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: Portal hypertension, Endoscopy, Non-selective betablockers, Transjugular intrahepatic portosystemic shunt

Core Tip: Variceal bleeding is a severe, and often deadly, complication of portal hypertension. Screening for varices, effective bleeding prophylaxis and standardized management of bleeding is critical to improve clinical outcomes. While carvedilol seems to be the treatment of choice for primary prophylaxis in compensated cirrhosis, the use of hepatic venous pressure gradient measurements and safety of non-selective betablockers in advanced cirrhosis with refractory ascites is controversial. The pre-emptive use of transjugular intrahepatic portosystemic shunt within 72 h after variceal bleeding prevents rebleeding and mortality in Child C10-C13 patients.