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Acute variceal bleeding is a serious complication of portal hypertension, usually due to cirrhosis, with high morbidity and mortality.
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Endoscopy plays a major role in the diagnosis and risk stratification of esophageal varices, but noninvasive tests including liver elastography also may be useful for screening.
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For the prevention of first variceal hemorrhage in patients with medium or large varices found on endoscopy, either nonselective β-blockers or endoscopic variceal ligation is recommended.
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Endoscopic Treatment of Esophageal Varices
Section snippets
Key points
Epidemiology
The global incidence of EVs is difficult to determine due to a variability among regions and the problem of underreporting. Recent statistics show that EVs are the seventh most common cause of GI bleeding in the United States.1 In Africa, however, EVs are the leading cause due to high prevalence of schistosomiasis.2 In the west, the most common cause of EVs is cirrhosis, and up to 85% of cirrhotic patients develop EVs at some point in their lives.3, 4, 5 The incidence of EVs in cirrhosis
Pathophysiology
EVs develop in the presence of PH, which is defined by a portal pressure (PP) of greater than 5 mm Hg. Classically, the PP has been measured indirectly through the determination of the hepatic venous pressure gradient (HVPG). This is done by measuring the pressure of the hepatic vein (HV) in 2 separate scenarios. A balloon catheter is introduced through the jugular or femoral vein and advanced to the HV. With the balloon deflated, the pressure of the HV is measured while the catheter floats
Diagnosis and risk stratification
The gold standard for the diagnosis of EVs is esophagogastroduodenoscopy (EGD). The advantages of EGD over other diagnostic methods include its ability to risk stratify through determining size and high-risk stigmata but most importantly its added therapeutic capacities. Whenever possible, EGD should be the preferred diagnostic and therapeutic tool of EV. In regions of the world where cost and availability limit the access to endoscopy, other methods can be used, but practitioners should
Prevention of first esophageal variceal hemorrhage
There are 3 scenarios for the endoscopic management of EVs: role in the prevention of first variceal bleed, treatment of acute variceal hemorrhage, and secondary prophylaxis after a variceal bleed. Recommendations for prevention of first variceal hemorrhage are based on the AASLD guidelines6 and the Baveno VI consensus workshop,19 as well as guidelines of the American Society for Gastrointestinal Endoscopy (ASGE),25 British Society of Gastroenterology (BSG),26 and European Society of
Endoscopic treatments for acute esophageal variceal hemorrhage and prevention of rebleeding
Recommendations for the treatment and prevention of recurrence of AVB are based primarily on consensus conferences and major gastroenterology and hepatology societies, including the Baveno VI consensus workshop19 and the AASLD,6 as well as the ASGE,25 BSG,26 and ESGE.27 The ESGE guidelines27 use a cascade approach to resource-sensitive statements from the Baveno VI guidelines.
Patients presenting with AVB are considered decompensated, with a 5-year mortality of at least 20% and much greater if
Summary
Although EVL is the first-choice treatment of AVB, there are certain situations where EVS may have a role. Treatment with either an SB tube or a self-expanding covered metallic esophageal stent can be used for AVB refractory to standard pharmacologic and endoscopic therapy. SB tube placement can be done with endoscopic assistance. BT and esophageal stents are considered bridge therapy until rescue TIPS is performed.
Clinics care points
Patients with cirrhosis should be screened for EVs. EVs screening and surveillance intervals for upper endoscopy in patients with cirrhosis have been recommended. EV ligation is an option for the prevention of first variceal hemorrhage in patients with medium or large varices found on endoscopy. The recommended type of endoscopic therapy for AVB is EV ligation (banding). This should be repeated at intervals until eradication of EVs to prevent rebleeding. Although banding is the first-choice
Disclosure
The authors have nothing to disclose.
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