Teaching Pearls:

• Esophageal varices are seen in roughly 50% of patients with cirrhosis.
• About 33% of patients with cirrhosis and esophageal varices will have at least one clinical presentation of esophageal variceal (EV) bleeding.
• Mortality of 15-20% associated with each episode of esophageal bleeding event.
• EV bleeding comprises of 33% of all cirrhosis-related deaths.
• Risk of EV bleeding correlates with size of varices and other characteristics such as nipple sign and red wales sign.
• Pre-primary prophylaxis – Management of cirrhotic patients without esophageal varices
  • Management focuses on treating the underlying cause of cirrhosis.
  • Screening occurs ~2-3 years.
• Primary Prophylaxis – Management of cirrhotic patients with EV but no clinical history of GI bleed.
  • Medical management with beta blockers
    • Performed in those with medium-large varices, or small varices with red wales/nipple sign.
  • Esophageal band ligation
    • Performed in those with large varices
  • Continued Monitoring
    • Those with small EV without red wales/nipple sign.
• Immediate interventions to consider in patients with suspected EV bleeding:
  • At least 2 large bore PIVs (16 or 18G) or central line
  • Fluid resuscitation
  • Type and screen blood
  • Monitor hemodynamics
  • Start protonix (bolus and gtt) and octreotide (bolus and gtt)
  • Start ceftriaxone for SBP prophylaxis
• Pantoprazole
  • PPI will increase the pH of the gastric lumen to 5-6 from 1-2.
  • pH changes help with improving clot formation
• Octreotide
  • Works by inhibiting endogenous substances – leads to splanchnic vasoconstriction, decreasing portal flow, leading to decreased portal pressures.
• SBP Prophylaxis Conditions
  • History of SBP
  • Cirrhosis with GI bleed
  • Ascitic TP <1
• Management of gastric varices differ from esophageal varices.
  • Cyanoacrylate injection and/or TIPS