Oesophageal Varices Primary Prophylaxis
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Direct answer
Primary prophylaxis of oesophageal varices aims to prevent the first variceal bleed in a patient who has varices but has never bled. Medium or large varices, or small varices with red wale signs, are treated with a non-selective beta blocker such as propranolol or carvedilol. Endoscopic band ligation is the alternative when beta blockers are contraindicated or not tolerated, and beta blockers are withheld during an acute bleed.
What you must remember
- Indication: Medium or large varices, or small varices with red wale signs or Child-Pugh class C disease; small varices without high-risk features are usually only observed.
- First-line drugs: Propranolol or carvedilol, titrated to tolerance, aiming for a resting heart rate of about 55 to 60 per minute with propranolol, while keeping systolic pressure above 90 mmHg.
- Band ligation: The alternative when beta blockers are contraindicated, repeated at intervals until the varices are obliterated.
- Beta blocker cautions: Avoid in refractory ascites, systolic pressure below 90 mmHg, sodium below about 125 to 130 mmol/L and asthma.
- Acute bleed drugs: Vasoactive agents such as terlipressin or octreotide, started early and continued for two to five days, never propranolol.
- Acute bleed care: Ceftriaxone prophylaxis, endoscopy within 12 hours, and a restrictive transfusion target of haemoglobin about 7 to 8 g/dL.
A worked decision: beta blocker or band ligation
Consider a 48-year-old man with alcohol-related cirrhosis, Child-Pugh class B, and a screening endoscopy showing medium varices with red wale signs.
- Confirm the indication: Primary prophylaxis is indicated, and a non-selective beta blocker is the first choice.
- Check the contraindications: Before starting propranolol or carvedilol, the clinician checks for refractory ascites, low systolic pressure, hyponatraemia and any history of asthma or bronchospasm.
- Switch to band ligation if needed: If he has active asthma, the beta blocker is avoided and band ligation becomes the alternative.
- Repeat banding to eradication: Band ligation is repeated every few weeks until the varices are eradicated, followed by surveillance endoscopy.
- Understand the portal pressure logic: Beta blockers reduce cardiac output and splanchnic blood flow, which lowers the hepatic venous pressure gradient. A gradient above about 12 mmHg marks the range in which bleeding becomes likely.
- Explain why the treatments differ: Band ligation does not lower portal pressure; it removes the varix mechanically. That is why the two are not interchangeable in every setting, and beta blockers are preferred when they are tolerated.
- Combine after a bleed: Combination therapy, a beta blocker plus band ligation, is reserved for secondary prophylaxis after a bleed, where it reduces rebleeding more than either treatment alone.
Where the acute bleed trips candidates
The traps cluster around the acute bleed and around thresholds.
- Trap: reaching for propranolol as the first drug in an acute bleed. Correct: a non-selective beta blocker is not started as bleed therapy and is withheld if the patient is hypotensive, since it can cause hypotension and blunt the compensatory tachycardia. The first drug is a vasoactive agent, started as soon as variceal bleeding is suspected rather than after endoscopy confirms it, alongside restrictive volume replacement.
- Trap: giving drug therapy for a small varix. Correct: a small varix without red signs does not earn drug therapy, so surveillance endoscopy is the answer, not a beta blocker.
- Trap: treating asthma as a dose-adjustment problem. Correct: non-selective blockade is a contraindication, and the examiner is testing that recognition.
Frequently asked questions
Which drugs are used for primary prophylaxis of oesophageal varices?
Propranolol or carvedilol, both non-selective beta blockers, are first-line for primary prophylaxis of oesophageal varices in medium or large varices. Band ligation is the alternative when these drugs are contraindicated or not tolerated, such as in asthma.
Why are beta blockers withheld during an acute variceal bleed?
Beta blockers are withheld during an acute variceal bleed because they can cause hypotension and blunt the tachycardia that signals blood loss. Acute variceal bleeding is instead managed with vasoactive drugs, ceftriaxone and early endoscopy.
What is the transfusion target in acute variceal bleeding?
A restrictive transfusion policy is used in acute variceal bleeding, with a haemoglobin threshold of about 7 g/dL and a target of 7 to 8 g/dL. Overtransfusion raises portal pressure and can provoke further bleeding, so a restrictive policy is preferred over a liberal one.
When is pre-emptive TIPS considered in variceal bleeding?
Pre-emptive TIPS, a transjugular intrahepatic portosystemic shunt placed early, ideally within 24 hours and at most 72 hours, is considered for high-risk patients such as those with Child-Pugh class C disease, or class B with active bleeding at endoscopy. It reduces rebleeding and mortality in these groups.
What is secondary prophylaxis after a variceal bleed?
Secondary prophylaxis after a variceal bleed combines a non-selective beta blocker with endoscopic band ligation, repeated until the varices are eradicated. This combination lowers rebleeding more effectively than either treatment alone, and it is the standard approach after a first episode.