Oesophageal Varices
On this page
Direct answer
Band ligation and non-selective beta-blockers, alone or in sequence, prevent the first variceal haemorrhage in every patient with high-risk varices — those that are medium or large, or small with red wale marks or Child C cirrhosis. Baveno VII has restructured the pathway around transient elastography: a liver stiffness of 25 kPa or more establishes clinically significant portal hypertension with cirrhosis and directs the patient straight to beta-blockade, while stiffness of 15 kPa or less with a platelet count of 150 or above rules out varices needing therapy and defers endoscopy. Carvedilol 12.5 mg daily is the preferred beta-blocker in compensated cirrhosis, outperforming propranolol in portal pressure reduction. Endoscopic band ligation every 2–4 weeks until variceal eradication is the alternative when beta-blockers fail or are contraindicated, with surveillance endoscopy 3–6 months after eradication and combination therapy for the hardest cases.
What you must remember
- Non-invasive rule-in: liver stiffness over 25 kPa on transient elastography means clinically significant portal hypertension (HVPG 10 mmHg or above) with near-certainty of cirrhosis — no endoscopy needed to justify starting a beta-blocker.
- Rule-out pair: stiffness 15 kPa or less plus platelets 150 or more safely excludes varices requiring treatment; repeat elastography (with platelet count) in one year rather than scoping.
- Carvedilol dosing: start 6.25 mg daily, up-titrate to 12.5 mg daily; its alpha-1 blockade adds portal vasodilatation, achieving an HVPG response in a higher proportion than propranolol; conventional targets — systolic pressure above 90 mmHg and heart rate above 50.
- Contraindications to beta-blockade: asthma, second- or third-degree heart block, bradycardia, hypotension; discontinue permanently if systolic pressure falls below 90 or heart rate below 50 despite dose reduction.
- Band ligation protocol: sessions every 2–4 weeks until eradication, then endoscopy at 3–6 months and annually thereafter; post-ligation ulcers cause small bleeds and are managed with a PPI.
- Haemodynamic logic: the treatment goal is an HVPG fall of at least 10 per cent or to 12 mmHg or below — the level below which first bleeding and decompensation become rare; propranolol achieves this in only about a third of patients.
- Primary prophylaxis is not sclerotherapy: sclerotherapy is obsolete for prophylaxis; small varices without risk features need no therapy, only surveillance.
- The paediatric and Indian dimension: extrahepatic portal vein obstruction is a leading cause of portal hypertension in Indian children; varices bleed at lower grades but liver function is preserved, so bleeding risk and management thresholds differ from cirrhotic varices.
A stepwise prophylaxis pathway
A 54-year-old with hepatitis B cirrhosis, compensated, platelets 96,000, stiffness 31 kPa. The Baveno VII logic: stiffness above 25 kPa — clinically significant portal hypertension assumed, start carvedilol without waiting for endoscopy; confirm tolerability at two weeks. If he were stiffness 19 kPa with platelets 110, that intermediate zone triggers an endoscopy: medium varices confirm high risk and reinforce the beta-blocker; no varices means surveillance with non-invasive testing in one year. If carvedilol produces symptomatic hypotension and the varices are high risk on endoscopy, the path becomes band ligation to eradication. If he bleeds despite adequate beta-blockade, combination therapy — ligation plus continued beta-blockade — follows after controlling the index bleed, and in a suitable candidate secondary prophylaxis merges into the acute-bleeding and pre-emptive TIPS algorithms. Walking a patient down this decision tree, stating the stiffness numbers at each fork, is precisely the clinical reasoning a DM viva examines.
The trap the exam sets
The commonest wrong answer is endoscopy for everyone with cirrhosis — Baveno VII deliberately curtails scoping patients who can be stratified non-invasively. The second trap is dose logic: propranolol is titrated to heart rate, carvedilol is capped at 12.5 mg in most patients because higher doses drop systemic pressure without further portal benefit. Candidates also forget that beta-blocker intolerance is permanent grounds to switch strategy rather than to rechallenge, and that beta-blockers are stopped in refractory ascites with hypotension (systolic below 90) — paracentesis-induced circulatory dysfunction worsens.
Frequently asked questions
Which varices need primary prophylaxis?
High-risk varices: medium or large varices, or small varices with red wale marks or in Child C patients; small low-risk varices are surveyed, not treated.
What liver stiffness threshold replaces endoscopy for starting prophylaxis?
Above 25 kPa implies clinically significant portal hypertension, and non-selective beta-blockade (carvedilol preferred) is started without endoscopy.
Why is carvedilol preferred over propranolol?
It achieves a greater HVPG reduction — alpha-1 blockade adds intrahepatic and portocollateral vasodilatation — and it is given once daily without haemodynamic titration.
How is band ligation scheduled?
Sessions every 2–4 weeks until varices are eradicated, with a surveillance endoscopy 3–6 months later and then annually to detect recurrence.
What HVPG change defines a treatment response?
A fall of at least 10 per cent from baseline, or to 12 mmHg or below, which sharply reduces the risk of first variceal bleeding and other decompensation.