Gastrointestinal varices secondary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Secondary Prevention

Secondary prevention of gastrointestinal varices involves prevention of rebleeding. The following options are available: Time to start secondary prophylaxis

• Secondary prophylaxis should start as soon as possible from day 6 of the index variceal bleeding episode
• The start time of secondary prophylaxis should be documented

Patients with cirrhosis who have not received primary prophylaxis

• Beta blockers (1a;A), band ligation (1a;A)or both (1b;A) should be used for prevention of recurrent bleeding
• Combination of beta blockers and band ligation is probably the best treatment (1b;A) but more trials are needed
• Assessment of haemodynamic response to drug therapy provides prognostic information about rebleeding risk

Patients with cirrhosis who are on beta blockers for primary prevention and bleed

• Band ligation should be added

Patients who have contraindications or intolerance to beta blockers

• Band ligation is the preferred treatment for prevention of rebleeding (5;D).

Patients who fail endoscopic and pharmacological treatment for prevention of rebleeding

• TIPS or surgical shunts (distal splenorenal shunt or 8 mm H-graft) are effective for those with Child class A/B cirrhosis and should be used (2b;B).
• In non-surgical candidates, TIPS is the only option
• Transplantation provides good long-term outcomes in Child class B/C cirrhosis and should be considered (2b;B). TIPS may be used as a bridge to transplantation (4;C).

Patients who have bled from isolated gastric varices, type 1 (IGV1) or gastro-oesophageal varices, type 2 (GOV 2)

• N-butyl-cyanoacrylate
• TIPS
• Beta blockers

Patients who have bled from gastro-esophageal varices, type 1 (GOV 1)

• May be treated with N-butyl-cyanoacrylate, band ligation of oesophageal varices or beta blockers (2b;B).

Patients who have bled from portal hypertensive gastropathy

• Beta blockers (1b;A) should be used for prevention of recurrent bleeding

Patients in whom beta blockers are contraindicated or fail and who cannot be managed by non-shunt therapy

• TIPS
• Surgical shunts