Esophageal varices (EV)

Question 1

Pathophysiology

Answer 1

Portal HTN causes hepatic/splanchnic vasodilation resulting in decreased perfusion that causes compensatory varices or small offshoots

May result in bleeding

Question 2

Risk factors for Variceal Bleeding

Answer 2

Large varices

Severity of cirrhosis

Red color markings on imaging

Active alcohol use

Question 3

Symptoms

Answer 3

Hematemesis

Melena

Fatigue

Hypotension, lightheadedness

Question 4

Prophylaxis treatment

Answer 4

Non-selective beta blocker

When? Moderate disease

Why?
B1 antagonism: decreased HR and CO
B2 antagonism: splanchnic vasoconstriction

Question 5

Nadolol

Answer 5

Initial: 20-40 mg PO QD

Max: 80 mg (if ascites); 160 mg (if not ascites)

Question 6

Propranolol

Answer 6

Initial: 20-40 mg PO BID

Max: 160 mg (if ascites); 320 mg (if not ascites)

Question 7

Carvedilol

Answer 7

Initial: 6.25 mg PO QD/BID
Max: 12.5 mg PO QD

Question 8

Monitoring

Answer 8

BP: Goal SBP > 90 mmHg
HR: Goal 55-60 bpm

Question 9

Endoscopic variceal ligation

Answer 9

What? Bands off varices
When? Management of acute variceal bleed

Question 10

Secondary management

Answer 10

Non-selective BB: continue indefinitely

Endoscopic variceal ligation: every 1-4 weeks

Question 11

Octreotide

Answer 11

Acute management