Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis

Abstract

Portal hypertension (PH), a common complication of liver cirrhosis, results in development of esophageal varices. When esophageal varices rupture, they cause significant upper gastrointestinal bleeding with mortality rates up to 20% despite state-of-the-art treatment. Thus, prophylactic measures are of utmost importance to improve outcomes of patients with PH. Several high-quality studies have demonstrated that non-selective beta blockers (NSBBs) or endoscopic band ligation (EBL) are effective for primary prophylaxis of variceal bleeding. In secondary prophylaxis, a combination of NSBB + EBL should be routinely used. Once esophageal varices develop and variceal bleeding occurs, standardized treatment algorithms should be followed to minimize bleeding-associated mortality. Special attention should be paid to avoidance of overtransfusion, early initiation of vasoconstrictive therapy, prophylactic antibiotics and early endoscopic therapy. Pre-emptive transjugular intrahepatic portosystemic shunt should be used in all Child C10-C13 patients experiencing variceal bleeding, and potentially in Child B patients with active bleeding at endoscopy. The use of carvedilol, safety of NSBBs in advanced cirrhosis (i.e. with refractory ascites) and assessment of hepatic venous pressure gradient response to NSBB is discussed. In the present review, we give an overview on the rationale behind the latest guidelines and summarize key papers that have led to significant advances in the field.

Keywords: Endoscopy; Non-selective betablockers; Portal hypertension; Transjugular intrahepatic portosystemic shunt.

Figure 1

Clinical algorithms recommended for cirrhotic patients in primary prophylaxis and secondary prophylaxis (adapted from the Austrian Billroth-III guidelines)[3]. EV: Esophageal varices; NSBB: Non-selective betablocker; EBL: Endoscopic band ligation; TIPS: Transjugular intrahepatic portosystemic shunt; BRTO: Balloon occluded retrograde transvenous variceal obliteration.

Figure 2

Clinical algorithm for treatment of patients with acute variceal bleeding (adapted from the Austrian Billroth-III guidelines)[3]. TIPS: Transjugular portosystemic shunt; i.v: Intravenous; NSBB: Non selective betablocker; EBL: Endoscopic band ligation; BRTO: Balloon occluded retrograde transvenous variceal obliteration.