[Prevention of esophageal varix rupture]

Preventive measures against esophageal varicose vein bleeding are needed for grade 2 risk resulting from the presence of large varix. Medical or endoscopic methods can be used.

With beta-blockers the incidence of a first bleeding episode is significantly reduced and mortality is almost significantly reduced. Three controlled trials have demonstrated that a nitrate derivative beta-blocker combination improves the efficacy of beta-blockers in terms of reduced bleeding. Nitrates can be prescribed alone in case of a contraindication for beta-blockers but the efficacy is poorly demonstrated.

Both incidence of first bleeding episode and mortality are significantly reduced after sclerotherapy. Variable results have however been reported and sclerotherapy is probably only effective in high-risk patients; the consensus conference has not recommended its use. On the contrary, endoscopic ligature is probably useful since 5 preliminary studies have demonstrated a significant effect on first bleeding and mortality. Its relative contribution compared with propranolol remains to be demonstrated.

The first intention therapy should rely on beta-blockers or nitrates in case of a contraindication or adverse effect. Endoscopic ligature can be discussed in high-risk patients. The beta-blocker-nitrate combination and the beta-blocker-endoscopic treatment combination cannot be recommended at the present time.

Meta-analyses have shown that beta-blockers or sclerotherapy significantly reduce the incidence of recurrent bleeding and mortality. Sclerotherapy significantly reduces the risk of recurrent bleeding compared with beta-blockers although there is no difference in mortality and the incidence of complications is significantly greater with sclerotherapy. Associating the two methods can significantly reduce recurrent bleeding but has no effect on mortality. Elastic ligature is significantly more effective in terms of recurrent bleeding and mortality or complication rate. Transjugular intrahepatic portosystemic shunt (TIPS) significantly reduces the incidence of recurrent bleeding but has no effect on mortality and the risk of hepatic encephalopathy is increased.

Elastic ligature can be proposed as a first intention treatment. Sclerotherapy is useful to eradicate varix after size reduction by ligature and to prevent recurrence. In case of failure, a TIPS or surgical shunt can be discussed. Liver transplantation would be indicated in high-risk patients keeping in mind that digestive tract bleeding is a supplementary argument favoring transplantation.

The international consensus group (CFEHTP) recommends elastic ligature or beta-blockers, endoscopic treatment being preferred. TIPS or surgical shunt may be discussed in case of failure.