Small Esophageal Varices in Patients with Cirrhosis—Should We Treat Them?

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Abstract

Purpose of Review

The natural history and classification systems of small varices (≤ 5 mm in diameter) in cirrhotic patients with portal hypertension are summarized. Studies that assessed the course of and therapeutic intervention for small varices are discussed.

Recent Findings

Current non-invasive methods show suboptimal sensitivity to detect small varices in patients with cirrhosis. Next to etiological therapy, hepatic venous pressure gradient (HVPG)-guided non-selective betablocker or carvedilol treatment has shown to impact on natural history of small varices.

Summary

The main therapeutic focus in cirrhotic patients with small varices is the cure of the underlying etiology. The optimal management of small varices should include measurement of HVPG. A pharmacological decrease in HVPG by non-selective betablocker therapy of ≥ 10% reduces the risk of progression to large varices, first variceal bleeding, and hepatic decompensation. If HVPG is not available, we would recommend carvedilol 12.5 mg q.d. for treatment of small varices in compensated patients without severe ascites. Only if small esophageal varices (EV) are not treated or in hemodynamic non-responders, follow-up endoscopies should be performed in 1–2 years of intervals considering the activity of liver disease or if hepatic decompensation occurs.

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Most cited references 66

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Alcoholic Liver Disease: Pathogenesis and Current Management

Natalia Osna, Terrence Donohue, Kusum Kharbanda (2017)

Excessive alcohol consumption is a global healthcare problem. The liver sustains the greatest degree of tissue injury by heavy drinking because it is the primary site of ethanol metabolism. Chronic and excessive alcohol consumption produces a wide spectrum of hepatic lesions, the most characteristic of which are steatosis, hepatitis, and fibrosis/cirrhosis. Steatosis is the earliest response to heavy drinking and is characterized by the deposition of fat in hepatocytes. Steatosis can progress to steatohepatitis, which is a more severe, inflammatory type of liver injury. This stage of liver disease can lead to the development of fibrosis, during which there is excessive deposition of extracellular matrix proteins. The fibrotic response begins with active pericellular fibrosis, which may progress to cirrhosis, characterized by excessive liver scarring, vascular alterations, and eventual liver failure. Among problem drinkers, about 35 percent develop advanced liver disease because a number of disease modifiers exacerbate, slow, or prevent alcoholic liver disease progression. There are still no FDA-approved pharmacological or nutritional therapies for treating patients with alcoholic liver disease. Cessation of drinking (i.e., abstinence) is an integral part of therapy. Liver transplantation remains the life-saving strategy for patients with end-stage alcoholic liver disease.

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Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis.

Àngels Escorsell, D. Grace, Antonio J. Pagán … (2005)

Nonselective beta-adrenergic blockers decrease portal pressure and prevent variceal hemorrhage. Their effectiveness in preventing varices is unknown. We randomly assigned 213 patients with cirrhosis and portal hypertension (minimal hepatic venous pressure gradient [HVPG] of 6 mm Hg) to receive timolol, a nonselective beta-blocker (108 patients), or placebo (105 patients). The primary end point was the development of gastroesophageal varices or variceal hemorrhage. Endoscopy and HVPG measurements were repeated yearly. During a median follow-up of 54.9 months, the rate of the primary end point did not differ significantly between the timolol group and the placebo group (39 percent and 40 percent, respectively; P=0.89), nor were there significant differences in the rates of ascites, encephalopathy, liver transplantation, or death. Serious adverse events were more common among patients in the timolol group than among those in the placebo group (18 percent vs. 6 percent, P=0.006). Varices developed less frequently among patients with a baseline HVPG of less than 10 mm Hg and among those in whom the HVPG decreased by more than 10 percent at one year and more frequently among those in whom the HVPG increased by more than 10 percent at one year. Nonselective beta-blockers are ineffective in preventing varices in unselected patients with cirrhosis and portal hypertension and are associated with an increased number of adverse events. (ClinicalTrials.gov number, NCT00006398.) Copyright 2005 Massachusetts Medical Society.

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Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study.

(1988)

We conducted a prospective study of 321 patients with cirrhosis of the liver and esophageal varices with no history of bleeding to see whether a comprehensive analysis of their clinical features and of the endoscopic appearances of their varices could help to identify those at highest risk for bleeding. Varices were classified endoscopically as suggested by the Japanese Research Society for Portal Hypertension. Patients were followed for 1 to 38 months (median, 23), during which 85 patients (26.5 percent) bled. Multiple regression analysis (Cox's model) revealed that the risk of bleeding was significantly related to the patient's modified Child class (an index of liver dysfunction based on serum albumin concentration, bilirubin level, prothrombin time, and the presence of ascites and encephalopathy), the size of the varices, and the presence of red wale markings (longitudinal dilated venules resembling whip marks) on the varices. A prognostic index based on these variables was devised that enabled us to identify a subset of patients with a one-year incidence of bleeding exceeding 65 percent. The index was prospectively validated on an independent sample of 75 patients with varices and no history of bleeding. We conclude that our prognostic index, which identifies groups of patients with one-year probabilities of bleeding ranging from 6 to 76 percent, can be used to identify candidates for prophylactic treatment.

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Author and article information

Contributors

Thomas Reiberger: +4314040047410 , thomas.reiberger@meduniwien.ac.at

Journal

Journal ID (nlm-ta): Curr Hepatol Rep

Journal ID (iso-abbrev): Curr Hepatol Rep

Title: Current Hepatology Reports

Publisher: Springer US (New York )

ISSN (Electronic): 2195-9595

Publication date (Electronic): 7 November 2018

Publication date PMC-release: 7 November 2018

Publication date (Print): 2018

Volume: 17

Issue: 4

Pages: 301-315

Affiliations

[1 ]ISNI 0000 0000 9259 8492, GRID grid.22937.3d, Vienna Hepatic Hemodynamic Lab, , Medical University of Vienna, ; Vienna, Austria

[2 ]ISNI 0000 0000 9259 8492, GRID grid.22937.3d, Division of Gastroenterology & Hepatology, Department of Medicine III, , Medical University of Vienna, ; Vienna, Austria

[3 ]ISNI 0000 0004 0437 0893, GRID grid.413303.6, Division of Gastroenterology, , Krankenanstalt Rudolfstiftung, ; Vienna, Austria

[4 ]GRID grid.459695.2, Division of Gastroenterology, Medicine II, , Universitätsklinikum St. Pölten, ; St. Pölten, Austria

Article

Publisher ID: 420

DOI: 10.1007/s11901-018-0420-z

PMC ID: 6267385

SO-VID: 98bb8bfc-47e4-4384-8c2e-5b0d2f4b6bff

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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Funding

Funded by: Medical University of Vienna

Open Access :

Open access funding provided by Medical University of Vienna.

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Keywords: small varices,portal hypertension,cirrhosis,variceal bleeding,low-risk varices

Data availability:

Keywords: small varices, portal hypertension, cirrhosis, variceal bleeding, low-risk varices

Small Esophageal Varices in Patients with Cirrhosis—Should We Treat Them?

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Abstract

Purpose of Review

Recent Findings

Summary

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Most cited references 66

Alcoholic Liver Disease: Pathogenesis and Current Management

Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis.

Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study.

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