The patient undergoes endoscopy with esophageal variceal ligation (EVL)
- The lower third of the esophagus shows multiple columns of large varices (>5mm)
- Stigmata of recent bleeding and red wale signs are seen
- The image on the right shows a band over the variceal column
What are the next steps?
Repeat EGD in 1-2 years
Try again! Patients with small varices undergo screening EGD every 1-2 years, but this patient has already had a variceal bleed.
Repeat EGD every 1-4 weeks until varices are obliterated
Good choice! Patients with EV bleed should undergo serial EGDs with ligation (EVL) until varices are obliterated. First surveillance should be done 3-6 months after eradication and every 6-12 months to monitor for recurrence thereafter.
Repeat EGD in 6 months
Try again! The patient should receive serial EGDs until the EV are completely obliterated, followed by surveillance 3-6 months later. Thereafter, surveillance can be prolonged to every 6-12 months.
Start patient on a non-selective beta blocker
Good choice! This patient should be started on a non-selective beta blocker (NSBB) 5 days after the initial bleed with either propranolol 20-40mg BID or nadolol 20-40mg once daily, both to be adjusted to a goal resting HR of 55-60 bpm. There is insufficient data to recommend carvedilol for secondary prophylaxis against rebleeding. Combination therapy of EVL with NSBB results in greater risk reduction for rebleeding compared with EVL alone.
Early TIPS (placed within 72 hours of admission) is a debatable topic. Few RCTs have shown a statistically significant decrease in mortality rate in select high risk patients (Child Pugh class B with active bleeding on endoscopy or Child Pugh class C), however observational studies have not confirmed a survival risk.
Despite treatment with EVL, the patient has recurrent hematemesis 4 days later.
What would you do next?
Liver Transplant evaluation
This patient would benefit from a liver transplant evaluation. Presence of EV imply decompensated cirrhosis and patients with EV bleed have a 22% recurrence rate, with each bleed carrying 15-20% risk of mortality. He fall in Child Pugh Class C, which puts him at a 1-3 year life expectancy. Furthermore, his current MELD-Na score is 28 which has a 27-32% 90 day estimated mortality rate without transplant. Transplant evaluation may be initiated for this critically ill patient.
EGD with repeat EVL
Try again! This would not be the first choice. This patient has now failed endoscopic therapy and should consider other options, such as TIPS.
Transjugular intrahepatic portosystemic shunt (TIPS) Placement
Excellent choice! For patients with EV bleed who fail first line methods including pharmacologic and endoscopic therapy or for those who bleed within 5 days of initial hemorrhage, TIPS is a great option. It has been shown to achieve hemostasis in 90-100% of cases and increase survival rate.
Try again! While ES is similar to EVL with regard to bleeding cessation, trials have shown that EVL is superior to ES with regards to outcomes of rebleeding, death and stricture formation.
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