Treatment of Oesophageal Varices in Liver Cirrhosis

The development of cirrhosis with resultant portal hypertension can lead to oesophageal varices at a rate of 7% per annum. Bleeding from varices happens when the portal pressure is ≥12 mm Hg and can threaten life.Eliminating the aetiology of cirrhosis is a pivotal step to prevent the formation of varices. In patients with established varices, primary prophylaxis with non-selective beta blockers (NSBB) may slow down the progression of varices and prevent the first variceal bleed. NSBB, similar to other agents such as renin/angiotensin blockers, statins, and rifaximin, may have the additional advantage of blunting inflammatory stimuli, which can contribute to the progression of varices. Variceal band ligation is an alternative for primary bleeding prophylaxis with excellent results. Any acute variceal bleed should be managed with band ligation after careful resuscitation. Early pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) in decompensated cirrhotic patients is very effective in controlling the bleeding and improves survival. Secondary prophylaxis against further variceal bleeding using NSBB and band ligation is recommended in most other patients. TIPS may be considered in appropriate patients as a secondary prophylaxis against recurrent variceal bleed. Future research should be directed towards the prevention of varices and targeting inflammation to reduce cirrhotic complications. Key Messages: Treatment strategies depend on the stage the patient is at along the natural history of varices: NSBB or band ligation for primary prophylaxis; band ligation or early TIPS for acute bleed; and a combination of NSBB + band ligation or TIPS for secondary prophylaxis (Fig. 1).