Gastrointestinal varices secondary prevention

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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

Secondary prevention of gastrointestinal varices involves prevention of rebleeding. The choice of method chosen for secondary prevention of gastrointestinal varices depends upon the condition of the patient, medication history and response to treatment. Methods used for secondary prevention include the use of beta blockers, band ligation, TIPS and liver transplantation.

Secondary Prevention

Secondary prevention of gastrointestinal varices involves prevention of rebleeding. The following options are available, according to the condition of the patient:[1][2][3][4]

Time to start secondary prophylaxis

  • Secondary prophylaxis should start as soon as possible from day 6 of the index variceal bleeding episode
  • The time of initiation of secondary prophylaxis should be recorded.

Patients with cirrhosis who have not received primary prophylaxis

  • In these patients, a combination of beta blockers and endoscopic band ligation may be used as a measure for secondary prophylaxis
  • Rebledding risk may be predicted by using the patient's response to pharmacological therapy as a prognostic factor

Patients with cirrhosis who are on beta blockers for primary prevention and bleed

Patients who have contraindications or intolerance to beta blockers

  • Band ligation is the treatment of choice for prevention of rebleeding

Patients who fail endoscopic and pharmacological treatment for prevention of rebleeding

  • TIPS or surgical shunts (distal splenorenal shunt or 8 mm H-graft) are effective for those with Child class A/B cirrhosis
  • In non-surgical candidates, TIPS is the sole option available
  • Transplantation is associated with good long-term outcomes in Child class B/C cirrhosis and should be considered
  • TIPS serves as a bridge to transplantation

Patients who have bled from isolated gastric varices, type 1 (IGV1) or gastro-oesophageal varices, type 2 (GOV 2)

Patients who have bled from gastro-esophageal varices, type 1 (GOV 1)

Patients who have bled from portal hypertensive gastropathy

Patients in whom beta blockers are contraindicated or fail and who cannot be managed by non-shunt therapy

  • TIPS
  • Surgical shunts

References

  1. Krige JE, Kotze UK, Bornman PC, Shaw JM, Klipin M (2006). "Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices". Ann. Surg. 244 (5): 764–70. PMC 1856595Freely accessible. PMID 17060770. doi:10.1097/01.sla.0000231704.45005.4e. 
  2. de Franchis R (2005). "Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension". J. Hepatol. 43 (1): 167–76. PMID 15925423. doi:10.1016/j.jhep.2005.05.009. 
  3. D'Amico G, De Franchis R (2003). "Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators". Hepatology. 38 (3): 599–612. PMID 12939586. doi:10.1053/jhep.2003.50385. 

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