Esophageal Varices

Diagnose CSPH when any overt portal-hypertension manifestation is present: hepatic decompensation, gastroesophageal varices on endoscopy, portosystemic collaterals on imaging, or hepatofugal portal-vein flow. These findings move the patient directly to portal-hypertension management; an invasive pressure measurement is not required for that decision. BMJBMJRequest Permissions - Frontline Gastroenterology

For compensated advanced chronic liver disease without overt portal-hypertension manifestations, combine vibration-controlled transient elastography (VCTE) LSM with platelet count. CSPH is diagnosed by the rule-of-five thresholds: LSM at least 25 kPa regardless of platelets; LSM 20-24.9 kPa with platelets below 150 × 10^9/L; or LSM 15-19.9 kPa with platelets below 110 × 10^9/L. BMJBMJRequest Permissions - Frontline Gastroenterology

Rule out CSPH when LSM is 15 kPa or less and platelets are at least 150 × 10^9/L; this combination has sensitivity and negative predictive value of at least 90%. Do not use an isolated LSM as a variceal-screening substitute: published LSM thresholds for predicting varices have variable specificity, including 43% specificity at 17.6 kPa in hepatitis C-associated cirrhosis. BMJ+1BMJRequest Permissions - Frontline GastroenterologyBMJUK guidelines on the management of variceal haemorrhage in ... - Gut

Endoscopy remains the definitive test for visualizing esophageal varices and identifying red wale marks. The highest-risk pattern combines larger varices, red wale marks, and advanced hepatic dysfunction; Child-Pugh B/C status and red wale marks independently predict first hemorrhage. BMJ+1BMJEsophageal varices - Symptoms, diagnosis and treatment | BMJ ...ScienceDirectEndoscopic diagnosis, grading and predictors of bleeding ...

If endoscopy in a patient with indeterminate noninvasive CSPH criteria identifies varices, initiate a nonselective beta-blocker (NSBB). This approach treats the presence of CSPH rather than waiting for a first hemorrhage. BMJBMJRequest Permissions - Frontline Gastroenterology

In compensated cirrhosis with gastric varices, NSBBs should be considered as primary prophylaxis because gastric varices indicate CSPH; the same portal-pressure strategy is relevant when gastroesophageal varices coexist. aasldaasldEndoscopic Management of Gastric Varices | AASLD

For acute upper gastrointestinal bleeding in a patient with portal hypertension or known varices, manage as acute variceal hemorrhage while diagnostic endoscopy is arranged. Initial management includes conservative transfusion, antimicrobial prophylaxis, vasoactive therapy, and endoscopic evaluation within 12 hours. Wolters KluwerWolters KluwerAASLD Practice Guidance on risk stratification... : Hepatology

Start a vasoactive agent promptly and continue it for 2-5 days. Octreotide and terlipressin are established adjuncts to endoscopic therapy; in a randomized trial of 324 patients receiving endoscopic band ligation, control of bleeding was 92.6% with terlipressin and 95.6% with octreotide, with no significant difference in in-hospital mortality. Nature+1NatureReal-world comparison of terlipressin vs. octreotide as an adjuvant treatment in the management of variceal bleeding | Scientific ReportsWolters KluwerTerlipressin vs. Octreotide in Bleeding... : American Journal of Gastroenterology

Perform EVL as the preferred endoscopic method for esophageal variceal hemostasis. If band ligation is technically difficult, endoscopic injection sclerotherapy is an alternative. Combined endoscopic and pharmacologic treatment is superior to EVL alone for acute variceal bleeding. Nature+1NatureReal-world comparison of terlipressin vs. octreotide as an adjuvant treatment in the management of variceal bleeding | Scientific ReportsaasldQuick Tips: Esophageal Varices | AASLD

For patients who recover from acute variceal hemorrhage without TIPS, initiate an NSBB when vasoactive therapy is discontinued. Use the NSBB indefinitely and combine it with EVL every 2-6 weeks for prevention of recurrent hemorrhage. Wolters Kluwer+1Wolters KluwerAASLD Practice Guidance on risk stratification... : HepatologyGastroenterologyScreening and Surveillance of Varices in Patients With Cirrhosis

Do not substitute EVL alone for combined secondary prevention when an NSBB can be used: adding an NSBB to EVL reduces rebleeding after an acute esophageal variceal bleed. aasldaasldQuick Tips: Esophageal Varices | AASLD

After variceal eradication, continue surveillance endoscopy. In patients without varices on an initial endoscopy, a follow-up examination at 2-3 years is described, with a 2-year interval when liver function deteriorates; a change in hepatic function should therefore shorten reassessment rather than waiting for a fixed long interval. ScienceDirectScienceDirectElastograph - an overview | ScienceDirect Topics

Do not assume all gastroesophageal varices have identical anatomy. GOV2 and isolated gastric varices type 1 (IGV1) involve the fundus and are considered cardiofundal varices; they are associated with portal hypertension from cirrhosis, hepatocellular carcinoma, or portal-vein thrombosis. IGV1 may also arise with splenic-vein thrombosis and splenomegaly. aasldaasldEndoscopic Management of Gastric Varices | AASLD

Cardiofundal varices account for about 20% of gastric varices and carry higher bleeding risk. Persistent gastric varices after endoscopic management should prompt repeat cross-sectional imaging to guide subsequent therapy; EUS-guided coil therapy is one advanced-endoscopic option used for secondary prophylaxis in multidisciplinary practice. aasldaasldEndoscopic Management of Gastric Varices | AASLD

When portal hypertension and varices occur without cirrhosis, evaluate for PSVD and associated immunologic disease, prothrombotic or genetic disorders, and drug or toxin exposures. Preserved liver function does not eliminate variceal or portal-vein thrombosis risk, so EGD screening and serial Doppler surveillance remain indicated. aasldaasldWhy is it important to think about non-cirrhotic portal hypertension? | AASLD