Guideline sources The following summarized guidelines for the evaluation and management of gastroesophageal varices (GEV) are prepared by our editorial team based on guidelines from the European Society of Gastrointestinal Endoscopy (ESGE 2022), the European Association for the Study of the Liver (EASL 2018), the American Association for the Study of Liver Diseases (AASLD 2017), the American College of Gastroenterology (ACG 2016), the British Society of Gastroenterology (BSG 2015), the American Society for Gastrointestinal Endoscopy (ASGE 2014), and the American College of Gastroenterology (ACG/AASLD 2007). 1 2 3 4 5 6 7 8 8 8 9 10 Definition GEV are abnormally dilated submucosal distal veins developing at sites near the formation of gastroesophageal collateral circulation. 8 Epidemiology GEV are most frequently caused by portal hypertension (a result of cirrhosis due to alcoholic liver disease, NASH, and hepatitis C infection). 8 Pathophysiology https://web.pathway.md/diseases/rec9MnwsHIoir9ytM 1/6 6/24/23, 3:16 AM Gastroesophageal varices Pathway The rate of hospitalization due to esophageal varices in the United States is estimated at 1181 per 100,000 population/year. 9 Disease course GEV correlate with the severity of liver disease and are present with other symptoms of chronic liver disease including spider nevi, jaundice, palmar erythema, splenomegaly, ascites, encephalopathy, and caput medusae. The disease increases the risk of variceal bleeding and rebleeding and is associated with increased morbidity and mortality. 10 Prognosis and risk of recurrence The six-week mortality rate of patients with index esophageal variceal bleeding is approximately 20%. 8 Guidelines 1. Screening and diagnosis Indications for screening: As per EASL 2018 guidelines, obtain screening upper gastrointestinal endoscopy for GEV, if not previously diagnosed and treated, in patients with decompensated cirrhosis. B Show 2 more As per BSG 2015 guidelines, obtain performing endoscopy in all patients with cirrhosis at the time of diagnosis. A As per ASGE 2014 guidelines, obtain screening endoscopy in all patients with a diagnosis of cirrhosis, to assess for esophageal and gastric varices. A Show 3 more As per ACG 2007 guidelines, perform screening upper gastrointestinal endoscopy when a diagnosis of cirrhosis is made in order to assess for the presence of esophageal and/or gastric varices. B 2. Classification and risk stratification Endoscopic classification: Classify esophageal varices as small or large (> 5 mm) on upper gastrointestinal endoscopy, with the latter classification encompassing medium and large-sized varices when 3 grades (small, medium, large) are used. B Report the presence or absence of red signs on varices. B 3. Medical management https://web.pathway.md/diseases/rec9MnwsHIoir9ytM 2/6 6/24/23, 3:16 AM Gastroesophageal varices Pathway Primary prevention of variceal hemorrhage: As per ESGE 2022 guidelines: Initiate nonselective -blockers (preferably carvedilol), if not contraindicated, to prevent the development of variceal bleeding in patients with compensated advanced chronic liver disease and clinically significant portal hypertension (hepatic venous pressure gradient > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa). B Perform endoscopic band ligation as the endoscopic prophylactic treatment of choice in patients unable to receive nonselective -blocker therapy with high-risk esophageal varices on screening upper gastrointestinal endoscopy. Repeat endoscopic band ligation every 2-4 weeks until variceal eradication is achieved. Obtain surveillance upper gastrointestinal endoscopy every 3-6 months in the first year following eradication. B As per EASL 2018 guidelines, initiate primary prophylaxis upon detection of high-risk varices - small varices with red signs, medium or large varices irrespective of Child-Pugh classification, or small varices in Child-Pugh C patients - in patients with decompensated cirrhosis A , ascites, or an acute intercurrent condition. B Show 7 more As per AASLD 2017 guidelines, initiate nonselective -blockers for the prevention of first variceal hemorrhage in patients with small varices at high risk of bleeding (red wale sign or red spot). E Show 5 more As per BSG 2015 guidelines, initiate primary prophylaxis in patients with grade I varices and red signs or grade 2-3 varices, irrespective of the severity of the liver disease. A Show 6 more As per ASGE 2014 guidelines, perform endoscopic variceal ligation in patients with large esophageal varices unable to tolerate or having contraindications to nonselective -blockers. B Show 3 more Secondary prevention of variceal hemorrhage: As per ESGE 2022 guidelines: Perform follow-up endoscopic band ligations at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis) in patients undergone endoscopic band ligation for acute esophageal variceal hemorrhage. B Initiate nonselective -blockers (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in esophageal variceal hemorrhage in patients with advanced chronic liver disease. A As per AASLD 2017 guidelines, initiate nonselective -blockers combined with endoscopic variceal ligation as first-line therapy for the prevention of rebleeding in patients with a history of variceal hemorrhage. E Show 3 more As per BSG 2015 guidelines, initiate nonselective -blockers (propranolol or nadolol) and variceal band ligation combination therapy for secondary prophylaxis in patients with variceal hemorrhage. A https://web.pathway.md/diseases/rec9MnwsHIoir9ytM 3/6 6/24/23, 3:16 AM Gastroesophageal varices Pathway Show 9 more As per ASGE 2014 guidelines: Repeat endoscopy with endoscopic variceal ligation after treatment of the acute episode of variceal hemorrhage until varices have been eradicated. B Consider repeating endoscopy at 1- to 8-week intervals for endoscopic variceal ligation for secondary prophylaxis. C Management of beta-blockers: Avoid high doses of nonselective -blockers in patients with refractory ascites and SBP (e.g. > 160 mg/day of propranolol or > 80 mg/day of nadolol), given that they might be associated with worse outcomes. D Decrease or temporarily hold nonselective -blockers in patients with refractory ascites and severe circulatory dysfunction (systolic BP < 90 mmHg, serum sodium < 130 meq/L) or hepatorenal syndrome. Consider re-introduction if clinical status improves. E 4. Specific circumstances Pregnant patients: Obtain screening upper endoscopy for esophageal varices in the second trimester in pregnant patients with suspected portal hypertension. B Initiate treatment with -blockers and/or offer band ligation in pregnant patients with large esophageal varices. B 5. Preventative measures Primary prevention: As per AASLD 2017 guidelines, insufficient evidence to support the use of nonselective - blockers for the prevention of varices formation. I As per ACG 2007 guidelines, do not use nonselective -blockers to prevent the development of varices in patients with cirrhosis. D 6. Follow-up and surveillance Surveillance endoscopy: As per BSG 2015 guidelines, consider repeating endoscopy at 2-3-year intervals if no varices are found at the time of the first endoscopy. C Show 2 more As per ACG 2007 guidelines: Repeat upper gastrointestinal endoscopy in 3 years in patients with compensated cirrhosis and no varices on the initial endoscopy. A https://web.pathway.md/diseases/rec9MnwsHIoir9ytM 4/6 6/24/23, 3:16 AM Gastroesophageal varices Pathway Obtain upper gastrointestinal endoscopy in patients with hepatic decompensation, and yearly thereafter. A References 1. Garcia-Tsao G, Abraldes JG, Berzigotti A et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017 Jan;65 1 310 335. Open 2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018 Aug;69 2 406 460. Open 3. Dhiraj Tripathi, Adrian J Stanley, Peter C Hayes et al. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015 Nov;64 11 1680 704. Open 4. Ian M Gralnek, Marine Camus Duboc, Juan Carlos Garcia-Pagan et al. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy ESGE Guideline. Endoscopy. 2022 Sep 29. Open 5. Garcia-Tsao G, Sanyal AJ, Grace ND et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007 Sep;46 3 922 38. Open 6. Tram T Tran, Joseph Ahn, Nancy S Reau. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol. 2016 Feb;111 2 176 94; quiz 196. Open 7. Joo Ha Hwang, Amandeep K Shergill, Ruben D Acosta et al. The role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc. 2014 Aug;80 2 221 7. Open 8. Umesha Boregowda, Chandraprakash Umapathy, Nasir Halim et al. Update on the management of gastrointestinal varices. 2019 Jan 21;10 1 1 21.2019 Jan 21;10 1 1 21. Open 9. Shantanu Solanki, Khwaja Fahad Haq, Raja Chandra Chakinala et al. Inpatient burden of esophageal varices in the United States: analysis of trends in demographics, cost of care, and outcomes. Ann Transl Med. 2019 Sep;7 18 480. Open 10. Said A Al-Busafi, Julia McNabb-Baltar, Amanda Farag et al. Clinical manifestations of portal hypertension. Int J Hepatol. 2012;2012 203794. Open 11. de Franchis R, Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015 Sep;63 3 743 52. Open 12. Umesha Boregowda, Chandraprakash Umapathy, Nasir Halim et al. Update on the management of gastrointestinal varices. World J Gastrointest Pharmacol Ther. 2019 Jan 21;10 1 1 21. Open 13. Italian Association for the Study of the Liver AISF , Italian Association for the Study of the Liver AISF. AISF position paper on liver disease and pregnancy. Dig Liver Dis. 2016 Feb;48 2 120 37. Open 14. Monika Sarkar, Carla W Brady, Jaquelyn Fleckenstein et al. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Jan;73 1 318 365. Open 15. Zachary Henry, Kalpesh Patel, Heather Patton et al. AGA Clinical Practice Update on Management of Bleeding Gastric Varices: Expert Review. Clin Gastroenterol Hepatol. 2021 Jun;19 6 1098 1107.e1. Open https://web.pathway.md/diseases/rec9MnwsHIoir9ytM 5/6 6/24/23, 3:16 AM Gastroesophageal varices Pathway https://web.pathway.md/diseases/rec9MnwsHIoir9ytM 6/6