Therapy

There are three instances when the endoscopist may be confronted with esophageal varices:

1. Before the first bleed

2. During the first bleed

3. After the first bleed

Treatment Before the First Bleed

The detection of esophageal varices before the first bleeding episode is generally accomplished during the staging examination for portal hypertension. Less commonly, the varices are detected incidentally.

Procedures

► It should be recognized during treatment planning that the prognosis depends more on the degree of hepatic insufficiency than on the severity of the esophageal varices.

► Mild varices do not require treatment.

► Pronounced varices with a high bleeding risk can be treated medically with 80-240 mg/day propranolol, which may be combined with 2 x 40 mg/day isosorbide mononitrate.

► Spironolactone in a dose of 100-200 mg/day can be considered as an alternative to beta-blockers.

► No endoscopic treatment

► No operative treatment

► No transjugular intrahepatic portosystemic shunting (TIPS) insertion

Treatment During the First Bleed

See page 147 ff.

Treatment After the First Bleed

The goal of emergency treatment is to control the primary bleeding and prevent rebleeding.

Procedures (Fig. 3.62)

► Esophageal varices are ligated or sclerosed with polidocanol. Fundic varices are obliterated with Histoacryl.

► In both cases, an initial second look is scheduled approximately four days after successful hemostasis.

► With good response to ligation or sclerotherapy, further follow-ups are scheduled at three weeks, three months, and six months.

► If the varices persist, sclerotherapy or ligation is continued at two- to four-week intervals with the goal of complete eradication.

► Small residual varices following primary ligation can be sclerosed.

► Propranolol may also be given as an adjunct.

Esophagus

Esophagus

Fig. 3.62 Management of bleeding varices (after Soehendra)

Stomach/duodenum

Obliterationwith Histoacryl

Fig. 3.62 Management of bleeding varices (after Soehendra)

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Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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