Endoscopic treatment of esophageal varices in patients with liver cirrhosis

Abstract

Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping and argon plasma coagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompanying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclusion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.

Keywords: Esophageal varices; Primary prophylaxis; Variceal bleeding; Secondary prophylaxis; Cirrhosis; Endoscopic treatment

Core tip: Endoscopic therapy is the major treatment option in the management of patients with esophageal varices and liver cirrhosis. The current treatment guidelines recommend the use of endoscopic therapy in both primary and secondary prophylaxis, as well as in the setting of the acute bleeding episode, along with pharmaceutical agents. This review summarizes data from randomized clinical trials and prospective clinical studies along with meta-analytical data, when applicable, to present the most updated recommendations for the endoscopic management of esophageal varices.