Management Strategies for Refractory Esophageal Varices

Abstract

Refractory esophageal varices that are difficult to control or unresponsive to endoscopic treatment remain a major clinical challenge in the management of portal hypertension. This review provides a comprehensive overview of treatment strategies for these cases, along with a comparative analysis of the American Association for the Study of Liver Diseases, Baveno VII, and Japanese clinical practice guidelines. Treatment approaches are classified into four domains: endoscopic therapy, interventional radiology (IVR), surgical procedures, and internal medicine-based strategies. In recent years, clinical practice has shifted from traditional surgical interventions and transjugular intrahepatic portosystemic shunt (TIPS) to minimally invasive IVR techniques, such as partial splenic embolization, percutaneous transhepatic obliteration, and transileocolic vein obliteration, often combined with endoscopic methods. In Japan, where TIPS is not routinely performed due to limited availability and lack of insurance coverage, these alternative IVR procedures are more commonly utilized. Differences among regional guidelines highlight the need for adaptable treatment strategies based on local resources and institutional expertise. Effective management of refractory cases requires multidisciplinary collaboration among gastroenterologists, interventional radiologists, and surgeons. This review emphasizes the importance of integrating international evidence with local clinical practice to develop a tailored, team-based approach that improves outcomes in patients with complex variceal disease.

Keywords: esophageal varices bleeding; internal medicine treatment; interventional radiology; refractory bleeding; surgical therapy.

FIGURE 1

Images of pipeline esophageal varices: (a) Endoscopic images of pipeline esophageal varices. (b) 3D‐CT images of pipeline esophageal varices. Pipeline esophageal varices run from the left gastric vein through the gastric cardia and gastroesophageal junction to the middle and upper esophagus (arrow).

FIGURE 2

Portal decompression techniques: (a) Transjugular intrahepatic portosystemic shunt (TIPS). A catheter is inserted into the hepatic vein via a transjugular approach, followed by a puncture from the hepatic vein into the portal vein. An expandable polytetrafluoroethylene‐covered stent graft is then inserted to create a connection between the portal and hepatic veins. TIPS reduces portal hypertension and prevents esophageal variceal bleeding. (b) Partial splenic embolization (PSE). PSE is performed via the femoral artery approach using a microcatheter to access the peripheral branches of the splenic blood vessels. Embolization is then performed using metal coils or a gelatin sponge. PSE reduces portal vein pressure and splenic vein blood flow.

FIGURE 3

Collateral embolization techniques: (a) Percutaneous transhepatic obliteration (PTO). PTO is a procedure in which a catheter is inserted percutaneously and transhepatically into the portal vein to embolize collateral circulation branching from the portal vein. (b) Transileocolic vein obliteration (TIO). TIO is a procedure in which the ileocolic vein is exposed through laparotomy and a catheter is inserted antegrade through the ileal vein to embolize the varices.