A 45-year-old man with a history of alcohol excess is diagnosed as having grade 3 esophageal varices during an outpatient endoscopy. Of the following options, what is the most appropriate management to prevent variceal bleeding?
A. Propranolol
B. Isosorbide mononitrate
C. Endoscopic sclerotherapy
D. Terlipressin
E. Lansoprazole
Answer: A. Propranolol
Discussion:
Esophageal Varices - Management:
Acute treatment of variceal haemorrhage
ABC: patients should ideally be resuscitated prior to endoscopy
correct clotting: FFP, vitamin K
vasoactive agents: terlipressin is currently the only licensed vasoactive agent and is supported by NICE guidelines. It has been shown to be of benefit in initial haemostasis and preventing rebleeding. Octreotide may also be used although there is some evidence that terlipressin has a greater effect on reducing mortality
prophylactic antibiotics have been shown in multiple meta-analyses to reduce mortality in patients with liver cirrhosis
endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation
Sengstaken-Blakemore tube if uncontrolled haemorrhage
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
Prophylaxis of variceal haemorrhage
propranolol: reduced rebleeding and mortality compared to placebo
endoscopic variceal band ligation (EVL) is superior to endoscopic sclerotherapy. It should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration
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