CAMBRIDGE, MD. — β-Blockers remain the best choice for primary prevention of bleeding from esophageal varices in patients with end-stage liver disease.
Variceal banding, while at least as effective as β-blockers in preventing a first bleed, should be reserved for those who don't respond to or can't tolerate β-blockers, or who are noncompliant with drug therapy, Sergey Kantsevoy, M.D., said at a hepatobiliary update sponsored by Johns Hopkins University.
Esophageal varices develop in up to 60% of patients with cirrhosis. If varices rupture, they carry a significant mortality risk of 20%–40%, depending on the severity of the liver disease. Therefore, all patients with end-stage liver disease should undergo upper endoscopy to screen for varices, said Dr. Kantsevoy of Johns Hopkins University, Baltimore.
Unselected patients don't benefit from primary prevention strategies for esophageal varices, but there is great benefit for high-risk patients, he said. However, despite the mortality risk of bleeds and the proven benefit of treatment, only 46% of those referred for liver transplantation had been screened for esophageal varices (Am. J. Gastroenterol. 2001;96:833–7).
If the initial endoscopy does not identify varices, the patient should have a repeat endoscopy every 2 years. If the varices are small, a repeat endoscopy every 1–2 years is indicated, depending on the severity of liver disease.
Patients with large varices should be offered prophylactic therapy. β-Blockers are the medical therapy of choice. They reduce portal pressure by reducing cardiac output and increasing resistance in collateral veins. The drugs have been shown to reduce the risk of a first variceal bleed by half and to reduce mortality by up to 45%, compared with placebo.
Unfortunately, Dr. Kantsevoy said, β-blockers are contraindicated in up to 20% of end-stage liver disease patients. In addition, “despite adequate β-blockage, at least 30% will not achieve reduction in portal pressure sufficient to prevent bleeding, and about 30% will have side effects including heart failure, hypotension, bronchoconstriction, fatigue, and impotence.”
Endoscopic variceal banding may be considered for these patients. Band ligation has been shown to be as effective as β-blockage at reducing the incidence of bleeding, but the procedure carries no significant mortality advantage over medical therapy.
Endoscopic sclerotherapy has been investigated in these patients, but it is not recommended for primary prevention because it is associated with a high rate of adverse events.
Postsclerotherapy complications occur in up to 20% of patients and include ulceration, stricture formation, and esophageal perforation, Dr. Kantsevoy said.