Primary prevention

The UK National Institute for Health and Care Excellence (NICE) recommends:[17]

  • Referring patients with cirrhosis at high risk of complications (e.g., oesophageal varices), or with complications, to a specialist hepatology centre

  • Calculating the Model for End-Stage Liver Disease (MELD) score every 6 months for patients with compensated cirrhosis

    • Consider a MELD score ≥12 as an indicator that the person is at high risk of complications of cirrhosis.

Propranolol should be offered as first-line treatment for the prevention of bleeding for patients with cirrhosis and medium to large oesophageal varices, as recommended by the British Society of Gastroenterology (BSG).[5] Other non-selective beta blockers (NSBBs) such as carvedilol or nadolol can be used as an alternative to propranolol. Baveno VII (the European consensus meeting on portal hypertension) also recommends propranolol, carvedilol, or nadolol as first-line agents.[29] Carvedilol is preferred in compensated cirrhosis, since it is more effective at reducing hepatic venous pressure gradient. This is partly due to its intrinsic anti-alpha adrenergic vasodilatory effects.

Follow your local protocols for guidance on when to use endoscopic band ligation. In practice, some UK experts follow the BSG guidelines, which recommend endoscopic variceal band ligation:[5] 

  • For patients who are intolerant to NSBBs or when NSBBs are contraindicated

  • If the patient chooses this as their preferred option.

However, bear in mind that recommendations from NICE in the UK differ. NICE only recommends endoscopic variceal band ligation for the primary prevention of bleeding in patients with medium and large oesophageal varices.[6][17] 

Band ligation of oesophageal varices for the primary prevention of bleeding reduces mortality, upper gastrointestinal bleeding, variceal bleeding, and serious adverse events compared with no intervention.[30] Note that band ligation cannot be done successfully in patients with small varices; it is only used in patients with medium to large varices.[30]

Annual endoscopy should be offered to patients with cirrhosis and small oesophageal varices, in line with recommendations from the BSG.[5] 

  • If there is clear evidence of disease progression, the BSG recommends modifying the endoscopy intervals according to clinical need.[5] 

The role of NSBBs for the primary prevention of bleeding in patients with cirrhosis and small varices is unclear.[5][17][31][32][33] A large, triple blinded, multi-centre randomised controlled trial looking at NSBB versus placebo for the primary prophylaxis of variceal haemorrhage in these patients is ongoing.[34] 

Secondary prevention

Patients with acute variceal haemorrhage are at high risk of rebleeding and therefore all need interventions for secondary prevention.

  • The British Society of Gastroenterology (BSG) defines variceal rebleeding as the occurrence of a single episode of clinically significant rebleeding from portal hypertensive sources from day 5.[5]

    • Clinically significant rebleeding is defined by the BSG as recurrent melaena or haematemesis alongside any of the following scenarios:[5] 

      • Hospital admission

      • Blood transfusion

      • 30 g/L drop in haemoglobin

      • Death within 6 weeks.

The BSG recommends the following for the secondary prevention of oesophageal variceal haemorrhage.[5] 

  • A combination of a non-selective beta-blocker (NSBB) plus endoscopic variceal band ligation.[6][29]​​[73][74][75] The Baveno VII consensus recommends propranolol, carvedilol, or nadolol as first-line NSBBs.[29]​ 

    • NSBBs or endoscopic variceal band ligation can be used in monotherapy as an alternative to combined treatment, taking into account the patient’s preferences when making your decision

    • Endoscopic variceal band ligation alone is an option if there are contraindications or intolerance to combined use with a non-selective beta-blocker.

  • Varices should be banded at 2- to 4-weekly intervals until eradication in patients undergoing variceal band ligation. Once varices have been eliminated, an endoscopy should be performed at 3 months, and then every 6 months.

  • Recurrent varices should be treated with further endoscopic variceal band ligation until eradication.

  • Transjugular intrahepatic portosystemic shunt (TIPS) is recommended for patients who rebleed despite combined NSBBs plus endoscopic variceal band ligation therapy or either intervention alone. TIPS can also be used based on patient choice.

    • TIPS with polytetrafluoroethylene (PTFE)-covered stents is used in preference to bare stents, as there is evidence that PTFE-covered stents are associated with a significantly higher primary patency rate and survival rate, and a significantly decreased rebleeding rate.[76] 

    • Absolute contraindications to TIPS placement include:[79] 

      • Severe pulmonary hypertension (mean pulmonary pressure >45 mmHg)

      • Severe tricuspid regurgitation

      • Congestive heart failure

      • Severe liver failure

      • Polycystic liver disease

      • Active sepsis.

    • Relative contraindications to TIPS include:

      • Severe obstructive arteriopathy

      • Hepatic artery and coeliac trunk stenosis (preventing adequate sinusoidal perfusion by the hepatic artery)

      • Recurrent hepatic encephalopathy

      • Hepatocellular carcinoma and other liver tumours

      • Bile duct dilation.

  • In patients with Child-Pugh class A or B cirrhosis where TIPS is not feasible, shunt surgery can be used if the local expertise and resources are available. [ Cochrane Clinical Answers logo ]  

BSG guidelines do not support the use of proton pump inhibitors (unless required for the treatment of peptic disease), ‘prophylactic’ clotting or platelet support to reduce the risk of rebleeding, or the routine use of recombinant factor VIIa.[5] Neither the BSG nor the BSH support the use of tranexamic acid in acute gastrointestinal bleeding.[53]​ Studies have shown that high-dose tranexamic acid does not reduce mortality in these patients.[77][78]

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