Gastrointestinal varices medical therapy

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

Medical Therapy

General considerations and disease stratification

The management of gastrointestinal varices in chronic liver disease should be tailored according to the clinical stage of liver disease and cirrhosis. The following table outlines the key stages of chronic liver disease and the treatement goals for the respective stage:

Disease stage	HPVG	Varices	Complications of portal hypertension	Management goals
Compensated liver disease	Less than 10 mmHg	-	-
	Greater than equal to 10 mmHg	-	-	Prevent decompensation
	Greater than equal to 10 mmHg	+	-	Prevent decompensation
Decompensated liver disease	Greater than equal to 12 mmHg	+	Acute variceal bleed	Control bleeding, prevent early rebleeding and death
	Greater than equal to 12 mmHg	+	Previous variceal hemorrhage without ascites or encephelopathy	Prevent further decompensation (further bleeding, ascites and encephelopathy)
	Greater than equal to 12 mmHg	+	Prior variceal hemorrhage with ascites and/or encehelopathy	Prevent further decompensation and death

Goal-directed management

The management of gastrointestinal varices is aimed at optimizing the following:

• Portal venous inflow
• Portal resistance
• Portal pressure

This is achieved through the following pharmacological therapies:

• Splanchnic vasoconstrictors:
  • Vasopressin and analogues
  • Somatostatin and analogues
  • Nonselective β-blockers
• Venodilators:
  • Nitrates

The following table shows the major mechanism affected by the various pharmacological therapies used in the management of varices:

Major pharmacological therapy	Portal flow	Portal resistance	Portal pressure
Vasoconstrictors (e.g. β-blockers)	↓↓	↑	↓
Venodilators (e.g. nitrates)	↓	↓	↓
Endoscopic therapy	–	–	–
TIPS/Shunt therapy	↑	↓↓↓	↓↓↓