Gastrointestinal varices secondary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Secondary Prevention

Secondary prevention of gastrointestinal varices involves prevention of rebleeding. The following options are available, according to the condition of the patient:

Time to start secondary prophylaxis

• Secondary prophylaxis should start as soon as possible from day 6 of the index variceal bleeding episode
• The time of initiation of secondary prophylaxis should be recorded.

Patients with cirrhosis who have not received primary prophylaxis

• In these patients, a combination of beta blockers and endoscopic band ligation may be used as a measure for secondary prophylaxis
• Rebledding risk may be predicted by using the patient's response to pharmacological therapy as a prognostic factor

Patients with cirrhosis who are on beta blockers for primary prevention and bleed

• Band ligation should be considered in addition to beta blockers

Patients who have contraindications or intolerance to beta blockers

• Band ligation is the treatment of choice for prevention of rebleeding

Patients who fail endoscopic and pharmacological treatment for prevention of rebleeding

• TIPS or surgical shunts (distal splenorenal shunt or 8 mm H-graft) are effective for those with Child class A/B cirrhosis
• In non-surgical candidates, TIPS is the sole option available
• Transplantation is associated with good long-term outcomes in Child class B/C cirrhosis and should be considered
• TIPS serves as a bridge to transplantation

Patients who have bled from isolated gastric varices, type 1 (IGV1) or gastro-oesophageal varices, type 2 (GOV 2)

• N-butyl-cyanoacrylate
• TIPS
• Beta blockers

Patients who have bled from gastro-esophageal varices, type 1 (GOV 1)

• May be treated via band ligation of oesophageal varices with cyanoacrylate or beta blockers

Patients who have bled from portal hypertensive gastropathy

• Beta blockers to prevent recurrent bleeding

Patients in whom beta blockers are contraindicated or fail and who cannot be managed by non-shunt therapy

• TIPS
• Surgical shunts