Gastrointestinal varices medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Overview

Medical therapy in cases of gastrointestinal varices includes goal-directed management of the cause of portal hypertension along with specific management of varices after their development. The treatment is aimed at optimizing portal venous inflow, portal pressure and portal resistance. The pharmacological therapy includes vasoconstrictors (beta blockers) and venodilators (nitrates). These therapies may be employed alone or in combination with endoscopic variceal ligation/sclerotherapy and transjugular intrahepatic shunt (TIPS) therapy depending upon the condition of the patient.

Medical Therapy

Medical therapy for gastrointestinal varices should include management of the underlying cause of portal hypertension and specific therapy for varices after they have developed.

Treatment of underlying causes

Alcoholic liver disease

For a detailed description for treatment of alcoholic liver disease, click here.

Hepatitis C

For a detailed description for treatment of Hepatitis C, click here[1][2][3][4][5][6]

Genotypes HCV 1 and 4

  • Preferred regimen (1): Peginterferon plus ribavirin for 48 weeks. The dose for peginterferon alfa-2a is 180 µg subcutaneously per week together with ribavirin using doses of 1,000 mg for those <75 kg in weight and 1,200 mg for those >75 kg; the dose for peginterferon alfa-2b is 1.5 µg/kg subcutaneously per week together with ribavirin using doses of 800 mg for those weighing <65 kg; 1,000 mg for those weighing >65 kg to 85 kg, 1,200 mg for >85 kg to 105 kg, and 1,400 mg for >105 kg.[7]

Genotypes HCV 2 and 3

Hepatitis B

For a detailed description for treatment of Hepatitis B, click here[9][10][11][12][13][14][15][16][17][18][13]
a. ALT greater than 2 times normal or moderate/severe hepatitis on biopsy, and HBV DNA >20,000 IU/mL - treatment may be initiated with any of the 7 approved antiviral medications, but pegIFN-α, tenofovir or entecavir are preferred.
b. ALT persistently normal or minimally elevated (<2 times normal) - should not be initiated on treatment.
c. Children with elevated ALT greater than 2 times normal - treatment may be initiated with IFN-α or lamivudine if ALT levels remain elevated at this level for longer than 6 months.

Autoimmune hepatitis

For a detailed description for treatment of autoimmune hepatits, click here.

Primary biliary cirrhosis

For a detailed description for treatment of primary biliary cirrhosis, click here.

Primary sclerosing cholangitis

For a detailed description for treatment of primary sclerosing cholangitis, click here.

Wilson's disease

For a detailed description for treatment of Wilson's disease, click here.

Treatment of Esophageal Varices

General considerations and disease stratification

The management of gastrointestinal varices in chronic liver disease should be tailored according to the clinical stage of liver disease and cirrhosis. The following table outlines the key stages of chronic liver disease and the treatment goals for the respective stage:

Disease stage HPVG Varices Complications of portal hypertension Management goals
Compensated liver disease Less than 10 mmHg - -
Greater than equal to 10 mmHg - - Prevent decompensation
Greater than equal to 10 mmHg + - Prevent decompensation
Decompensated liver disease Greater than equal to 12 mmHg + Acute variceal bleed Control bleeding, prevent early rebleeding and death
Greater than equal to 12 mmHg + Previous variceal hemorrhage without ascites or encephalopathy Prevent further decompensation (further bleeding, ascites and encephalopathy)
Greater than equal to 12 mmHg + Prior variceal hemorrhage with ascites and/or encephalopathy Prevent further decompensation and death

Goal-directed management

The management of gastrointestinal varices is aimed at optimizing the following:[23][24]

This is achieved through the following pharmacological therapies:[25][23]

The following table shows the major mechanism affected by the various pharmacological therapies used in the management of varices:[26][27][28][23][25]

Major pharmacological therapy Portal flow Portal resistance Portal pressure
Vasoconstrictors (e.g. β-blockers) ↓↓
Venodilators (e.g. nitrates)
Endoscopic therapy
TIPS/Shunt therapy ↓↓↓ ↓↓↓

1 Small non-bleeding varices

  • 1.1 Adult
    • 1.1.1 Child-Pugh B and C or increased risk of bleeding
      • Preferred regimen (1): Propranolol immediate-release initial dose of 20 mg BID; adjust to maximal tolerated dose
      • Alternative regimen (1): Nadolol initial dose of 40 mg once daily; adjust to maximal tolerated dose
    • 1.1.2 No increased risk of bleeding
      • Preferred regimen (1): Propranolol immediate-release initial dose of 20 mg BID; adjust to maximal tolerated dose
      • Alternative regimen (1): Nadolol initial dose of 40 mg once daily; adjust to maximal tolerated dose
    • 1.1.3 No previous use of beta blockers
      • Preferred regimen (1): EGD should be repeated in 2 years
    • 1.1.4 Hepatic decompensation
      • Preferred regimen (1): EGD should be done at that time and repeated annually

2 Large non-bleeding varices[29][30][31][32][33][34][35][36][37]

2.1 Adult

  • 2.1.1 Child-Pugh B and C or increased risk of bleeding
    • Preferred regimen (1): Propranolol immediate-release initial dose of 20 mg BID; adjust to maximal tolerated dose
    • Preferred regimen (2): Endoscopic variceal ligation
    • Alternative regimen (1): Nadolol initial dose of 40 mg once daily; adjust to maximal tolerated dose
  • 2.1.2 No increased risk of bleeding
    • Preferred regimen (1): Propranolol immediate-release initial dose of 20 mg BID; adjust to maximal tolerated dose
    • Preferred regimen (2): Endoscopic variceal ligation
    • Alternative regimen (1): Nadolol initial dose of 40 mg once daily; adjust to maximal tolerated dose
  • 2.1.3 No previous use of beta blockers
    • Preferred regimen (1): EGD should be repeated in 2 years
    • Preferred regimen (2): Endoscopic variceal ligation
  • 2.1.4 Hepatic decompensation
    • Preferred regimen (1): EGD should be done at that time and repeated annually
    • Preferred regimen (2): Endoscopic variceal ligation

3 Acute hemorrhage[38][39][40]

  • 3.1 Adult
    • Preferred regimen (1): Endoscopy (sclerotherapy or endoscopic variceal ligation) within 12 hours of bleed plus octreotide initial IV bolus of 50 µg followed by a continuous infusion of 50 µg/hour (should be continued for 3-5 days after confirmation of diagnosis) plus norfloxacin 400 mg PO BID for 7 days
    • Preferred regimen (2): Vasopressin continuous IV infusion of 0.2–0.4 units/minute that can be increased to a maximal dose of 0.8 units/minute. It should always be accompanied by IV nitroglycerin at a starting dose of 40 µg/minute, which can be increased to a maximum of 400 µg/minute, adjusted to maintain a systolic blood pressure >90 mmHg
    • Preferred regimen (3): Endoscopy within 12 hours of bleed plus telipressin initial dose of 2 mg IV every 4 hours and can be titrated down to 1 mg IV every 4 hours once hemorrhage is controlled (should be continued for 3-5 days after confirmation of diagnosis) plus norfloxacin 400 mg PO BID for 7 days
    • Alternative regimen (1): Endoscopy (sclerotherapy or endoscopic variceal ligation) within 12 hours of bleed plus octreotide initial IV bolus of 50 µg followed by a continuous infusion of 50 µg/hour (should be continued for 3-5 days after confirmation of diagnosis) plus ciprofloxacin 400 mg PO BID for 7 days
  • 3.1.1 Adult (Child-Pugh B and C)
    • Preferred regimen (1): Endoscopy (sclerotherapy or endoscopic variceal ligation) within 12 hours of bleed plus octreotide initial IV bolus of 50 µg followed by a continuous infusion of 50 µg/hour (should be continued for 3-5 days after confirmation of diagnosis) plus IV ceftriaxone 1 g/day
  • 3.1.2 Adult (Bleeding despite pharmacological plus endoscopic therapy)
  • 3.1.3 Adult (Temporary measure- in case of planned TIPS or endoscopy)

Treatment of Gastric Varices

The following treatment options may be employed for the treatment of bleeding gastric varices:

1 Fundic varices

  • 1.1 Adult
    • Preferred regimen (1): Endoscopic variceal obturation using tissue adhesives such as cyanoacrylate

References

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