Current management of oesophageal varices

Patients with chronic liver disease and large varices with endoscopic features which put them at high risk of bleeding, especially if they have a HVPG of more than 12 mmHg, should be treated with beta-blockers at a dose which lowers their pulse by 25%, as prophylaxis against future bleeding. Once a patient bleeds from oesophageal varices, emergency treatment with octreotide should be commenced until endoscopic sclero- or ligation therapy is performed. If these treatments are not readily available, or if bleeding continues in spite of treatment, balloon tamponade is employed to arrest bleeding. In the event of recurrent bleeding, further sclero- or ligation therapy should be attempted, but continued bleeding would dictate surgical therapy or insertion of a TIPS. What operation is performed would depend on the local expertise. In a suitable candidate, liver transplantation would be considered. If bleeding is controlled by sclero- or ligation therapy, chronic sclerotherapy should be continued until the varices are obliterated, and beta-blockers commenced. Regular follow-up should be arranged to encourage abstinence from alcohol if appropriate, and to decide the most opportune time for transplantation if indicated.