Early detection of varices
The UK National Institute for Health and Care Excellence (NICE) recommends the following for patients with cirrhosis:[17]
Refer patients with cirrhosis at high risk of complications (e.g., oesophageal varices), or with complications, to a specialist hepatology centre.
Calculate the Model for End-Stage Liver Disease (MELD) score every 6 months for patients with compensated cirrhosis. [ MELD Score for End-Stage Liver Disease (NOT appropriate for patients under the age of 12) (SI units) Opens in new window ] Consider a MELD score ≥12 as an indicator that the person is at high risk of complications of cirrhosis.
Offer upper gastrointestinal endoscopy to all patients diagnosed with cirrhosis, to screen for oesophageal varices.
Prevention of variceal bleeding
Follow local protocols for the primary prevention of variceal bleeding.
For patients with cirrhosis and medium to large oesophageal varices, NICE guidance recommends:[17]
Initiate a non-selective beta-blocker, specifically, carvedilol or propranolol.
Carvedilol and propranolol should be used with caution in people with cirrhosis because they have a greater effect on the heart rate and blood pressure of people with liver disease than those without.
Carvedilol should be avoided in people with severe hepatic impairment (for example, in those with large-volume or refractory ascites).
When starting treatment, use a low dose and titrate depending on the results of heart and blood pressure monitoring.
If non-selective beta-blockers are not tolerated, contraindicated, or the person cannot take tablets regularly because of their circumstances, offer endoscopic variceal band ligation (EVBL) instead.
The NICE guideline committee agreed it was important to discuss all treatment options, and talk about individual preferences and personal circumstances, to identify the right treatment.
NICE also advises that simultaneous EVBL can be considered if medium or large varices are detected during upper gastrointestinal endoscopy.
British Society of Gastroenterology (BSG) guidance aligns closely, but recommends propranolol as the first choice, with carvedilol or nadolol as valid alternatives.[5]
Baveno VII (the European consensus meeting on portal hypertension) also recommends propranolol, carvedilol, or nadolol as suitable first-line agents.[29] Carvedilol is preferred in compensated cirrhosis, since it is more effective at reducing hepatic venous pressure gradient. This is partly due to its intrinsic anti-alpha adrenergic vasodilatory effects.[29]
The role of combined treatment with non-selective beta blockers and EVBL is unclear.[17]
Band ligation of oesophageal varices for the primary prevention of bleeding reduces mortality, upper gastrointestinal bleeding, variceal bleeding, and serious adverse events compared with no intervention.[30] Note that band ligation cannot be done successfully in patients with small varices; it is only used in patients with medium to large varices.[30]
Annual endoscopy should be offered to patients with cirrhosis and small oesophageal varices, in line with recommendations from the BSG.[5]
If there is clear evidence of disease progression, the BSG recommends modifying the endoscopy intervals according to clinical need.[5]
The role of non-selective beta-blockers for the primary prevention of bleeding in patients with cirrhosis and small varices is unclear.[5][17][31][32][33] A large, triple blinded, multi-centre randomised controlled trial looking at non-selective beta-blockers versus placebo for the primary prophylaxis of variceal haemorrhage in these patients is ongoing.[34]
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