eMedicine Specialties > Gastroenterology > Esophagus

Esophageal Varices: Follow-up

Author: Samy A Azer, MD, PhD, MPH, Professor of Medical Education, Chair of Medical Education Research and Development Unit, Faculty of Medicine, Universiti Teknologi MARA, Malaysia; Visiting Professor of Medical Education, Faculty of Medicine, University of Toyama, Japan; Former Senior Lecturer in Medical Education, Faculty Education Unit, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne and University of Sydney, Australia
Contributor Information and Disclosures

Updated: Jan 4, 2010

Follow-up

Further Inpatient Care

  • Because of the frequency and severity of recurrent variceal bleeding, effective preventive treatment is mandatory in patients surviving an episode of acute variceal bleeding. This may include one of the following options:
    • Elective portocaval shunt
    • Distal splenorenal shunt
    • Devascularization procedures
    • Sclerotherapy
    • Endoscopic variceal banding ligation
    • TIPS may be indicated if medical treatment or endoscopic therapy is ineffective.

Further Outpatient Care

  • The administration of propranolol and other nonselective beta-blockers in patients with cirrhosis reduces the portal pressure by reducing the portal collateral flow. This results from splanchnic vasoconstriction promoted by the blockade of vasodilating beta2-adrenoceptors in the splanchnic circulation and by decreasing heart rate and cardiac output due to blockade of cardiac beta1-adrenoceptors.
  • Beta-blocker therapy is indicated in patients with esophageal varices and in patients treated for variceal hemorrhage with sclerotherapy or banding. Patients selected for beta-blocker therapy should have no contraindications to beta-blockers.

Inpatient & Outpatient Medications

  • Adjust the dose of beta-blockers.
  • If therapy with beta-blockers is not successful, addition of a second drug (eg, nitroglycerin, a long-acting nitrate) should be considered in an attempt to further decrease HVPG.

Transfer

  • Patients with acute esophageal bleeding require urgent treatment in a hospital setting.

Complications

  • Severe and persistent upper GI hemorrhage (ie, requiring >5-U transfusion)
  • High morbidity and mortality (30-40% of the group with severe persistent GI hemorrhage) - Factors such as underlying liver disease and associated abnormalities of the renal, cardiovascular, and immune systems contribute to the high morbidity and mortality of those with esophageal varices.
  • Complications associated with GI bleeding - Vascular collapse; the sequelae of hypotension, cardiomyopathy, arrhythmias, aspiration pneumonia, sepsis, spontaneous bacterial peritonitis, overtransfusion, and rebound rebleeding of varices; and encephalopathy
  • Complications related to blood transfusion
  • Complications related to the therapeutic procedures used in management of bleeding esophageal varices
    • Balloon tamponade - Aspiration pneumonia, esophageal perforation, superficial lesions of the gastric mucosa, pressure necrosis to the nasal passages, mouth, or lips
    • Sclerotherapy - Perforation of the esophagus (2-6%), esophageal ulceration and bleeding (2-13%), pleural effusion (16-48%), fever (30%), chest pain (40%), and esophageal stricture (7%)
    • Variceal banding - Rebleeding during the course of banding
    • Surgical procedures - For example, distal splenorenal shunt surgery is associated with an increased incidence of hepatic encephalopathy.
    • Liver transplantation - Rejection, infection, sepsis, and complications related to immunosuppressive drugs used postoperatively
    • Complications related to pharmacotherapy

Prognosis

  • Patients with an HVPG of 20 mm Hg measured 48 hours after bleeding esophageal varices have a higher 1-year mortality rate.
  • Other factors that can affect the prognosis of patients with esophageal varices include the following:
    • Rebleeding
    • Child classification, especially the presence of ascites
    • Active alcohol intake in patients with chronic alcohol-related liver diseases
    • Occurrence of complications (eg, bacteremia and/or endotoxemia, spontaneous bacterial peritonitis, portosystemic encephalopathy, hepatorenal syndrome)
  • Several factors are known to influence the prognosis of esophageal bleeding. These include the following:
    • The natural course of the disease causing portal hypertension
    • The severity of portal hypertension
    • The location and number of the bleeding varices
    • The functional status of the liver and the severity of liver disease (early rebleeding, within 5 d of admission, occurred in 21% of patients classified as Child-Pugh grade A, 40% of patients classified as grade B, and 63% of patients classified as grade C)
    • Presence of associated systemic disorders
    • Continued alcohol abuse
    • Response to emergency treatment

Patient Education

  • All patients with esophageal varices should take beta-blockers to reduce the risk of bleeding, unless beta-blockers are contraindicated by coexisting medical conditions. Patients should also be educated about the adverse effects of beta-blockers and the possible risks of their abrupt discontinuation.
  • Educate patients about the benefits and disadvantages of available treatment options.

Miscellaneous

Medicolegal Pitfalls

  • Vasopressin should not be administered via a central line, especially in elderly patients.
  • Initiating therapy to prevent recurrent bleeding as soon as the acute bleeding episode is adequately controlled is critical.
  • Liver transplantation should be considered for patients with end-stage liver disease. The selection of candidates is dictated by the patient's clinical status, etiology of cirrhosis, abstinence from alcohol, and availability of a donor organ.

Special Concerns

  • Patients with massive acute bleeding from esophageal varices who refuse blood transfusions because of their religious beliefs may constitute a challenge to the treating team.
 


More on Esophageal Varices

Overview: Esophageal Varices
Differential Diagnoses & Workup: Esophageal Varices
Treatment & Medication: Esophageal Varices
Follow-up: Esophageal Varices
References
Further Reading
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References

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  2. Obara K. Hemodynamic mechanism of esophageal varices. Dig Endosc. Jan 2006;18(1):6-9.

  3. Ravindra KV, Eng M, Marvin M. Current management of sinusoidal portal hypertension. Am Surg. Jan 2008;74(1):4-10. [Medline].

  4. Gupta TK, Toruner M, Chung MK, Groszmann RJ. Endothelial dysfunction and decreased production of nitric oxide in the intrahepatic microcirculation of cirrhotic rats. Hepatology. Oct 1998;28(4):926-31. [Medline]. [Full Text].

  5. D'Amico G, Pagliaro L, Bosch J. Pharmacological treatment of portal hypertension: an evidence-based approach. Semin Liver Dis. 1999;19(4):475-505. [Medline].

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  7. Samonakis DN, Triantos CK, Thalheimer U, Patch DW, Burroughs AK. Management of portal hypertension. Postgrad Med J. Nov 2004;80(949):634-41. [Medline]. [Full Text].

  8. Chang YW. Indication of treatment for esophageal varices: who and when?. Dig Endosc. Jan 2006;18(1):10-5.

  9. [Best Evidence] Kumar A, Jha SK, Sharma P, et al. Addition of propranolol and isosorbide mononitrate to endoscopic variceal ligation does not reduce variceal rebleeding incidence. Gastroenterology. Sep 2009;137(3):892-901, 901.e1. [Medline].

  10. Lay CS, Tsai YT, Lee FY, et al. Endoscopic variceal ligation versus propranolol in prophylaxis of first variceal bleeding in patients with cirrhosis. J Gastroenterol Hepatol. Feb 2006;21(2):413-9. [Medline].

  11. [Best Evidence] Gluud LL, Klingenberg S, Nikolova D, Gluud C. Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials. Am J Gastroenterol. Dec 2007;102(12):2842-8; quiz 2841, 2849. [Medline].

  12. Arguedas MR, Heudebert GR, Eloubeidi MA, Abrams GA, Fallon MB. Cost-effectiveness of screening, surveillance, and primary prophylaxis strategies for esophageal varices. Am J Gastroenterol. Sep 2002;97(9):2441-52. [Medline].

  13. Garcia-Tsao G. Angiotensin II receptor antagonists in the pharmacological therapy of portal hypertension: a caution. Gastroenterology. Sep 1999;117(3):740-2. [Medline].

  14. Garcia-Tsao G. Portal hypertension. Curr Opin Gastroenterol. May 2000;16(3):282-9. [Medline].

  15. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. Sep 2007;102(9):2086-102. [Medline].

  16. Goulis J, Patch D, Burroughs AK. Bacterial infection in the pathogenesis of variceal bleeding. Lancet. Jan 9 1999;353(9147):139-42. [Medline].

  17. [Best Evidence] Groszmann RJ, Garcia-Tsao G, Bosch J, et al, for the Portal Hypertension Collaborative Group. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med. Nov 24 2005;353(21):2254-61. [Medline]. [Full Text].

  18. Nakamura S, Konishi H, Kishino M, et al. Prevalence of esophagogastric varices in patients with non-alcoholic steatohepatitis. Hepatol Res. Jun 2008;38(6):572-9. [Medline].

  19. Nevens F. Review article: a critical comparison of drug therapies in currently used therapeutic strategies for variceal haemorrhage. Aliment Pharmacol Ther. Sep 2004;20 Suppl 3:18-22; discussion 23. [Medline]. [Full Text].

  20. Patch D, Armonis A, Sabin C, et al. Single portal pressure measurement predicts survival in cirrhotic patients with recent bleeding. Gut. Feb 1999;44(2):264-9. [Medline]. [Full Text].

  21. Poo JL, Jimenez W, Maria Munoz R, et al. Chronic blockade of endothelin receptors in cirrhotic rats: hepatic and hemodynamic effects. Gastroenterology. Jan 1999;116(1):161-7. [Medline].

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Further Reading

Related eMedicine Topics

Clinical Trials

Clinical Guidelines

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Keywords

esophageal varices, esophageal varix, gastroesophageal varices, portal hypertension, esophageal bleeding, esophageal disease, cardioesophageal junction varices, esophagogastric varices, varices in the fundus and esophagus, varices at the gastroesophageal junction

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Contributor Information and Disclosures

Author

Samy A Azer, MD, PhD, MPH, Professor of Medical Education, Chair of Medical Education Research and Development Unit, Faculty of Medicine, Universiti Teknologi MARA, Malaysia; Visiting Professor of Medical Education, Faculty of Medicine, University of Toyama, Japan; Former Senior Lecturer in Medical Education, Faculty Education Unit, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne and University of Sydney, Australia
Samy A Azer, MD, PhD, MPH is a member of the following medical societies: American College of Gastroenterology, Association for Psychological Science, Gastroenterological Society of Australia, New York Academy of Sciences, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Waqar A Qureshi, MD, Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and Veterans Affairs Medical Center
Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Simmy Bank, MD, Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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