Gastrointestinal varices secondary prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Secondary prevention of gastrointestinal varices involves prevention of rebleeding. The choice of method chosen for secondary prevention of gastrointestinal varices depends upon the condition of the patient, medication history and response to treatment. Methods used for secondary prevention include the use of beta blockers, band ligation, TIPS and liver transplantation.

Secondary prevention of gastrointestinal varices involves prevention of rebleeding. The following options are available, according to the condition of the patient:^[1][2][3][4]

Time to start secondary prophylaxis

• Secondary prophylaxis should start as soon as possible from day 6 of the index variceal bleeding episode
• The time of initiation of secondary prophylaxis should be recorded.

Patients with cirrhosis who have not received primary prophylaxis

• In these patients, a combination of beta blockers and endoscopic band ligation may be used as a measure for secondary prophylaxis
• Rebledding risk may be predicted by using the patient’s response to pharmacological therapy as a prognostic factor

Patients with cirrhosis who are on beta blockers for primary prevention and bleed

• Band ligation should be considered in addition to beta blockers

Patients who have contraindications or intolerance to beta blockers

• Band ligation is the treatment of choice for prevention of rebleeding

Patients who fail endoscopic and pharmacological treatment for prevention of rebleeding

• TIPS or surgical shunts (distal splenorenal shunt or 8 mm H-graft) are effective for those with Child class A/B cirrhosis
• In non-surgical candidates, TIPS is the sole option available
• Transplantation is associated with good long-term outcomes in Child class B/C cirrhosis and should be considered
• TIPS serves as a bridge to transplantation

Patients who have bled from isolated gastric varices, type 1 (IGV1) or gastro-oesophageal varices, type 2 (GOV 2)

• N-butyl-cyanoacrylate
• TIPS
• Beta blockers

Patients who have bled from gastro-esophageal varices, type 1 (GOV 1)

• May be treated via band ligation of esophageal varices with cyanoacrylate or beta blockers

Patients who have bled from portal hypertensive gastropathy

• Beta blockers to prevent recurrent bleeding

Patients in whom beta blockers are contraindicated or fail and who cannot be managed by non-shunt therapy

• TIPS
• Surgical shunts