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Endoscopic Treatment of Esophageal Varices

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Therapeutic Gastrointestinal Endoscopy

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Abstract

Acute variceal hemorrhage is one of the most fatal complications of cirrhosis. About 30–50% of the patients with cirrhosis have esophageal varices at diagnosis, and about 10% of the patients with cirrhosis develop varices every year. Therefore, the most important examination in reducing the incidence and mortality of variceal hemorrhage is screening endoscopy for presence of varices, urgent endoscopic therapy for emergent active variceal bleeding, and prophylactic endoscopic treatment for prevention of variceal bleeding. Many guidelines and reviews suggest that endoscopy should be carried out within 12 h in the management of active variceal hemorrhage. The most effective endoscopic treatment for esophageal variceal hemorrhage is band ligation, so-called endoscopic variceal ligation (EVL). Endoscopic injectional sclerotherapy (EIS) has been replaced by EVL and should no longer be offered as standard of care in acute esophageal variceal hemorrhage. In this chapter, we discuss current endoscopic treatment of acute variceal hemorrhage and endoscopic prevention of variceal hemorrhage.

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Author information

Authors and Affiliations

  1. Department of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea

    Hyun Woong Lee & Young Hoon Youn

Authors
  1. Hyun Woong Lee
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  2. Young Hoon Youn
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Corresponding author

Correspondence to Young Hoon Youn .

Editor information

Editors and Affiliations

  1. Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea (Republic of)

    Hoon Jai Chun

  2. Department of Gastroenterology, Asan Medical Center, Seoul, Korea (Republic of)

    Suk-Kyun Yang

  3. Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea (Republic of)

    Myung-Gyu Choi

Appendix: Quiz

Appendix: Quiz

What is the diagnosis and the best treatment option for this patient with cirrhosis?

Question: A 55-year-old man with liver cirrhosis induced by alcohol was admitted to University Hospital with a 5-day history of intermittent melena. Upon admission, his vital signs were as follows: blood pressure of 110/70 mmHg, heart rate of 70/min, respiratory rate of 18/min, and body temperature of 36.8 °C. Head and neck examinations were unremarkable except for anemic conjunctiva. His abdomen was distended with shifting dullness and the spleen was palpable. Initial laboratory data were as follows: WBC 1400/mm3, Hb 8.1 g/dL, platelet 63,000/mm3, BUN 35 mg/dL, creatinine 1.2 mg/dL, albumin 2.9 g/dL, AST 126 IU/L, ALT 45 IU/L, ALP 147 IU/L, total bilirubin 1.8 mg/dL, INR 1.45, and AFP 2.4 ng/dL. The hepatitis B and C marker was negative. Initial diagnosis was Child’s B liver cirrhosis. The patient was treated with intravenous (IV) pantoprazole, IV terlipressin, and IV third-generation cephalosporin and was transfused with fresh frozen plasma and packed red blood cells. Emergency esophagogastroduodenoscopy revealed the presence of grade 2 esophageal varices (Fig. 1.12). Abdominal computed tomography (CT) showed liver cirrhosis with massive ascites, splenomegaly, and esophagogastric varices with portosystemic collaterals (Fig. 1.13).

  1. 1.

    What is the diagnosis?

    1. A.

      Esophageal ulcer.

    2. B.

      Esophageal erosion.

    3. C.

      Herpes esophagitis.

    4. D.

      Mallory-Weiss syndrome.

    5. E.

      Esophageal variceal hemorrhage.

  2. 2.

    What is the best treatment option?

    1. A.

      Nonselective beta-blocker.

    2. B.

      Endoscopic injectional sclerotherapy.

    3. C.

      Sengstaken-Blakemore tube insertion.

    4. D.

      Transjugular intrahepatic portosystemic shunt.

    5. E.

      Endoscopic variceal ligation and nonselective beta-blocker.

Fig. 1.12
figure 12

Grade 2 esophageal varices

Full size image
Fig. 1.13
figure 13

Liver cirrhosis with massive ascites, splenomegaly, and esophagogastric varices with portosystemic collaterals

Full size image

Answer:

  1. 1.

    (E) Esophageal variceal hemorrhage.

  2. 2.

    (E) Endoscopic variceal ligation and nonselective beta-blocker.

Esophageal variceal hemorrhage is defined as bleeding from an esophageal varix at the time of endoscopy or the presence of large varices with blood in the stomach and no other recognizable cause of bleeding. We can see endoscopic feature of recent esophageal variceal bleeding, such as a red plug on esophageal varix, which is a blood clot and also the stigmata of recent bleeding (Fig. 1.12).

Nonselective beta-blocker (NSBB, propranolol or nadolol) + esophageal variceal ligation (EVL) combination therapy are strongly recommended as secondary prophylaxis. NSBB or EVL monotherapy is suggested as not best option but alternative option. EVL alone is used to eradicate varices if there are contraindications or intolerance to combined use with NSBB. We suggest that TIPS is used for patients who rebleed despite combined EVL and NSBB therapy. EIS cannot be recommended for prophylaxis of esophageal variceal hemorrhage in patients with cirrhosis because of iatrogenic complications such as strictures.

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Lee, H.W., Youn, Y.H. (2019). Endoscopic Treatment of Esophageal Varices. In: Chun, H., Yang, SK., Choi, MG. (eds) Therapeutic Gastrointestinal Endoscopy. Springer, Singapore. https://doi.org/10.1007/978-981-13-1184-0_1

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  • DOI: https://doi.org/10.1007/978-981-13-1184-0_1

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  • Publisher Name: Springer, Singapore

  • Print ISBN: 978-981-13-1183-3

  • Online ISBN: 978-981-13-1184-0

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