Gastroesophageal varices are present in almost half of patients with cirrhosis at the time of diagnosis, with the highest rate among patients with Child–Turcotte–Pugh class B or C disease. The 1-year rate of recurrent variceal hemorrhage is approximately 60%. The 6-week mortality with each episode of variceal hemorrhage is approximately 15 to 20%.
How should acute variceal hemorrhage be treated in patients with compensated cirrhosis?
Patients who have Child class A or B disease or who have an hepatic venous pressure gradient (HVPG) of less than 20 mm Hg have a low or intermediate risk and should receive standard therapy — specifically, the combination of a vasoconstrictor (terlipressin, somatostatin, or analogues, administered from the time of admission and maintained for 2 to 5 days) and endoscopic therapy (preferably endoscopic variceal ligation, performed at diagnostic endoscopy less than 12 hours after admission), together with short-term prophylactic antibiotics (either norfloxacin or ceftriaxone). Placement of a transjugular intrahepatic portosystemic shunt is currently considered a salvage therapy for the 10 to 20% of patients in whom standard medical therapy fails. What treatments should be used to prevent recurrent variceal hemorrhage?
Given the high recurrence rate, patients who survive an acute variceal hemorrhage should receive therapy to prevent recurrence before they are discharged from the hospital. Combination pharmacologic therapy (nonselective beta-blockers such as propranolol or nadolol plus nitrates) or combination endoscopic variceal ligation plus drug therapy are warranted because of the high risk of recurrence, even though the side effects will be greater than those with single-agent therapy (recommended for primary prophylaxis).
Should patients with cirrhosis but without varices be treated with non-selective beta-blockers for primary prophylaxis?
A: Patients without gastroesophageal varices or with gastroesophageal varices that have never bled are at relatively low risk for bleeding and death; therefore, therapies for these patients should be the least invasive. In patients without varices, treatment with nonselective beta-blockers is not recommended because they do not prevent the development of varices and are associated with side effects.
In patients with cirrhosis without varices, which one of the following measurements is the best method to stratify risk?
A: In patients without varices and in those with variceal hemorrhage, measurement of portal pressure with the use of the HVPG is the best method to stratify risk. Portal hypertension is present when the HVPG is greater than 5 mm Hg, but it is considered clinically significant when the HVPG is greater than 10 mm Hg, because in patients without varices, this pressure is the strongest predictor of the development of varices, clinical decompensation, and hepatocellular carcinoma. The HVPG is obtained by means of catheterization of a hepatic vein with a balloon catheter through a jugular or femoral vein.
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Teaching topics from the New England Journal of Medicine - Vol. 362, No. 9, March 4, 2010
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