Gastrointestinal varices secondary prevention

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

Overview

Secondary prevention of gastrointestinal varices involves prevention of rebleeding. The following options are available:

Time to start secondary prophylaxis

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

Patients with cirrhosis who have not received primary prophylaxis

Beta blockers (1a;A), band ligation (1a;A)or both (1b;A) should be used for prevention of recurrent bleeding
Combination of beta blockers and band ligation is probably the best treatment (1b;A) but more trials are needed
Assessment of haemodynamic response to drug therapy provides prognostic information about rebleeding risk

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

Patients who have contraindications or intolerance to beta blockers

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 and should be used (2b;B).
In non-surgical candidates, TIPS is the only option
Transplantation provides good long-term outcomes in Child class B/C cirrhosis and should be considered (2b;B). TIPS may be used as a bridge to transplantation (4;C).

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

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

May be treated with N-butyl-cyanoacrylate, band ligation of oesophageal varices or beta blockers (2b;B).

Patients who have bled from portal hypertensive gastropathy

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