Andreas Cardenas, MD, on Primary Prophylaxis of Variceal Bleeding
In this video, Dr Cardenas discusses the current management of gastroesophageal variceal bleeding and evolutionary trends for the treatment of gastrointestinal bleeding in patients with cirrhosis.
Andres Cardenas MD, MMSc, PhD, is a faculty member and consultant at the Hospital Clinic in Barcelona and associate professor of medicine at the University of Barcelona in Spain.
Hi, my name is Dr. Andreas Cardenas. I'm a staff member at the hospital clinic in Barcelona and associate professor of medicine at the University of Barcelona. My area of expertise is cirrhosis and its complications, and liver transplantation.
Today, I'm going to discuss important things about primary prophylaxis of variceal bleeding and also current concepts of acute variceal bleeding. When we have a patient with cirrhosis, we have to think about the fact that this patient probably has portal hypertension, and that is defined as increased portal pressure over 5 millimeters of mercury.
They start having problems of esophageal varices when their portal pressure is over 10 millimeters per mercury. If we think about a patient with cirrhosis, we also want to think about the fact that most of them are at risk of developing varices. We screen for these patients, look at their platelet count and then the FibroScan.
When their FibroScan is very high or they have decompensated cirrhosis, we have to do an upper endoscopy. The upper endoscopy will give us information about the esophagus and see if there are varices or not and also look at the stomach for signs of gastropathy, gastric varices, and at the duodenum, which occasionally might have ectopic varices.
In the endoscopy, we also look at the signs of red spots, the varices of the esophagus and the stomach. We stratify our patients. If they have large varices — these are varices over 5 millimeters of size — and they have red spots, these patients are at high risk of bleeding.
In addition, those with small varices less than 5 millimeters size with red spots, if they have advanced liver disease with Child C cirrhosis, then these patients are also at risk of bleeding.
The preferred strategy to prevent these patients from bleeding is the use of beta‑blockers. We now use carvedilol as a drug of choice because several studies have shown that is a very effective and safe medication that lowers portal pressure and will also prevent other complications of cirrhosis, such as ascites and hepatorenal syndrome, among others.
If we think about prophylaxis for our patients, our preference is to start with beta‑blockers. Some centers and some authors prefer to use endoscopic band ligation because endoscopic band ligation will eradicate the varices, but the downside of that is that it does not decrease portal pressure.
As of today, in 2021, the preferred strategy, if possible, is to start with beta‑blockers. If patients tolerate the beta‑blockers, leave them on long term. That will consider that some of these patients that are in beta‑blockers may not respond.
About 20% to 30% of them will not respond, and they will have to be switched to endoscopic band ligation. Some of them have contraindications if they have heart disturbances, AV blocks, they have pulmonary hypertension, or if they have other problems such as uncontrolled asthma.
Our patients that are considered primary prophylaxis, we start with carvedilol. If they tolerate the carvedilol, they will stay on it long term. If they do not tolerate carvedilol, have side effects, we will do band ligation. In most cases, it will prevent patients from bleeding.
Another new concept to take into account is the use of TIPS for variceal bleeding. That's the most important new concept out there. TIPS is a stent that is placed between the hepatic vein and the portal vein via interventional radiology, with the possibility of decreasing portal pressure. This stent is placed between these two veins with the aim of reducing portal pressure by at least 40% if possible.
If we are going to consider TIPS in our patients, there are many indications for TIPS. In the set of acute variceal bleeding, we now consider TIPS early on, meaning that once the patient presents in emergency department with acute variceal bleeding, we start thinking about the possibility of using TIPS.
We do this because we risk‑stratify patients. We know that patients that bleed and have high Child scores between 10 and 14 are at very high risk of doing poorly with standard medical therapy, which includes endoscopy, vasoconstrictors, and antibiotics. These patients that undergo TIPS, if they're candidates, will do very well with less rebleeding and better survival.
Now, that said, some patients cannot undergo TIPS early on, and that means within 3 days, either because they're too old over the age of 70 or 75. They have uncontrolled portal problems such as pulmonary hypertension. They have congestive heart failure. They have overt or significant hepatic encephalopathy, grade 3 or 4 and higher, or they have portal thrombosis with extension to the mesenteric veins. These patients cannot undergo a TIPS.
But if they are candidates, we now consider all these patients should be considered for TIPS within 3 days after they are admitted and after they've had their standard medical therapy. That's because these patients have less rebleeding and better survival.
Hopefully, this year, we will have our Baveno Meeting which occurs every 5 years. We were supposed to have it last year, but we couldn't. We now are planning to have this consensus meeting where I’ll have the opportunity to participate as a panelist. We will discuss the various options for primary prophylaxis, the future of TIPS within patients that undergo acute variceal bleeding, and new and emerging therapies for portal hypertension.
I urge you to continue treating your patients with beta‑blockers that they tolerate and consider early TIPS for your patience with Child C points between 10 and 14.
Patients with cirrhosis are at risk of developing varices, and we need to prevent them from bleeding. If they bleed, we need to treat them adequately. New options include TIPS. Hopefully, we will have more information later this year. Thank you very much.