About one-third of pts with cirrhosis have varices, and one-third of pts with varices will develop bleeding. Bleeding is a life-threatening complication; risk of bleeding correlates with variceal size and location, the degree of portal hypertension (portal venous pressure >12 mmHg), and the severity of cirrhosis, e.g., Child-Pugh classification (see Table 157-3 Child-Pugh Classification of Cirrhosis).
Diagnosis 
Esophagogastroscopy: procedure of choice for evaluation of upper GI hemorrhage in pts with known or suspected portal hypertension. Celiac and mesenteric arteriography are alternatives when massive bleeding prevents endoscopy and to evaluate portal vein patency (portal vein may also be studied by ultrasound with Doppler and MRI).
| TREATMENT |
Esophagogastric Varices
See Chap. 43 Gastrointestinal Bleeding for general measures to treat GI bleeding. CONTROL OF ACUTE BLEEDING
Choice of approach depends on clinical setting and availability. - Endoscopic intervention is employed as first-line treatment to control bleeding acutely. Endoscopic variceal ligation (EVL) is used to control acute bleeding in >90% of cases. EVL is less successful when varices extend into proximal stomach. Some endoscopists will use variceal injection (sclerotherapy) as initial therapy, particularly when bleeding is vigorous.
- Vasoconstricting agents:somatostatin or octreotide (50-100 µg/h by continuous infusion).
- Balloon tamponade (Sengstaken-Blakemore- or Minnesota tube). Can be used when endoscopic therapy is not immediately available or in pts who need stabilization prior to endoscopic therapy. Complications-obstruction of pharynx, asphyxiation, aspiration, esophageal ulceration. Generally reserved for massive bleeding, failure of vasopressin and/or endoscopic therapy.
- Transjugular intrahepatic portosystemic shunt (TIPS)-portacaval shunt placed by interventional radiologic technique, reserved for failure of other approaches; risk of hepatic encephalopathy (20-30%), shunt stenosis or occlusion, infection.
PREVENTION OF RECURRENT BLEEDING
- EVL should be repeated until obliteration of all varices is accomplished.
- Propranolol or nadolol-nonselective beta blockers that act as portal venous antihypertensives; may decrease the risk of variceal hemorrhage and mortality due to hemorrhage.
- TIPS-regarded as useful “bridge” to liver transplantation in pt who has failed pharmacologic therapy and is awaiting a donor liver.
- Portosystemic shunt surgery used less commonly with the advent of TIPS; could be considered for pts with good hepatic synthetic function.
PREVENTION OF INITIAL BLEED
For pts at high risk of variceal bleeding, consider prophylaxis with EVL and/or nonselective beta blockers. |