• 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

General Measures

• Treat comorbidities, generally related to cirrhosis
• Hospital management of bleeding varices:
  • Appropriate resuscitation and maintenance of blood volume
  • Treat coagulopathy, if necessary.
  • IV somatostatin to lower portal venous pressure usually used as adjuvant to endoscopic management. Begin with IV bolus of 50 mg followed by drip of 50 mg/h (3)[A].
  • Urgent upper endoscopy for diagnosis and treatment. Variceal band ligation or sclerotherapy for bleeding varices or those not bleeding, which are medium to large in size to decrease risk of bleeding. Variceal band ligation is preferred due to better bleeding cessation with fewer complications (4)[A].
  • Repeat ligation or sclerosant injection if bleeding recurs.
  • If endoscopic treatment fails to stop bleeding or cannot be accomplished, may need to use Sengstaken Blakemore or Minnesota tube to stabilize patient for a transjugular intrahepatic portosystemic shunt
• Management of nonbleeding varices:
  • If ligation started, usually in medium to large varices (grade 2–4), repeat banding at 1–3 week intervals. 4–6 treatments are usually required to obliterate varices.
  • For those not treated endoscopically, begin non-selective beta-blockers such as propranolol or nadolol. Increase dose for goal of heart rate reduction of 25% of baseline (SBP >90, HR >50). For those who do not tolerate the side effects of this regimen, proceed with endoscopic variceal band ligation as primary prophylaxis (5)[A].
  • If bleeding recurs, or portal pressure measurement shows portal pressure still >12 mm Hg, isosorbide mononitrate may be added, though endoscopic band ligation preferred if possible (6)[B].
  • Refractory bleeding may require use of TIPS, or portocaval shunt (7)[B]
  • Refer for liver transplantation where appropriate.

Issue for Referral
Primarily those associated with liver transplantation

• Endoscopic variceal ligation- preferred approach to those who cannot tolerate beta-blockers.
• Endoscopic sclerotherapy
• Transjugular intrahepatic portasystemic shunt (TIPS)
• Portacaval shunt
• Esophageal transection
• Liver transplantation
• In patients with current or prior bleeding from esophageal varices, endoscopic variceal ligation is superior to endoscopic sclerotherapy (8)[A].

Admission Criteria
Inpatient for acute bleeding

Discharge Criteria
Cessation of bleeding, stability of other comorbidities