #11 Varices – Cirrhosis Care

  https://cirrhosiscare.ca/treatment-provider/varices-hcp/

  Patients with compensated cirrhosis and fibroscan based liver stiffness 20 kPa AND platelet count 150,000 OR those who are already on carvedilol or a non-selective beta blocker, do not need endoscopy to screen for varices […] All patients with a suspected variceal bleed should receive antibiotic prophylaxis (ceftriaxone, 1 g i.v. daily for 7 days or until discharge whichever occurs sooner) […] After a variceal bleed, prevention of re-bleeding includes a combination of variceal ligation and non-selective beta-blockers (in the absence of contraindications) […] Choosing between Beta-blockers versus Endoscopic variceal ligation for primary prophylaxis against variceal bleeding […] Intolerance to one NSBB may sometimes be overcome by switching to another NSBB.

• #12 Core Concepts – Screening for Varices and Prevention of Bleeding – Management of Cirrhosis-Related Complications – Hepatitis C Online

  https://www.hepatitisc.uw.edu/go/management-cirrhosis-related-complications/varices-screening-prevention-bleeding/core-concept/all

  Persons with compensated cirrhosis will typically develop varices at a rate of 7 to 8% per year. […] It is important to decrease the risk of variceal hemorrhage, which occurs at a rate of approximately 10 to 15% per year; the highest rates of hemorrhage occur in persons with large varices, decompensated cirrhosis, or red wale markings on the varices. […] The approach to primary prophylaxis depends on the findings from the screening EGD. If no varices are observed at the time of EGD, then primary prophylaxis is not indicated. […] For patients not receiving prophylaxis with a nonselective beta-blocker, EGD should be repeated (1) annually if there is ongoing liver injury or hepatic decompensation, (2) every 2 years for those individuals with liver injury that is quiescent, or (3) at the time of hepatic decompensation.

• #13 Core Concepts – Screening for Varices and Prevention of Bleeding – Management of Cirrhosis-Related Complications – Hepatitis C Online

  https://www.hepatitisc.uw.edu/go/management-cirrhosis-related-complications/varices-screening-prevention-bleeding/core-concept/all

  Persons with compensated cirrhosis will typically develop varices at a rate of 7 to 8% per year. […] It is important to decrease the risk of variceal hemorrhage, which occurs at a rate of approximately 10 to 15% per year; the highest rates of hemorrhage occur in persons with large varices, decompensated cirrhosis, or red wale markings on the varices. […] The approach to primary prophylaxis depends on the findings from the screening EGD. If no varices are observed at the time of EGD, then primary prophylaxis is not indicated. […] For patients not receiving prophylaxis with a nonselective beta-blocker, EGD should be repeated (1) annually if there is ongoing liver injury or hepatic decompensation, (2) every 2 years for those individuals with liver injury that is quiescent, or (3) at the time of hepatic decompensation.

• #14

  https://journals.lww.com/ajg/fulltext/2007/09000/prevention_and_management_of_gastroesophageal.38.aspx

  Screening esophagogastroduodenoscopy (EGD) for the diagnosis of esophageal and gastric varices is recommended when the diagnosis of cirrhosis is made (Class IIa, Level C). […] On EGD, esophageal varices should be graded as small or large (5 mm) with the latter classification encompassing medium-sized varices when 3 grades are used (small, medium, large). The presence or absence of red signs (red wale marks or red spots) on varices should be noted (Class IIa, Level C). […] In patients with cirrhosis who do not have varices, nonselective -blockers cannot be recommended to prevent their development (Class III, Level B). […] In patients who have compensated cirrhosis and no varices on the initial EGD, it should be repeated in 3 years (Class I, Level C). If there is evidence of hepatic decompensation, EGD should be done at that time and repeated annually (Class I, Level C).

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

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

  In patients with small varices ( 5 mm or minimally elevated veins above the esophageal mucosal surface), surveillance is preferred over other therapeutic modalities. In patients with medium to large varices (more than 5 mm or esophageal vein raised beyond mucosal surface occupying the esophageal lumen) without a high risk of bleeding, a nonselective beta-blocker is the preferred first line treatment, although esophageal varices ligation (EVL) may be considered. […] Patients at high risk for bleeding have large varices, red wale markings on the varices, and severe liver failure; either nonselective beta-blockers or EVL can be used as the primary prophylaxis. […] In patients with medium or large varices with bleeding stigmata regardless of the size, and patients with decompensated cirrhosis, nonselective beta-blockers are preferred as they have been shown to decrease the number of bleeding episodes.

• #16 Core Concepts – Screening for Varices and Prevention of Bleeding – Management of Cirrhosis-Related Complications – Hepatitis C Online

  https://www.hepatitisc.uw.edu/go/management-cirrhosis-related-complications/varices-screening-prevention-bleeding/core-concept/all

  The medium/large category of varices consists of varices greater than 5 mm in size that typically have a more prominent and tortuous appearance within the esophageal lumen than seen with small varices. […] For individuals with medium/large varices, use of a nonselective beta-blocker or treatment with endoscopic variceal ligation has been shown to significantly reduce the risk of variceal bleeding. […] The 2023 AASLD guidance recommends primary prophylaxis with either (1) a nonselective beta-blocker (including carvedilol) or (2) endoscopic variceal ligation, with preference given to nonselective beta-blockers due to benefits beyond preventing variceal bleeding. […] Nonselective beta-blockers can reduce the risk of rebleeding by about 40% and improve overall survival by 20%. […] Endoscopic variceal ligation therapy is superior to sclerotherapy for secondary prophylaxis and decreases the rebleeding rate to around 32%. […] Combination therapy with a nonselective beta-blocker and endoscopic variceal ligation therapy is considered the standard first-line therapy for secondary prophylaxis of variceal bleeding.

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

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

  In patients with small varices ( 5 mm or minimally elevated veins above the esophageal mucosal surface), surveillance is preferred over other therapeutic modalities. In patients with medium to large varices (more than 5 mm or esophageal vein raised beyond mucosal surface occupying the esophageal lumen) without a high risk of bleeding, a nonselective beta-blocker is the preferred first line treatment, although esophageal varices ligation (EVL) may be considered. […] Patients at high risk for bleeding have large varices, red wale markings on the varices, and severe liver failure; either nonselective beta-blockers or EVL can be used as the primary prophylaxis. […] In patients with medium or large varices with bleeding stigmata regardless of the size, and patients with decompensated cirrhosis, nonselective beta-blockers are preferred as they have been shown to decrease the number of bleeding episodes.

• #18

  https://journals.lww.com/ajg/fulltext/2007/09000/prevention_and_management_of_gastroesophageal.38.aspx

  Screening esophagogastroduodenoscopy (EGD) for the diagnosis of esophageal and gastric varices is recommended when the diagnosis of cirrhosis is made (Class IIa, Level C). […] On EGD, esophageal varices should be graded as small or large (5 mm) with the latter classification encompassing medium-sized varices when 3 grades are used (small, medium, large). The presence or absence of red signs (red wale marks or red spots) on varices should be noted (Class IIa, Level C). […] In patients with cirrhosis who do not have varices, nonselective -blockers cannot be recommended to prevent their development (Class III, Level B). […] In patients who have compensated cirrhosis and no varices on the initial EGD, it should be repeated in 3 years (Class I, Level C). If there is evidence of hepatic decompensation, EGD should be done at that time and repeated annually (Class I, Level C).

• #19 Primary prophylaxis of variceal bleeding in patients with cirrhosis: A comparison of different strategies

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8716979/

  Patients with cirrhosis and esophageal varices bleed at a yearly rate of 5%-15%, and, when variceal hemorrhage develops, mortality reaches 20%. […] In order to avoid variceal bleeding and death, individuals with cirrhosis at high risk of bleeding must undergo primary prophylaxis, for which currently recommended strategies are the use of traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a NSBB with additional alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL). […] The Baveno VI consensus recommends that patients with cirrhosis and medium-large varices should be submitted to prophylaxis with either traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a beta-blocker with an alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL).

• #20 Primary prevention of bleeding from esophageal varices in patients with cirrhosis – UpToDate

  https://www.uptodate.com/contents/primary-prevention-of-bleeding-from-esophageal-varices-in-patients-with-cirrhosis

  Referral for liver transplantation evaluation – We refer patients with decompensated cirrhosis for liver transplantation evaluation because transplantation is effective long-term therapy for preventing variceal bleeding and other complications of portal hypertension. […] For patients with cirrhosis and esophageal varices at high risk for bleeding, we recommend prophylaxis with a nonselective beta blocker rather than no pharmacologic intervention because evidence suggests that beta blockers resulted in lower risk of mortality. […] For patients who cannot take beta blockers – For patients who have a contraindication to or cannot tolerate beta blockers, we suggest endoscopic variceal ligation (EVL) rather than no intervention because evidence suggests that EVL resulted in lower risk of variceal bleeding and mortality.

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

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

  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. [...] 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.” [...] Consistent with AASLD guidelines, 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.

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

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

  If contraindications, patient intolerance, or patient noncompliance exist regarding the use of nonselective beta-blockers, EVL should be considered. […] Noncardioselective beta-blockers are used most commonly for primary prophylaxis of variceal bleeding, and they include propranolol, nadolol and carvedilol. These nonselective beta-blockers reduce portal and collateral blood flow as well as have smaller effects on the increase in portal resistance and decrease in portal pressure. […] Nonselective beta-blockers have been shown to decrease the risk of initial bleeding by approximately 45-50%, and they reduce bleeding in more than 50% of patients with medium or large varices. […] Propranolol is administered at a dose of 20 mg every 12 hours, which is increased or decreased every 3-4 days until a 25% reduction in the resting heart rate occurs or the heart rate is down to 55 beats per minute (bpm).

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

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

  If contraindications, patient intolerance, or patient noncompliance exist regarding the use of nonselective beta-blockers, EVL should be considered. […] Noncardioselective beta-blockers are used most commonly for primary prophylaxis of variceal bleeding, and they include propranolol, nadolol and carvedilol. These nonselective beta-blockers reduce portal and collateral blood flow as well as have smaller effects on the increase in portal resistance and decrease in portal pressure. […] Nonselective beta-blockers have been shown to decrease the risk of initial bleeding by approximately 45-50%, and they reduce bleeding in more than 50% of patients with medium or large varices. […] Propranolol is administered at a dose of 20 mg every 12 hours, which is increased or decreased every 3-4 days until a 25% reduction in the resting heart rate occurs or the heart rate is down to 55 beats per minute (bpm).

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

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

  If contraindications, patient intolerance, or patient noncompliance exist regarding the use of nonselective beta-blockers, EVL should be considered. […] Noncardioselective beta-blockers are used most commonly for primary prophylaxis of variceal bleeding, and they include propranolol, nadolol and carvedilol. These nonselective beta-blockers reduce portal and collateral blood flow as well as have smaller effects on the increase in portal resistance and decrease in portal pressure. […] Nonselective beta-blockers have been shown to decrease the risk of initial bleeding by approximately 45-50%, and they reduce bleeding in more than 50% of patients with medium or large varices. […] Propranolol is administered at a dose of 20 mg every 12 hours, which is increased or decreased every 3-4 days until a 25% reduction in the resting heart rate occurs or the heart rate is down to 55 beats per minute (bpm).

• #25 Primary prophylaxis of variceal bleeding in patients with cirrhosis: A comparison of different strategies

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8716979/

  Patients with cirrhosis and esophageal varices bleed at a yearly rate of 5%-15%, and, when variceal hemorrhage develops, mortality reaches 20%. […] In order to avoid variceal bleeding and death, individuals with cirrhosis at high risk of bleeding must undergo primary prophylaxis, for which currently recommended strategies are the use of traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a NSBB with additional alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL). […] The Baveno VI consensus recommends that patients with cirrhosis and medium-large varices should be submitted to prophylaxis with either traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a beta-blocker with an alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL).

• #26 Esophageal Varices Prophylaxis – Selecting a Beta-Blocker – Med Ed 101

  https://www.meded101.com/esophageal-varices-prophylaxis-selecting-a-beta-blocker/

  Esophageal varices are large veins in the lower part of the esophagus that can be caused by portal hypertension which is a complication of liver disease. The first line treatment for esophageal varices prophylaxis is the non-selective beta-blockers (NSBB). A study showed that NSBB reduced portal pressure and decreased the risk of the first bleed from 25% down to 15% when used for primary esophageal varices prophylaxis. Another study showed that when using NSBBs for two years with the indication of primary prophylaxis of variceal bleeding, relative risk of the first variceal bleeding event was reduced by 50% and decreased mortality. […] Carvedilol when used at the dose of 6.25 mg once daily was seen to drop hepatic vein pressure gradient more effectively than propranolol or nadolol. This makes it a viable option in esophageal varicies prophylaxis. Preventing initial bleeds in the setting of esophageal varices is important and can be aided with NSBBs. Some may argue that carvedilol is a superior option due to its impact on decreasing the hepatic vein pressure gradient and causing intrahepatic vasodilation, but propranolol and nadolol are effective medications as well with a longer track record of use.

• #27 Primary prophylaxis of variceal bleeding in patients with cirrhosis: A comparison of different strategies

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8716979/

  Patients with cirrhosis and esophageal varices bleed at a yearly rate of 5%-15%, and, when variceal hemorrhage develops, mortality reaches 20%. […] In order to avoid variceal bleeding and death, individuals with cirrhosis at high risk of bleeding must undergo primary prophylaxis, for which currently recommended strategies are the use of traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a NSBB with additional alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL). […] The Baveno VI consensus recommends that patients with cirrhosis and medium-large varices should be submitted to prophylaxis with either traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a beta-blocker with an alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL).

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

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

  Beta-blockers are best continued for the patient’s lifetime, because the risk of variceal hemorrhage returns to that of the untreated population once beta-blockers are withdrawn. […] Prophylactic EVL currently cannot be recommended as a routine measure for primary prevention as it offers no advantage over the use of beta-blockers alone for preventing esophageal variceal bleeding. […] However, this procedure may be an option in secondary prophylaxis for patients with grade 3 varices who have contraindications to or cannot tolerate beta-blockers.

• #29 Primary prevention of bleeding from esophageal varices in patients with cirrhosis – UpToDate

  https://www.uptodate.com/contents/primary-prevention-of-bleeding-from-esophageal-varices-in-patients-with-cirrhosis

  Referral for liver transplantation evaluation – We refer patients with decompensated cirrhosis for liver transplantation evaluation because transplantation is effective long-term therapy for preventing variceal bleeding and other complications of portal hypertension. […] For patients with cirrhosis and esophageal varices at high risk for bleeding, we recommend prophylaxis with a nonselective beta blocker rather than no pharmacologic intervention because evidence suggests that beta blockers resulted in lower risk of mortality. […] For patients who cannot take beta blockers – For patients who have a contraindication to or cannot tolerate beta blockers, we suggest endoscopic variceal ligation (EVL) rather than no intervention because evidence suggests that EVL resulted in lower risk of variceal bleeding and mortality.

• #30 Primary Prophylaxis of Variceal Bleeding – Gastroenterology & Hepatology

  https://www.gastroenterologyandhepatology.net/archives/august-2011/primary-prophylaxis-of-variceal-bleeding/

  Endoscopic variceal ligation (EVL) is the standard-of-care therapy for treating and preventing recurrence of acute esophageal variceal hemorrhage. […] EVL can also be used to prevent a patient’s first variceal bleeding episode, particularly in patients who have medium or large varices showing high-risk signs for bleeding or patients who are intolerant to β-blocker therapy. […] The patient treated by Nikoloff and associates had grade 3 varices with red wales and cherry red spots (ie, large varices with high-risk signs). Therefore, the need for primary prophylaxis with EVL was clear due to the patient’s intolerance of NSBB therapy because of her asthma. […] EVL is considered to be a relatively safe technique. […] The first choice for primary prophylaxis of esophageal variceal bleeding is an NSBB, such as propranolol, as these agents are cheaper than EVL and easy to administer.

• #31 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.

• #32 UK guidelines on the management of variceal haemorrhage in cirrhotic patients | Gut

  https://gut.bmj.com/content/64/11/1680

  We recommend non-cardioselective blockers (NSBB) or variceal band ligation (VBL). We suggest pharmacological treatment with propranolol as first line. VBL is offered if there are contraindications to NSBB. The choice of VBL or NSBB should also take into account patient choice (level 1a, grade A). […] In cases of contraindications or intolerance to NSBB, we recommend variceal band ligation (level 1a, grade A). […] We recommend all patients with cirrhosis should be endoscoped at the time of diagnosis (level 1a, grade A). There is no indication to repeat endoscopy in patients receiving NSBB. […] If grade I varices and red signs or grade 23 varices are diagnosed, we recommend that patients have primary prophylaxis irrespective of the severity of the liver disease (level 1a, grade A). […] Proton pump inhibitors are not recommended unless otherwise required for peptic ulcer disease (level 1b, grade B).

• #33 UK guidelines on the management of variceal haemorrhage in cirrhotic patients | Gut

  https://gut.bmj.com/content/64/11/1680

  We recommend non-cardioselective blockers (NSBB) or variceal band ligation (VBL). We suggest pharmacological treatment with propranolol as first line. VBL is offered if there are contraindications to NSBB. The choice of VBL or NSBB should also take into account patient choice (level 1a, grade A). […] In cases of contraindications or intolerance to NSBB, we recommend variceal band ligation (level 1a, grade A). […] We recommend all patients with cirrhosis should be endoscoped at the time of diagnosis (level 1a, grade A). There is no indication to repeat endoscopy in patients receiving NSBB. […] If grade I varices and red signs or grade 23 varices are diagnosed, we recommend that patients have primary prophylaxis irrespective of the severity of the liver disease (level 1a, grade A). […] Proton pump inhibitors are not recommended unless otherwise required for peptic ulcer disease (level 1b, grade B).

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

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

  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. [...] 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.” [...] Consistent with AASLD guidelines, 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.

• #35

  https://journals.lww.com/ajg/fulltext/2007/09000/prevention_and_management_of_gastroesophageal.38.aspx

  In patients with cirrhosis and small varices that have not bled but have criteria for increased risk of hemorrhage (Child B/C or presence of red wale marks on varices), nonselective -blockers should be used for the prevention of first variceal hemorrhage (Class IIa, Level C). […] In patients with medium/large varices that have not bled but have a high risk of hemorrhage (Child B/C or variceal red wale markings on endoscopy), nonselective -blockers (propranolol or nadolol) or EVL may be recommended for the prevention of first variceal hemorrhage (Class I, Level A). […] Nitrates (either alone or in combination with -blockers), shunt therapy, or sclerotherapy should not be used in the primary prophylaxis of variceal hemorrhage (Class III, Level A). […] Patients with cirrhosis who survive an episode of active variceal hemorrhage should receive therapy to prevent recurrence of variceal hemorrhage (secondary prophylaxis) (Class I, Level A). […] Combination of nonselective -blockers plus EVL is the best option for secondary prophylaxis of variceal hemorrhage (Class I, Level A).

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

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

  In patients with small varices ( 5 mm or minimally elevated veins above the esophageal mucosal surface), surveillance is preferred over other therapeutic modalities. In patients with medium to large varices (more than 5 mm or esophageal vein raised beyond mucosal surface occupying the esophageal lumen) without a high risk of bleeding, a nonselective beta-blocker is the preferred first line treatment, although esophageal varices ligation (EVL) may be considered. […] Patients at high risk for bleeding have large varices, red wale markings on the varices, and severe liver failure; either nonselective beta-blockers or EVL can be used as the primary prophylaxis. […] In patients with medium or large varices with bleeding stigmata regardless of the size, and patients with decompensated cirrhosis, nonselective beta-blockers are preferred as they have been shown to decrease the number of bleeding episodes.

• #37 Esophageal varices – Knowledge @ AMBOSS

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

  Esophageal varices are dilated collateral veins resulting from increased blood flow due to portal hypertension, often caused by cirrhosis. […] Management of nonbleeding esophageal varices focuses on the prevention of bleeding and involves regular surveillance and, in some cases, primary prophylaxis of bleeding using nonselective beta blockers or eradication of varices using endoscopic variceal ligation (EVL). […] Prevention of first episode of variceal bleeding: Medium or large esophageal varices: Provide either pharmacological prophylaxis or EVL. […] Small esophageal varices with high-risk features for esophageal variceal hemorrhage: Provide pharmacological prophylaxis as indicated. […] Pharmacological prophylaxis (off-label): Nonselective beta blockers (recommended); Propranolol OR nadolol; Carvedilol (alternative).

• #38 Management of gastroesophageal varices in cirrhotic patients: current status and future directions | Annals of Hepatology

  https://www.elsevier.es/en-revista-annals-hepatology-16-articulo-management-gastroesophageal-varices-in-cirrhotic-S1665268119306507

  Bleeding from gastroesophageal varices (GEV) is a serious event in cirrhotic patients and can cause death. […] Establishing methods for prophylaxis and emergent treatments for GEV bleeding is imperative to improve the outcomes of cirrhotic patients. […] In medical practice, clinicians should determine the optimal treatment for GEV based on treatment situations and principles. Two possible treatment situations are primary prophylaxis for bleeding and emergent treatment for bleeding followed by secondary prophylaxis. […] Primary prophylaxis for bleeding from EV. […] Non-selective -blockers are recommended for patients with small varices that have an increased risk of bleeding, as with Child-Pugh class B/C cirrhosis or varices with red wale markings. […] EVL is the first choice of treatment for patients with medium to large varices and a high risk of bleeding.

• #39 UK guidelines on the management of variceal haemorrhage in cirrhotic patients | Gut

  https://gut.bmj.com/content/64/11/1680

  Isosorbide mononitrate monotherapy is not recommended as primary prophylaxis (level 1b, grade A). There is insufficient evidence to recommend isosorbide mononitrate in combination with NSBB (level 1b, grade A). […] Shunt surgery or transjugular intrahepatic portosystemic stent shunt (TIPSS) is not recommended as primary prophylaxis (level 1a, grade A). […] Sclerotherapy is not recommended as primary prophylaxis (level 1a, grade A). […] Areas requiring further study: Role of NSBB in patients without varices, with focus on carvedilol. […] Role of NSBB in patients with small varices, with focus on carvedilol. […] Comparison of carvedilol versus propranolol in primary prophylaxis. […] Identification of, and trials assessing, new drugs for primary prophylaxis such as statins. […] Quality indicator: Percentage of patients at diagnosis of cirrhosis who have had an endoscopy to screen for varices (level 1a, grade A). […] Percentage of patients receiving primary prophylaxis among those newly diagnosed with grade I varices and red signs or grade 23 varices.

• #40 UK guidelines on the management of variceal haemorrhage in cirrhotic patients | Gut

  https://gut.bmj.com/content/64/11/1680

  Isosorbide mononitrate monotherapy is not recommended as primary prophylaxis (level 1b, grade A). There is insufficient evidence to recommend isosorbide mononitrate in combination with NSBB (level 1b, grade A). […] Shunt surgery or transjugular intrahepatic portosystemic stent shunt (TIPSS) is not recommended as primary prophylaxis (level 1a, grade A). […] Sclerotherapy is not recommended as primary prophylaxis (level 1a, grade A). […] Areas requiring further study: Role of NSBB in patients without varices, with focus on carvedilol. […] Role of NSBB in patients with small varices, with focus on carvedilol. […] Comparison of carvedilol versus propranolol in primary prophylaxis. […] Identification of, and trials assessing, new drugs for primary prophylaxis such as statins. […] Quality indicator: Percentage of patients at diagnosis of cirrhosis who have had an endoscopy to screen for varices (level 1a, grade A). […] Percentage of patients receiving primary prophylaxis among those newly diagnosed with grade I varices and red signs or grade 23 varices.

• #41

  https://journals.lww.com/ajg/fulltext/2007/09000/prevention_and_management_of_gastroesophageal.38.aspx

  In patients with cirrhosis and small varices that have not bled but have criteria for increased risk of hemorrhage (Child B/C or presence of red wale marks on varices), nonselective -blockers should be used for the prevention of first variceal hemorrhage (Class IIa, Level C). […] In patients with medium/large varices that have not bled but have a high risk of hemorrhage (Child B/C or variceal red wale markings on endoscopy), nonselective -blockers (propranolol or nadolol) or EVL may be recommended for the prevention of first variceal hemorrhage (Class I, Level A). […] Nitrates (either alone or in combination with -blockers), shunt therapy, or sclerotherapy should not be used in the primary prophylaxis of variceal hemorrhage (Class III, Level A). […] Patients with cirrhosis who survive an episode of active variceal hemorrhage should receive therapy to prevent recurrence of variceal hemorrhage (secondary prophylaxis) (Class I, Level A). […] Combination of nonselective -blockers plus EVL is the best option for secondary prophylaxis of variceal hemorrhage (Class I, Level A).

• #42 Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis

  https://www.wjgnet.com/1948-5182/full/v13/i7/731.htm

  The pre-emptive use of transjugular intrahepatic portosystemic shunt within 72 h after variceal bleeding prevents rebleeding and mortality in Child C10-C13 patients. […] In primary prophylaxis, NSBB or EBL are equal in outcomes and are therefore both recommended as monotherapies to prevent a first variceal bleeding event. However, carvedilol due to its higher potency to lower portal pressure resulting in higher proportions of HVPG responders may be the treatment of choice for primary prophylaxis in compensated cirrhosis. […] In secondary prophylaxis to avoid rebleeding, monotherapy of NSBB or EBL are associated with higher mortality in secondary prophylaxis than combined NSBB + EBL therapy, which is in contrast to studies in the primary prophylaxis setting. Thus, current guidelines recommend the combination of EBL + NSBBs.

• #43 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 who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis). Strong recommendation, moderate 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.

• #44 Esophageal varices – Knowledge @ AMBOSS

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

  Combination therapy with EVL and pharmacotherapy is not recommended for primary prophylaxis of esophageal variceal hemorrhage. […] Prevention of recurrent variceal bleeding: Patients without TIPS: combination therapy with nonselective beta blockers and EVL. […] The combination of EVL and nonselective beta blockers for the prevention of recurrent esophageal variceal hemorrhage is more effective than either therapy alone.

• #45 Core Concepts – Screening for Varices and Prevention of Bleeding – Management of Cirrhosis-Related Complications – Hepatitis C Online

  https://www.hepatitisc.uw.edu/go/management-cirrhosis-related-complications/varices-screening-prevention-bleeding/core-concept/all

  The medium/large category of varices consists of varices greater than 5 mm in size that typically have a more prominent and tortuous appearance within the esophageal lumen than seen with small varices. […] For individuals with medium/large varices, use of a nonselective beta-blocker or treatment with endoscopic variceal ligation has been shown to significantly reduce the risk of variceal bleeding. […] The 2023 AASLD guidance recommends primary prophylaxis with either (1) a nonselective beta-blocker (including carvedilol) or (2) endoscopic variceal ligation, with preference given to nonselective beta-blockers due to benefits beyond preventing variceal bleeding. […] Nonselective beta-blockers can reduce the risk of rebleeding by about 40% and improve overall survival by 20%. […] Endoscopic variceal ligation therapy is superior to sclerotherapy for secondary prophylaxis and decreases the rebleeding rate to around 32%. […] Combination therapy with a nonselective beta-blocker and endoscopic variceal ligation therapy is considered the standard first-line therapy for secondary prophylaxis of variceal bleeding.

• #46 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 who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis). Strong recommendation, moderate 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.

• #47 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 who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis). Strong recommendation, moderate 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.

• #48 Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis

  https://www.wjgnet.com/1948-5182/full/v13/i7/731.htm

  The pre-emptive use of transjugular intrahepatic portosystemic shunt within 72 h after variceal bleeding prevents rebleeding and mortality in Child C10-C13 patients. […] In primary prophylaxis, NSBB or EBL are equal in outcomes and are therefore both recommended as monotherapies to prevent a first variceal bleeding event. However, carvedilol due to its higher potency to lower portal pressure resulting in higher proportions of HVPG responders may be the treatment of choice for primary prophylaxis in compensated cirrhosis. […] In secondary prophylaxis to avoid rebleeding, monotherapy of NSBB or EBL are associated with higher mortality in secondary prophylaxis than combined NSBB + EBL therapy, which is in contrast to studies in the primary prophylaxis setting. Thus, current guidelines recommend the combination of EBL + NSBBs.

• #49 Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis

  https://www.wjgnet.com/1948-5182/full/v13/i7/731.htm

  The pre-emptive use of transjugular intrahepatic portosystemic shunt within 72 h after variceal bleeding prevents rebleeding and mortality in Child C10-C13 patients. […] In primary prophylaxis, NSBB or EBL are equal in outcomes and are therefore both recommended as monotherapies to prevent a first variceal bleeding event. However, carvedilol due to its higher potency to lower portal pressure resulting in higher proportions of HVPG responders may be the treatment of choice for primary prophylaxis in compensated cirrhosis. […] In secondary prophylaxis to avoid rebleeding, monotherapy of NSBB or EBL are associated with higher mortality in secondary prophylaxis than combined NSBB + EBL therapy, which is in contrast to studies in the primary prophylaxis setting. Thus, current guidelines recommend the combination of EBL + NSBBs.

• #50 Primary prevention of bleeding from esophageal varices in patients with cirrhosis – UpToDate

  https://www.uptodate.com/contents/primary-prevention-of-bleeding-from-esophageal-varices-in-patients-with-cirrhosis

  Primary prevention of bleeding from esophageal varices in patients with cirrhosis […] Thus, strategies to prevent the first episode of variceal bleeding are important for patients with cirrhosis and portal hypertension. […] The rationale for screening for esophageal varices is to identify patients at risk for bleeding from esophageal varices so as to prevent bleeding and improve survival in such patients. […] Screening for esophageal varices is indicated for patients with CSPH and includes the following groups: All patients with decompensated cirrhosis […] Patients with compensated cirrhosis and either liver stiffness measurement (LSM) >20 kPa or platelet count <150,000/microL. [...] General measures to prevent the first episode of variceal bleeding include: Manage underlying liver disease – Patients with cirrhosis are evaluated for interventions that will slow or reverse the progression of liver disease

• #51 Primary prevention of bleeding from esophageal varices in patients with cirrhosis – UpToDate

  https://www.uptodate.com/contents/primary-prevention-of-bleeding-from-esophageal-varices-in-patients-with-cirrhosis

  Primary prevention of bleeding from esophageal varices in patients with cirrhosis […] Thus, strategies to prevent the first episode of variceal bleeding are important for patients with cirrhosis and portal hypertension. […] The rationale for screening for esophageal varices is to identify patients at risk for bleeding from esophageal varices so as to prevent bleeding and improve survival in such patients. […] Screening for esophageal varices is indicated for patients with CSPH and includes the following groups: All patients with decompensated cirrhosis […] Patients with compensated cirrhosis and either liver stiffness measurement (LSM) >20 kPa or platelet count <150,000/microL. [...] General measures to prevent the first episode of variceal bleeding include: Manage underlying liver disease – Patients with cirrhosis are evaluated for interventions that will slow or reverse the progression of liver disease

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

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

  VARICES OVERVIEW […] Cirrhosis is a disease in which the liver becomes severely scarred, usually as a result of many years of continuous injury. The most common causes of cirrhosis include steatotic (fatty) liver (due mostly to obesity), alcohol use disorder, and chronic hepatitis B or C virus infection. Some people have more than one cause of injury to the liver. […] 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. […] WHAT ARE VARICES? […] Varices are expanded blood vessels that develop most commonly in the esophagus and stomach. In people with cirrhosis, varices develop when blood flow through the liver is obstructed (blocked) by scarring, increasing the pressure inside the portal vein, which carries blood from the intestines to the liver; this condition is called portal hypertension.

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

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

  COMPLICATIONS OF VARICES […] 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. Some people who bleed from varices will die, emphasizing the importance of preventing bleeding and treating the liver disease. […] 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. […] STRATEGIES TO PREVENT BLEEDING FROM VARICES […] Avoid alcohol — One of the most important ways to reduce the risk of bleeding from varices is to stop drinking alcohol. Alcohol can worsen cirrhosis, increase the risk of bleeding, and significantly increase the risk of dying.

• #54 Esophageal Varices – What You Need to Know

  https://www.drugs.com/cg/esophageal-varices.html

  How can I prevent my varices from bleeding? […] Do not drink alcohol. This will help prevent more damage to your esophagus and liver. Ask your healthcare provider for information if you need help to quit drinking. […] Eat healthy foods. Healthy foods include fruits, vegetables, whole-grain breads, low-fat dairy products, beans, lean meats, and fish. Ask if you need to be on a special diet. You may need to eat foods that reduce stomach acid. Stomach acid can get into your esophagus and cause the varices to break open and bleed. […] Limit sodium (salt). You may need to decrease the amount of sodium you eat if you have swelling caused by fluid buildup. Fluid buildup can cause increased pressure in your veins. Sodium is found in table salt and salty foods such as canned foods, frozen foods, and potato chips. […] Drink liquids as directed. Too much liquid can increase the pressure in your veins. Ask your healthcare provider how much liquid to drink each day and which liquids are best for you.

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

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

  Avoid NSAIDs — Nonsteroidal antiinflammatory drugs, or „NSAIDs,” include aspirin, ibuprofen, and naproxen. These drugs do not cause variceal bleeding but may cause upper gastrointestinal (GI) bleeding in people with portal hypertension. […] Weight loss/control of associated conditions — Many people with cirrhosis have steatotic liver disease due to obesity. Losing weight can remove fat from the liver and may reduce further injury. […] Beta blockers — Beta blockers, which are traditionally used to treat high blood pressure, are the most commonly recommended medication to prevent bleeding from varices. Beta blockers decrease pressure inside the varices, which can reduce the risk of bleeding. […] Variceal band ligation — 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.

• #56 Azthena logo with the word Azthena

  https://www.news-medical.net/health/Preventing-Esophageal-Varices.aspx

  Esophageal varices are the abnormal enlargement of veins at the bottom part of the esophagus (i.e., the part close to the stomach). […] It is important to understand clearly why this condition develops and the ways to prevent them from rupture. Some of the preventive measures are as follows. […] Maintaining a good diet is essential for prevention of cirrhosis of the liver. […] Patients are suggested to have a soft diet naturally soft foods that includes ripe banana, egg, and cooked food in order to prevent veins from rupturing. […] It is recommended to have five small meals a day. […] The treatment options for such conditions are categorized as first level treatments – sclerotherapy, which is injection of a solution (mostly salt solution) to stop the blood flow – and the second level treatment – taking proper medication. This process will prevent further development of esophageal varices. […] The best option to prevent this disease is by treating the alcohol addiction. […] In addition to the above factors, it is necessary to educate people about esophageal varices to inform patients more about the causes, impact, and preventive measures of this disease.

• #57 Azthena logo with the word Azthena

  https://www.news-medical.net/health/Preventing-Esophageal-Varices.aspx

  Esophageal varices are the abnormal enlargement of veins at the bottom part of the esophagus (i.e., the part close to the stomach). […] It is important to understand clearly why this condition develops and the ways to prevent them from rupture. Some of the preventive measures are as follows. […] Maintaining a good diet is essential for prevention of cirrhosis of the liver. […] Patients are suggested to have a soft diet naturally soft foods that includes ripe banana, egg, and cooked food in order to prevent veins from rupturing. […] It is recommended to have five small meals a day. […] The treatment options for such conditions are categorized as first level treatments – sclerotherapy, which is injection of a solution (mostly salt solution) to stop the blood flow – and the second level treatment – taking proper medication. This process will prevent further development of esophageal varices. […] The best option to prevent this disease is by treating the alcohol addiction. […] In addition to the above factors, it is necessary to educate people about esophageal varices to inform patients more about the causes, impact, and preventive measures of this disease.

• #58 Azthena logo with the word Azthena

  https://www.news-medical.net/health/Preventing-Esophageal-Varices.aspx

  Esophageal varices are the abnormal enlargement of veins at the bottom part of the esophagus (i.e., the part close to the stomach). […] It is important to understand clearly why this condition develops and the ways to prevent them from rupture. Some of the preventive measures are as follows. […] Maintaining a good diet is essential for prevention of cirrhosis of the liver. […] Patients are suggested to have a soft diet naturally soft foods that includes ripe banana, egg, and cooked food in order to prevent veins from rupturing. […] It is recommended to have five small meals a day. […] The treatment options for such conditions are categorized as first level treatments – sclerotherapy, which is injection of a solution (mostly salt solution) to stop the blood flow – and the second level treatment – taking proper medication. This process will prevent further development of esophageal varices. […] The best option to prevent this disease is by treating the alcohol addiction. […] In addition to the above factors, it is necessary to educate people about esophageal varices to inform patients more about the causes, impact, and preventive measures of this disease.

• #59 Esophageal Varices – What You Need to Know

  https://www.drugs.com/cg/esophageal-varices.html

  How can I prevent my varices from bleeding? […] Do not drink alcohol. This will help prevent more damage to your esophagus and liver. Ask your healthcare provider for information if you need help to quit drinking. […] Eat healthy foods. Healthy foods include fruits, vegetables, whole-grain breads, low-fat dairy products, beans, lean meats, and fish. Ask if you need to be on a special diet. You may need to eat foods that reduce stomach acid. Stomach acid can get into your esophagus and cause the varices to break open and bleed. […] Limit sodium (salt). You may need to decrease the amount of sodium you eat if you have swelling caused by fluid buildup. Fluid buildup can cause increased pressure in your veins. Sodium is found in table salt and salty foods such as canned foods, frozen foods, and potato chips. […] Drink liquids as directed. Too much liquid can increase the pressure in your veins. Ask your healthcare provider how much liquid to drink each day and which liquids are best for you.

• #60 Esophageal Varices – What You Need to Know

  https://www.drugs.com/cg/esophageal-varices.html

  How can I prevent my varices from bleeding? […] Do not drink alcohol. This will help prevent more damage to your esophagus and liver. Ask your healthcare provider for information if you need help to quit drinking. […] Eat healthy foods. Healthy foods include fruits, vegetables, whole-grain breads, low-fat dairy products, beans, lean meats, and fish. Ask if you need to be on a special diet. You may need to eat foods that reduce stomach acid. Stomach acid can get into your esophagus and cause the varices to break open and bleed. […] Limit sodium (salt). You may need to decrease the amount of sodium you eat if you have swelling caused by fluid buildup. Fluid buildup can cause increased pressure in your veins. Sodium is found in table salt and salty foods such as canned foods, frozen foods, and potato chips. […] Drink liquids as directed. Too much liquid can increase the pressure in your veins. Ask your healthcare provider how much liquid to drink each day and which liquids are best for you.

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

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

  Avoid NSAIDs — Nonsteroidal antiinflammatory drugs, or „NSAIDs,” include aspirin, ibuprofen, and naproxen. These drugs do not cause variceal bleeding but may cause upper gastrointestinal (GI) bleeding in people with portal hypertension. […] Weight loss/control of associated conditions — Many people with cirrhosis have steatotic liver disease due to obesity. Losing weight can remove fat from the liver and may reduce further injury. […] Beta blockers — Beta blockers, which are traditionally used to treat high blood pressure, are the most commonly recommended medication to prevent bleeding from varices. Beta blockers decrease pressure inside the varices, which can reduce the risk of bleeding. […] Variceal band ligation — 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.

• #62 Varices – Cirrhosis Care

  https://cirrhosiscare.ca/treatment-provider/varices-hcp/

  Patients with compensated cirrhosis and fibroscan based liver stiffness 20 kPa AND platelet count 150,000 OR those who are already on carvedilol or a non-selective beta blocker, do not need endoscopy to screen for varices […] All patients with a suspected variceal bleed should receive antibiotic prophylaxis (ceftriaxone, 1 g i.v. daily for 7 days or until discharge whichever occurs sooner) […] After a variceal bleed, prevention of re-bleeding includes a combination of variceal ligation and non-selective beta-blockers (in the absence of contraindications) […] Choosing between Beta-blockers versus Endoscopic variceal ligation for primary prophylaxis against variceal bleeding […] Intolerance to one NSBB may sometimes be overcome by switching to another NSBB.

• #63 WGO Esophageal Varices Guideline Summary

  https://www.guidelinecentral.com/guideline/1090246/

  Esophageal varices are Porto-systemic collaterals i.e., vascular channels that link the portal venous and the systemic venous circulation. […] The presence of one or more of these conditions represents an indication for endoscopy to search for varices and carry out primary prophylaxis against bleeding in cirrhotic patients (Table 4). […] Although they are effective in stopping bleeding, none of these measures, with the exception of endoscopic therapy, has been shown to affect mortality. […] Combined endoscopic and pharmacologic treatment is shown to achieve better control of acute bleeding than endoscopic treatment alone. […] Prophylactic antibiotic therapy has been shown to reduce bacterial infections, variceal rebleeding, and increase the survival rate. […] Long-term endoscopic control and banding or sclerotherapy of recurrent varices every 3-6 months

• #64 Primary prevention of bleeding from esophageal varices in patients with cirrhosis – UpToDate

  https://www.uptodate.com/contents/primary-prevention-of-bleeding-from-esophageal-varices-in-patients-with-cirrhosis

  Referral for liver transplantation evaluation – We refer patients with decompensated cirrhosis for liver transplantation evaluation because transplantation is effective long-term therapy for preventing variceal bleeding and other complications of portal hypertension. […] For patients with cirrhosis and esophageal varices at high risk for bleeding, we recommend prophylaxis with a nonselective beta blocker rather than no pharmacologic intervention because evidence suggests that beta blockers resulted in lower risk of mortality. […] For patients who cannot take beta blockers – For patients who have a contraindication to or cannot tolerate beta blockers, we suggest endoscopic variceal ligation (EVL) rather than no intervention because evidence suggests that EVL resulted in lower risk of variceal bleeding and mortality.

• #65 WGO Esophageal Varices Guideline Summary

  https://www.guidelinecentral.com/guideline/1090246/

  If endoscopic band ligation is not available or contraindicated, non cardioselective beta-blockers (propranolol, nadolol, or carvedilol) starting at a low dosage and if necessary increasing the dosage step by step until a reduction in the resting heart rate by 25%, but not lower than 55 beats/min, is achieved. […] In younger patients with less advanced cirrhosis (Child-Pugh A), the addition of isosorbide 5-mononitrate may be considered if sclerotherapy or pharmacotherapy fail. […] 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. […] As outlined above, several therapeutic options are effective in most clinical situations involving acute variceal hemorrhage, as well as in secondary and primary prophylaxis against it.

• #66 Management of Patients With Gastric Varices – Gastroenterology & Hepatology

  https://www.gastroenterologyandhepatology.net/archives/october-2022/management-of-patients-with-gastric-varices/

  Approach to Patients Without Prior Gastric Variceal Hemorrhage (Primary Prophylaxis) […] Current guidelines recommend the use of nonselective β-blockers (NSBBs), which are often indicated to treat concomitant EVs. However, this is based on data extrapolated from studies of EVs, and a definite benefit in GVs has not been established. […] One randomized controlled trial (RCT) compared endoscopic cyanoacrylate injection (ECI) with NSBBs for primary prophylaxis in 89 patients with GOV2s or IGV1s deemed to be at higher risk of bleeding (GVs >10 mm). […] After a median follow-up of 26 months, patients undergoing ECI had lower rebleeding rates (13%) than patients treated with NSBBs (28%; P=.039) and patients not receiving treatment (45%; P=.003). […] NSBBs used for primary prophylaxis include nadolol, propranolol, and carvedilol.

• #67 Management of Patients With Gastric Varices – Gastroenterology & Hepatology

  https://www.gastroenterologyandhepatology.net/archives/october-2022/management-of-patients-with-gastric-varices/

  Approach to Patients Without Prior Gastric Variceal Hemorrhage (Primary Prophylaxis) […] Current guidelines recommend the use of nonselective β-blockers (NSBBs), which are often indicated to treat concomitant EVs. However, this is based on data extrapolated from studies of EVs, and a definite benefit in GVs has not been established. […] One randomized controlled trial (RCT) compared endoscopic cyanoacrylate injection (ECI) with NSBBs for primary prophylaxis in 89 patients with GOV2s or IGV1s deemed to be at higher risk of bleeding (GVs >10 mm). […] After a median follow-up of 26 months, patients undergoing ECI had lower rebleeding rates (13%) than patients treated with NSBBs (28%; P=.039) and patients not receiving treatment (45%; P=.003). […] NSBBs used for primary prophylaxis include nadolol, propranolol, and carvedilol.

• #68 SciELO Brazil – EVALUATION OF PRIMARY PROPHYLAXIS WITH PROPRANOLOL AND ELASTIC BAND LIGATION IN VARICEAL BLEEDING IN CIRRHOTIC CHILDREN AND ADOLESCENTS EVALUATION OF PRIMARY PROPHYLAXIS WITH PROPRANOLOL AND ELASTIC BAND LIGATION IN VARICEAL BLEEDING IN C

  https://www.scielo.br/j/ag/a/7ZFRyF78gTVY5y7KSLfvGJS/

  The efficacy of nonselective -blocker and endoscopic procedures, such as endoscopic variceal ligation, as primary prophylaxis of variceal hemorrhage in cirrhotic adults was demonstrated by numerous controlled trials, but in pediatric population, few are the number of studies. […] The objective of this study is to evaluate the primary prophylaxis with -blocker in cirrhotic children and adolescents with portal hypertension. […] Patients were evaluated by endoscopy, and those who had varicose veins of medium and large caliber or reddish spots, regardless of the caliber of varices, received primary prophylaxis. […] The use of propranolol showed a high number of contraindications and side effects, requiring referral to endoscopic prophylaxis. The endoscopic prophylaxis was effective in reducing episodes of bleeding.

• #69 SciELO Brazil – EVALUATION OF PRIMARY PROPHYLAXIS WITH PROPRANOLOL AND ELASTIC BAND LIGATION IN VARICEAL BLEEDING IN CIRRHOTIC CHILDREN AND ADOLESCENTS EVALUATION OF PRIMARY PROPHYLAXIS WITH PROPRANOLOL AND ELASTIC BAND LIGATION IN VARICEAL BLEEDING IN C

  https://www.scielo.br/j/ag/a/7ZFRyF78gTVY5y7KSLfvGJS/

  Primary prophylaxis is intended to prevent the first episode of variceal bleeding in an individual who has varices. […] The efficacy of nonselective -blocker and endoscopic procedures, such as endoscopic variceal ligation (EVL), as primary prophylaxis of variceal hemorrhage in cirrhotic adults was demonstrated by numerous controlled trials. […] The objective of this study is to evaluate the primary prophylaxis with -blocker in cirrhotic children and adolescents with portal hypertension. […] The high suspension rate (41.2%) due to adverse effects or poor compliance in patients using propranolol makes it impractical to be used as primary prophylaxis, despite its potential, but not proved, benefits. The endoscopic primary prophylaxis seemed to be safe and effective, since none of the patients who underwent EVL bled or had significant complications during the follow-up. […] However, more studies are needed to show the real efficacy and safety of propranolol and endoscopic prophylaxis for variceal bleeding in cirrhotic children.

• #70 SciELO Brazil – EVALUATION OF PRIMARY PROPHYLAXIS WITH PROPRANOLOL AND ELASTIC BAND LIGATION IN VARICEAL BLEEDING IN CIRRHOTIC CHILDREN AND ADOLESCENTS EVALUATION OF PRIMARY PROPHYLAXIS WITH PROPRANOLOL AND ELASTIC BAND LIGATION IN VARICEAL BLEEDING IN C

  https://www.scielo.br/j/ag/a/7ZFRyF78gTVY5y7KSLfvGJS/

  Primary prophylaxis is intended to prevent the first episode of variceal bleeding in an individual who has varices. […] The efficacy of nonselective -blocker and endoscopic procedures, such as endoscopic variceal ligation (EVL), as primary prophylaxis of variceal hemorrhage in cirrhotic adults was demonstrated by numerous controlled trials. […] The objective of this study is to evaluate the primary prophylaxis with -blocker in cirrhotic children and adolescents with portal hypertension. […] The high suspension rate (41.2%) due to adverse effects or poor compliance in patients using propranolol makes it impractical to be used as primary prophylaxis, despite its potential, but not proved, benefits. The endoscopic primary prophylaxis seemed to be safe and effective, since none of the patients who underwent EVL bled or had significant complications during the follow-up. […] However, more studies are needed to show the real efficacy and safety of propranolol and endoscopic prophylaxis for variceal bleeding in cirrhotic children.

• #71 :: JKMS :: Journal of Korean Medical Science

  https://jkms.org/DOIx.php?id=10.3346/jkms.2013.28.11.1657

  In conclusion, over long-term follow up after esophageal variceal eradication using EVL alone in children with esophageal variceal bleeds, rebleeding episodes and recurrence of esophageal varices were rare. EVL is a safe and highly effective method for the long-term prophylaxis of variceal rebleeding in children with portal hypertension.

• #72

  https://link.springer.com/article/10.1007/s11901-020-00525-x

  Portal hypertension is an important manifestation of chronic liver diseases, and the complications of portal hypertension, especially gastroesophageal variceal hemorrhage, are associated with high morbidity and mortality. […] This review addresses the pathophysiology, natural history, differential diagnoses, and diagnostic criteria of portal hypertension. We will also discuss the primary prevention, acute management, and secondary prevention of esophageal and gastric varices. […] Despite many improvements, there remain significant challenges in the prevention and treatment of portal hypertension, and further research, both in basic and clinical studies are needed to fill current gaps in knowledge. […] Endoscopic variceal ligation in prophylaxis of first variceal bleeding in cirrhotic patients with high-risk esophageal varices.

• #73 UK guidelines on the management of variceal haemorrhage in cirrhotic patients | Gut

  https://gut.bmj.com/content/64/11/1680

  Isosorbide mononitrate monotherapy is not recommended as primary prophylaxis (level 1b, grade A). There is insufficient evidence to recommend isosorbide mononitrate in combination with NSBB (level 1b, grade A). […] Shunt surgery or transjugular intrahepatic portosystemic stent shunt (TIPSS) is not recommended as primary prophylaxis (level 1a, grade A). […] Sclerotherapy is not recommended as primary prophylaxis (level 1a, grade A). […] Areas requiring further study: Role of NSBB in patients without varices, with focus on carvedilol. […] Role of NSBB in patients with small varices, with focus on carvedilol. […] Comparison of carvedilol versus propranolol in primary prophylaxis. […] Identification of, and trials assessing, new drugs for primary prophylaxis such as statins. […] Quality indicator: Percentage of patients at diagnosis of cirrhosis who have had an endoscopy to screen for varices (level 1a, grade A). […] Percentage of patients receiving primary prophylaxis among those newly diagnosed with grade I varices and red signs or grade 23 varices.

• #74 UK guidelines on the management of variceal haemorrhage in cirrhotic patients | Gut

  https://gut.bmj.com/content/64/11/1680

  Isosorbide mononitrate monotherapy is not recommended as primary prophylaxis (level 1b, grade A). There is insufficient evidence to recommend isosorbide mononitrate in combination with NSBB (level 1b, grade A). […] Shunt surgery or transjugular intrahepatic portosystemic stent shunt (TIPSS) is not recommended as primary prophylaxis (level 1a, grade A). […] Sclerotherapy is not recommended as primary prophylaxis (level 1a, grade A). […] Areas requiring further study: Role of NSBB in patients without varices, with focus on carvedilol. […] Role of NSBB in patients with small varices, with focus on carvedilol. […] Comparison of carvedilol versus propranolol in primary prophylaxis. […] Identification of, and trials assessing, new drugs for primary prophylaxis such as statins. […] Quality indicator: Percentage of patients at diagnosis of cirrhosis who have had an endoscopy to screen for varices (level 1a, grade A). […] Percentage of patients receiving primary prophylaxis among those newly diagnosed with grade I varices and red signs or grade 23 varices.

• #75 UK guidelines on the management of variceal haemorrhage in cirrhotic patients | Gut

  https://gut.bmj.com/content/64/11/1680

  Isosorbide mononitrate monotherapy is not recommended as primary prophylaxis (level 1b, grade A). There is insufficient evidence to recommend isosorbide mononitrate in combination with NSBB (level 1b, grade A). […] Shunt surgery or transjugular intrahepatic portosystemic stent shunt (TIPSS) is not recommended as primary prophylaxis (level 1a, grade A). […] Sclerotherapy is not recommended as primary prophylaxis (level 1a, grade A). […] Areas requiring further study: Role of NSBB in patients without varices, with focus on carvedilol. […] Role of NSBB in patients with small varices, with focus on carvedilol. […] Comparison of carvedilol versus propranolol in primary prophylaxis. […] Identification of, and trials assessing, new drugs for primary prophylaxis such as statins. […] Quality indicator: Percentage of patients at diagnosis of cirrhosis who have had an endoscopy to screen for varices (level 1a, grade A). […] Percentage of patients receiving primary prophylaxis among those newly diagnosed with grade I varices and red signs or grade 23 varices.

• #76 UK guidelines on the management of variceal haemorrhage in cirrhotic patients | Gut

  https://gut.bmj.com/content/64/11/1680

  Isosorbide mononitrate monotherapy is not recommended as primary prophylaxis (level 1b, grade A). There is insufficient evidence to recommend isosorbide mononitrate in combination with NSBB (level 1b, grade A). […] Shunt surgery or transjugular intrahepatic portosystemic stent shunt (TIPSS) is not recommended as primary prophylaxis (level 1a, grade A). […] Sclerotherapy is not recommended as primary prophylaxis (level 1a, grade A). […] Areas requiring further study: Role of NSBB in patients without varices, with focus on carvedilol. […] Role of NSBB in patients with small varices, with focus on carvedilol. […] Comparison of carvedilol versus propranolol in primary prophylaxis. […] Identification of, and trials assessing, new drugs for primary prophylaxis such as statins. […] Quality indicator: Percentage of patients at diagnosis of cirrhosis who have had an endoscopy to screen for varices (level 1a, grade A). […] Percentage of patients receiving primary prophylaxis among those newly diagnosed with grade I varices and red signs or grade 23 varices.

• #77 Primary prophylaxis of variceal bleeding in patients with cirrhosis: A comparison of different strategies

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8716979/

  The most important medical associations in the field of hepatology support these recommendations. […] Nevertheless, there are divergences in medical literature regarding the superiority of one prophylactic alternative over the others. […] This article aims at reviewing the main strategies for primary prophylaxis against variceal hemorrhage, as well as comparing their strengths and weaknesses. […] Primary prophylaxis against variceal bleeding is of the utmost importance for patients with cirrhosis and high-risk varices. Currently recommended strategies include NSBBs, carvedilol or EVL. While EVL might be superior to pharmacological therapy regarding the prevention of the first bleeding episode, pharmacological therapy seems to prevent different complications of liver disease and probably play a more prominent role concerning mortality reduction. The sequential use of these alternatives or their combination should be further studied so that patients might benefit from the best aspects of each strategy.

• #78 Primary prophylaxis of variceal bleeding in patients with cirrhosis: A comparison of different strategies

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8716979/

  The most important medical associations in the field of hepatology support these recommendations. […] Nevertheless, there are divergences in medical literature regarding the superiority of one prophylactic alternative over the others. […] This article aims at reviewing the main strategies for primary prophylaxis against variceal hemorrhage, as well as comparing their strengths and weaknesses. […] Primary prophylaxis against variceal bleeding is of the utmost importance for patients with cirrhosis and high-risk varices. Currently recommended strategies include NSBBs, carvedilol or EVL. While EVL might be superior to pharmacological therapy regarding the prevention of the first bleeding episode, pharmacological therapy seems to prevent different complications of liver disease and probably play a more prominent role concerning mortality reduction. The sequential use of these alternatives or their combination should be further studied so that patients might benefit from the best aspects of each strategy.

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