• World Gastroenterology Organisation (WGO). Esophageal varices. Munich (Germany): World Gastroenterology Organisation (WGO); 2008 Jun. 17 p.

This is the current release of the guideline.

Risk Factors

The presence of one or more of the conditions in Table 1 below represents an indication for endoscopy to search for varices and carry out primary prophylaxis against bleeding in cirrhotic patients.

Table 1: Risk Factors for Esophageal Varices and Hemorrhage

HVPG, hepatic venous pressure gradient

Diagnosis and Differential Diagnosis

Esophagogastroduodenoscopy (EGD) is the gold standard for the diagnosis of esophageal varices. If the gold standard is not available, other possible diagnostic steps would be Doppler ultrasonography of the blood circulation (not endoscopic ultrasonography). Although this is a poor second choice, it can certainly demonstrate the presence of varices. Further alternatives include radiography/barium swallow of the esophagus and stomach, and portal vein angiography and manometry.

It is important to assess the location (esophagus or stomach) and size of the varices, signs of imminent, first acute, or recurrent bleeding, and (if applicable) to consider the cause and severity of liver disease.

Table 2: Guideline for Diagnosing Esophageal Varices

Differential Diagnosis of Esophageal Varices/Hemorrhage

The differential diagnosis for variceal hemorrhage includes all etiologies of (upper) gastrointestinal bleeding. Peptic ulcers are also more frequent in cirrhotics.

Table 3: Differential Diagnosis of Esophageal Varices/Hemorrhage

Note: all of these lead to the development of esophageal varices as a result of portal hypertension.

Other Considerations

Table 4: Considerations in the Diagnosis, Prevention, and Management of Esophageal Varices and Variceal Hemorrhage

Management of Varices and Hemorrhage

The following treatment options are available in the management of esophageal varices and hemorrhage (see Tables 5 and 6 below). Although they are effective in stopping bleeding, none of these measures, with the exception of endoscopic therapy, has been shown to affect mortality.

Table 5: Pharmacological Therapy

Table 6. Endoscopic Therapy

Endoscopic sclerotherapy and variceal ligation are effective in stopping bleeding in up to 90% of patients. Endoscopic band ligation is as effective as sclerotherapy, but is associated with fewer side effects. However, endoscopic band ligation may be more difficult to apply than sclerotherapy in patients with severe active bleeding.

A TIPS is a good alternative when endoscopic treatment and pharmacotherapy fail.

The use of balloon tamponade is decreasing, as there is a high risk of rebleeding after deflation and a risk of major complications. Nevertheless, balloon tamponade is effective in most cases in stopping hemorrhage at least temporarily, and it can be used in regions of the world where EGD and TIPS are not readily available. It can help stabilize the patient in order to gain time and access to EGD and/or TIPS later.

Clinical Practice: The Approach in Patients with Cirrhosis and Various Stages of Varices/Hemorrhage

Patients with Cirrhosis But No Varices (see Figure 4a in the original guideline document)

• Beta-blockers do not prevent varices
• Repeat EGD in 3 years
• Immediate EGD if hepatic decompensation occurs

Patients with Cirrhosis and Small Varices, But No Hemorrhage (see Figure 4b in the original guideline document)

• Increased risk of hemorrhage: Child B/C or presence of red wale marks: nonselective beta-blockers for prevention of first variceal hemorrhage
• No increased risk: beta-blockers can be used - long-term benefits not established
• Not receiving beta-blockers: Repeat EGD in 2 years
• In case of hepatic decompensation: EGD at once; repeat annually
• Patients on beta-blockers: follow-up EGD not necessary

Because many patients do not respond to beta-blocker treatment or bleeding prophylaxis, it is recommended that EGD be repeated after 2 years (as for those not receiving beta-blockers).

Patients with Cirrhosis and Medium or Large Varices, But No Hemorrhage (see Figure 4c in the original guideline document)

• High risk of hemorrhage: Child B/C or variceal red wale markings: beta-blockers (propranolol or nadolol) or endoscopic variceal ligation (EVL) recommended for prevention of first variceal hemorrhage
• Not at highest risk: Child A patients and no red signs: Nonselective beta-blockers (propranolol or nadolol) preferred
• In case of contraindications/intolerance/noncompliance, consider EVL
• Noncardioselective beta-blockers (propranolol or nadolol), starting at a low dosage, if necessary increasing the dose step by step until a reduction in the resting heart rate of 25%, but not lower than 55 beats/min, is reached.
• In comparison with beta-blockers, endoscopic variceal ligation was found to reduce bleeding episodes and severe adverse events significantly, but it had no effect on the mortality rate.

Patients with Cirrhosis and Acute Variceal Hemorrhage

Table 7: Management of Acute Variceal Hemorrhage in Patients with Cirrhosis

Acute variceal hemorrhage is often associated with bacterial infection due to gut translocation and motility disturbances. Prophylactic antibiotic therapy has been shown to increase the survival rate.

• In acute or massive variceal bleeding, tracheal intubation can be extremely helpful to avoid bronchial aspiration of blood.
• In patients with variceal hemorrhage in the gastric fundus: endoscopic variceal obturation using tissue adhesives (such as cyanoacrylate) is preferred; the second choice is EVL.
• TIPS should be considered in uncontrollable fundic variceal bleeding or recurrence despite combined pharmacological and endoscopic therapy.
• Emergency sclerotherapy is not better than pharmacological therapy for acute variceal bleeding in cirrhosis.
• Treating bleeding in the esophagus with somatostatin analogues does not appear to reduce deaths, but may lessen the need for blood transfusions.

Patients with Cirrhosis Who Have Recovered from Acute Variceal Hemorrhage (see Figure 4e in the original guideline document)

• Secondary prophylaxis: nonselective beta-blockers plus EVL:
  • Adjust beta-blocker to maximal tolerated dose
  • Repeat EVL every 1-2 weeks until obliteration with EGD at 1-3 months
• In Child A/B patients with recurrent hemorrhage despite combination therapy:
  • Consider surgical shunt in Child A patients
  • Refer to transplant center for evaluation

Long-term endoscopic control and banding or sclerotherapy of recurrent varices every 3-6 months (only sclerotherapy will be available in many places in the developing world). If endoscopic band ligation is not available or contraindicated, noncardioselective beta-blockers (propranolol or nadolol) starting at a low dosage and if necessary increasing the dosage step by step until a reduction in the resting heart rate by 25%, but not lower than 55 beats/min, is achieved.

In younger patients with less advanced cirrhosis (Child-Pugh A), the addition of isosorbide 5-mononitrate (starting at 2 x 20 mg per day and increasing to 2 x 40 mg per day) may be considered if sclerotherapy or pharmacotherapy fail. TIPS should be considered, especially in candidates for liver transplantation. In selected cases (patients with well-preserved liver function, stable liver disease), a calibrated H graft or a distal splenorenal shunt (Warren shunt) may be considered.

Portosystemic shunts are associated with lower rates of variceal rebleeding in comparison with sclerotherapy/banding, but they increase the incidence of hepatic encephalopathy.

Liver transplantation should always be considered if the patient has Child-Pugh grades B or C.

Recommendations for First-Line Management of Cirrhotic Patients at Each Stage in the Natural History of Varices (see Figure 5 in the original guideline document)

No varices

• Repeat endoscopy in 2-3 years

Small varices - no hemorrhage

• Repeat endoscopy in 1-2 years

Medium/large varices - no hemorrhage

• Beta-blocker (propranolol, nadolol)
• EVL if beta-blockers are not tolerated

Variceal hemorrhage

• Specific therapy: safe vasoactive drug + EVL

Recurrent hemorrhage

• Beta-blockers +/- isosorbide 5-mononitrate (ISMN) or EVL
• Beta-blockers + EVL

Cascade for Treatment

A cascade is a hierarchical set of diagnostic or therapeutic techniques for the same disease, ranked by the resources available.

As outlined above, several therapeutic options are effective in most clinical situations involving acute variceal hemorrhage, as well as in secondary and primary prophylaxis against it. The optimal therapy in an individual setting very much depends on the relative ease of local availability of these methods and techniques. This is likely to vary widely in different parts of the world.

If endoscopy is not readily available, one has to resort to pharmacotherapy in any case of suspected variceal bleeding (e.g., in patients with hematemesis and signs of cirrhosis). Similarly, pharmacological therapy might be administered in circumstances such as primary prophylaxis in a cirrhotic patient with signs of portal hypertension (splenomegaly, thrombocytopenia) and/or impaired liver function, and as secondary prophylaxis in a cirrhotic patient with a history of upper gastrointestinal bleeding.

If pharmacotherapy is also not available and variceal bleeding is suspected, one must resort to general resuscitation measures and transport the patient as soon as possible to an institution where the necessary diagnostic/therapeutic means are available; balloon tamponade could be extremely helpful in such a situation.

Cascade for the Treatment of Acute Esophageal Variceal Hemorrhage

Note: The combination of band ligation and sclerotherapy is not routinely used except when the bleeding is too extensive for a vessel to be identified for banding. In such cases, sclerotherapy can be carried out in order to control the bleeding and clear the field sufficiently for banding to be done afterward.

Caution: There are many conditions that can lead to esophageal varices. There are also many treatment options, depending on the resources available. For a resource-sensitive approach to treatment in Africa, for example, Fedail SS. Esophageal varices in Sudan. Gastrointest Endosc 2002;56:781-2 can be consulted.

Algorithms for the approach in patients with cirrhosis and various stages of varices/hemorrhage are provided in the original guideline document.

The type of supporting evidence is not specifically stated for each recommendation.

• World Gastroenterology Organisation (WGO). Esophageal varices. Munich (Germany): World Gastroenterology Organisation (WGO); 2008 Jun. 17 p.

Not applicable: The guideline was not adapted from another source.

2008 Jun

World Gastroenterology Organisation - Medical Specialty Society

World Gastroenterology Organisation (WGO-OMGE)

Review Committee

Committee Members: Prof. P. Dite (Co-Chairman, Czech Republic); Prof. D. Labrecque (Co-Chairman, USA); Prof. Michael Fried (Switzerland); Prof. A. Gangl (Austria); Prof. A.G. Khan (Pakistan); Prof. D. Bjorkman (USA); Prof. R. Eliakim (Israel); Prof. R. Bektaeva (Kazakhstan); Prof. S.K. Sarin (India); Prof. S. Fedail (Sudan); Dr. J.H. Krabshuis (France); Dr. A. Le Mair (The Netherlands)

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on December 31, 2008. This summary was updated by ECRI Institute on May 5, 2009, following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium).

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