Review Question - QID 102596

The preferred method of primary and secondary prevention for variceal bleeding is a nonselective beta blocker, such as propanolol or nadolol.

Esophageal varices are a complication of cirrhosis and portal hypertension. Other complications of cirrhosis include ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome. In the acute setting, variceal bleeding can be treated with intravenous octreotide, endoscopic banding, and sclerotherapy, while long-term solutions include TIPS procedure and liver transplantation.

Heidelbaugh and Sherbondy discuss the complications of cirrhosis and chronic liver disease. They suggest propanolol 40-80 mg twice daily as the preferred method of prevention and mention isosorbide mononitrate as an alternative in patients who cannot tolerate beta-blockade.

Gonzalez et al. conducted a meta-analysis of studies comparing combined endoscopic intervention and beta-blockade with either method alone in patients who had already experienced variceal bleeding. They reported that combined therapy was significantly more effective in preventing future variceal bleeding than either therapy alone, although there was no statistical difference in mortality benefit.

Incorrect answers:
Answer 1: The risk of rebleeding without treatment is extremely high; observation is not recommended.
Answer 2: Octreotide is useful in the acute setting of variceal bleeding, not as prevention.
Answer 4: Nitrates are second-line options for treatment of esophageal varices if beta-blockade is contraindicated.
Answer 5: TIPS is typically reserved for patients in whom pharmaceutical interventions are not effective. TIPS increases the risk for hepatic encephalopathy.