5-Minute Clinical Consult: Esophageal Varices

Esophageal Varices

Medication (Drugs)

For varices:
- B-Blockers: Decrease risk of first bleed by 45–50%, in primary prophylaxis of variceal hemorrhage (1)[A].
- Propranolol: 40 mg b.i.d. increase until heart rate decreased by 25% from baseline
- Nadolol 80 mg daily, increase as above
- Isosorbide mononitrate further reduces portal pressure. Begin at 20 mg b.i.d. No significant benefit in preventing first bleeds when given in combination with beta-blockers. Should not be given as monotherapy (2)[B].
- During banding or sclerotherapy: Proton pump inhibitor, such as lansoprazole 30 mg/d until varices obliterated
During bleeding, consider antibiotic prophylaxis for spontaneous peritonitis and other infections with ciprofloxacin for 7–10 days.
Contraindications: Severe asthma with beta-blockers
Precautions: Symptomatic hypotension

First Line
Beta-blockers, proton pump inhibitors, antibiotics

Second Line
Isosorbide mononitrate

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