Indication of Treatment for Esophageal Varices: Who and When?

Variceal bleeding is a major cause of death in patients with liver cirrhosis. However, indication (to whom) and timing (when) of the treatment for patients who have never had previous variceal bleeing is not completely established. Given the poor outcome associated with variceal bleeding, the identification of those at high risk and the prevention of a first bleeding episode are critical objectives. Clinical factors associated with an increased risk of a first variceal bleeding include continued alcohol use and poor liver function. Endoscopic predictive factors for the risk of bleeding are large size of varices and presence of red signs on the varices. Current recommendations for primary prophylaxis pertain only to cirrhotics with large varices. However, more patients with small varices will bleed than those with large ones. Non‐selective beta‐blockers are the prophylactic therapy of choice in patients with medium‐sized/large varices, irrespective of the severity of liver dysfunction. Beta‐blockers should be continued life long. Endoscopic variceal band ligation should be contemplated in high‐risk patients who have contraindications or side effects of beta‐blockers. It is salutary to remember that prophylactic sclerotherapy caused harm and its use was abandoned. The use of venodilators (nitrates) alone should be discouraged because there is as yet no proof of their efficacy and evidence suggests that they could worsen the already altered circulatory state of the cirrhotic patient. In patients with small varices, follow‐up endoscopy should be performed every 1–2 years because the risk of bleeding is so small.