Varices

Top tips:

  1. Patients with compensated cirrhosis and fibroscan based liver stiffness <20 kPa AND platelet count >150,000, do not need endoscopy to screen for varices
  2. All patients with a suspected variceal bleed should receive antibiotic prophylaxis (ceftriaxone, 1 g i.v. daily for 7 days or until discharge whichever occurs sooner)
  3. After a variceal bleed, prevention of re-bleeding includes a combination of variceal ligation and non-selective beta-blockers (in the absence of contraindications)
  4. Intolerance to one beta-blocker can often be overcome by switching to a different beta-blocker

Order panel for Variceal bleeding:

For adults with cirrhosis admitted with a Variceal bleed:

Variceal Bleed Order Panel

General Cirrhosis Admission and Discharge Order Sets

*Add specific panels to general admission orders as appropriate*

For adults with cirrhosis requiring hospital admission
Cirrhosis Adult Admission Orders

For adults with cirrhosis requiring hospital discharge
Cirrhosis Adult Discharge Orders

Dr. Abraldes cartoon-needs white hair

Check out the bottom of the page for short videos from Dr. Abraldes!

Variceal Surveillance, Primary and Secondary Prophylaxis of Esophageal and Gastric Varices:

Compensated Cirrhosis

Defined by: the absence of ascites, hepatic encephalopathy, variceal bleeding or jaundice (see more info)

Decompensated Cirrhosis

Defined by: the presence of ascites, hepatic encephalopathy, variceal bleeding or jaundice (see more info)

Choosing between Beta-blockers versus Endoscopic variceal ligation for primary prophylaxis against variceal bleeding
  Non-selective Beta-blockers Endoscopic Variceal Ligation
Main Advantages
  • Low cost
  • No need for follow-up endoscopies unless bleeding occurs
  • Might prevent other complications of cirrhosis (ascites)
  • No contraindications other than those of upper endoscopy
  • No need to titrate medication
  • Main Disadvantages
  • Requires dose titration (simplest with carvedilol)
  • 15% of patients have contraindications
  • 15% have intolerance (fatigue, orthostatic symptoms, impotence, bronchial hyper-reactivity).
  • Higher cost
  • Need for repeated procedures and endoscopic surveillance
  • Practical tips on the use of NSBBs
    Propranolol
    Practical Tips
  • Allows using a very low dose in patients with low tolerance (from 5 mg OD)
  • Liver clearance (lower dose required in patients with significant liver dysfunction)
  • Intolerance to one NSBB may sometimes be overcome by switching to another NSBB
  • Recommended dose
    • Initial dose: 20-40 mg orally twice a day
    • Adjust every 2-3 days until treatment goal is achieved
    • Maximal daily dose:
      • 320 mg /day in patients without ascites
      • 160 mg/day in patients with ascites.

    Therapy goals
  • Resting heart rate of 55-60 beats per minute
  • Systolic blood pressure should not decrease < 90 mmHg
  • Nadolol
    Practical Tips
  • Renal clearance --> Avoid in patients with renal failure or unstable renal function
  • Dose once daily
  • Intolerance to one NSBB may sometimes be overcome by switching to another NSBB
  • Recommended dose
    • 20-40 mg orally once a day
    • Adjust every 2-3 days until treatment goal is achieved
    • Maximal daily dose:
      • 160 mg/day in patients without ascites
      • 80 mg/day in patients with ascites

    Therapy goals
  • Resting heart rate of 55-60 beats per minute
  • Systolic blood pressure should not decrease < 90 mmHg
  • Carvedilol
    Practical Tips
  • Easier to titrate that Nadolol or Propranolol
  • Preferred in patients with arterial hypertension
  • Recommended dose
    • Start with 6.25 mg once a day
    • After 3 days increase to 6.25 mg twice daily
    • Maximal dose: 12.5 mg/day (except in patients with persistent arterial hypertension)

    Therapy goals
  • Systolic arterial blood pressure should not decrease < 90 mmHg
  • Acute Variceal Bleeding

    Acute Variceal Hemorrhage

    Management of Rectal Varices

    A Practical Approach to Rectal Varices

    • Management of Ectopic varices, including rectal varices requires a multidisciplinary approach. No randomized trials have been conducted so far to guide management
    • CT scan with venous phase essential to define the anatomy of the portal systemic collaterals feeding the rectal varices
    • Endoscopic treatment for rectal varices with either banding ligation or sclerotherapy is controversial, since it is associated with high rate of complications
    • A better initial approach might be transhepatic embolization of the rectal varices. This achieves hemostasis without recurrence in a high number of patients
    • In case of recurrence, TIPS can be attempted if no contraindications

    Introducing Dr. Abraldes!

    Video 1 – The top things that may be useful for you to know about this page as a family physician including: Do all patients need to be screened for varices? and How to titrate up non-selective beta blockers.

    Video 2 – How I use the Fibroscan and platelet count to determine if my patient needs to be screened for varices. What to do if there are delays with scopes (e.g. COVID)?

    Video 3 – Practical tips for managing a variceal bleed in cirrhosis – how I do it!

    Video 4 – Transjugular intrahepatic portosystemic shunt (TIPS) for cirrhosis and variceal bleeding – indications and cautions.

    Patient materials:

    You can direct patients to the following:
    Varices

    TIPS

    Portal hypertension

    Upper endoscopy 

    Variceal banding

      Calculators:

    Use these calculators:

    Child Pugh

    MELD-Na

    Downloadable content:

    You can download these to print or view offline:
    AASLD guidelines

    EASL guidelines (decompensated cirrhosis)

    Baveno guidelines 2015

    References:

    This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.

    Authors: Dr. Juan Abraldes, Dr. Guadalupe Garcia-Tsao, Dr. Kelly Burak, Dr. Puneeta Tandon

    References:

    1. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018 Aug;69(2):406-460 PMID 29653741
    2. de Franchis R et al. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015 Sep; 63(3):743-52 PMID 26047908
    3. Villanueva C et al. β-blockers to prevent decompensation of cirrhosis in patients with clinically significant portal hypertension (PREDESCI): a randomised, double-blind, placebo-controlled, multicentre trial PMID 30910320
    4. Garcia-Tsao G et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017 Jan;65(1):310-335. PMID 27786365
    5. Burak KW HepAPPtology.
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