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
Secondary prevention of gastrointestinal varices involves prevention of rebleeding. The following options are available, according to the condition of the patient:[1][2][3][4]
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
References
- ↑ Krige JE, Kotze UK, Bornman PC, Shaw JM, Klipin M (2006). "Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices". Ann. Surg. 244 (5): 764–70. doi:10.1097/01.sla.0000231704.45005.4e. PMC 1856595. PMID 17060770.
- ↑ de Franchis R (2005). "Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension". J. Hepatol. 43 (1): 167–76. doi:10.1016/j.jhep.2005.05.009. PMID 15925423.
- ↑ "Esophageal varices: from appearance to rupture; natural history and prognostic indicators | SpringerLink".
- ↑ D'Amico G, De Franchis R (2003). "Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators". Hepatology. 38 (3): 599–612. doi:10.1053/jhep.2003.50385. PMID 12939586.