QuestionSBA
QuestionChoice
This is a cardioselective beta blocker, so is not suitable for use to reduce portal pressures.
10015645
e
Bisoprolol
QuestionChoice
Terlipressin is used in acute phase of variceal bleeds to reduce portal pressures. It is not given prophylactically and has to be administered IV.
10015643
c
Terlipressin
QuestionChoice
Propranolol is the only non-selective beta blocker listed here and therefore the only one that can reduce portal pressures; all the others are cardioselective.
10015641
a
Propranolol
QuestionChoice
This is a cardioselective beta blocker, so is not suitable for use to reduce portal pressures.
10015644
d
Metoprolol
QuestionChoice
This is a cardioselective beta blocker, so is not suitable for use to reduce portal pressures.
10015642
b
Atenolol
QuestionComment
Propanolol for Prophylaxis
Terlipressin to Treat :)
48553
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nice

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Cremasteric Suplex
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GIMP101
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what if ur asthmatic
51748
QuestionComment
endoscopic band ligation is an effective primary prophylaxis option for preventing variceal bleeding in those with contraindications to beta blockers


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deleted_user
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Relapse Ketone
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how do you find this information on the BNF?
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# Summary

Oesophageal and gastric varices are dilated veins that arise due to portal hypertension, often secondary to cirrhosis. They are prone to bleeding due to high portal pressures, posing a significant risk of mortality in patients. Diagnosis involves endoscopy at the time of cirrhosis diagnosis, with treatment centred on haemodynamic resuscitation, blood transfusions, and administration of terlipressin and broad-spectrum antibiotics. Primary prophylaxis is recommended for patients with grade 1 varices with red signs, or grade 2 or 3 varices. Prevention strategies include pharmacological interventions like non-selective beta-blockers and endoscopic variceal band ligation.

# Definition

Varices are dilated veins which are formed due to portal hypertension. They are most commonly secondary to liver cirrhosis and are prone to rupture due to the high pressure in the portal system, leading to significant internal bleeding. Oesophageal varices are abnormally enlarged veins located in the lower part of the oesophagus. Gastric varices are dilated submucosal veins located in the stomach.

# Epidemiology

Varices are common in patients with advanced liver disease. They occur in about 50% of patients with cirrhosis, and variceal bleeding is a leading cause of mortality in these patients. Gastric varices are less common than oesophageal varices but can cause significant gastrointestinal bleeding. They are often more difficult to treat due to their location and the complexity of the vascular structures in the stomach.

# Aetiology

Oesophageal varices occur as a result of portal hypertension, often due to cirrhosis. Other causes of portal hypertension include portal vein thrombosis, schistosomiasis, and hepatic fibrosis.

# Signs and Symptoms

Patients with oesophageal varices may be asymptomatic until a variceal bleed occurs. A variceal bleed may present with:

- Haematemesis (vomiting of blood)
- Melena (black, tarry stools)
- Palpitations
- Syncope (fainting)
- Hypotension (low blood pressure)

# Differential Diagnosis

Differential diagnoses for oesophageal varices include other causes of upper gastrointestinal bleeding such as:

- **Gastric ulcers:** Symptoms may include epigastric pain, nausea, vomiting, and weight loss.
- **Duodenal ulcers:** Symptoms may include epigastric pain (especially at night), nausea, vomiting, and weight loss.
- **Mallory-Weiss tear:** Symptoms may include painful retching followed by the onset of bloody vomiting.

# Investigations

- Endoscopy is the primary investigation for oesophageal varices, allowing for direct visualisation and grading of the varices. 
- Patients with cirrhosis should have a one-off OGD at the time of diagnosis. If patients are found not to have varices at the time of their first endoscopy, a repeat endoscopy should be done every 3 years as surveillance

# Management
The management of oesophageal varices includes:

- Resuscitation ensuring haemodynamic stability. This may involve blood transfusions and correction of clotting abnormalities with Vitamin K, FFP, and platelet transfusions.
- Administration of Terlipressin, a vasopressin analogue that reduces portal pressure and bleeding.
- Administration of broad-spectrum antibiotics to reduce the risk of bacteraemia and spontaneous bacterial peritonitis.
- Variceal band ligation via endoscopy for oesophageal varices, and sclerotherapy for gastric varices
- For uncontrollable bleeding, insertion of a Sengstaken-Blakemore tube may be required.
- In patients with a history of alcoholism, thiamine may be needed to correct any deficiency.

# Prevention

Prevention strategies for variceal bleeding include the use of non-selective beta-blockers and variceal band ligation. If these fail, patients may be recommended for a transjugular intrahepatic portosystemic shunt (TIPSS).

# References

[NICE CKS - Cirrhosis](https://www.nice.org.uk/guidance/ng50/chapter/Recommendations)

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Oesophageal and Gastric Varices
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Gastroenterology
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Oesophageal and Gastric Varices
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Quesmed Tutorial: Medical Emergencies
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Oesophageal and Gastric Varices
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Emergency Management of Upper GI bleed
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In gastroenterology, non-selective beta blockers, such as propranolol, are the medication of choice for preventing re-bleeding from oesophageal varices due to their ability to reduce portal pressures.
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Bleeding from upper GI tract
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Bleeding from upper GI tract
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Cancer
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Bleeding from upper GI tract
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Gastrointestinal including liver
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Bleeding from upper GI tract
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A 62-year-old male with a significant alcohol history undergoes emergency endoscopy for haematemesis. Bleeding oesophageal varices are seen during endoscopy and are treated with band ligation.

After the patient is stabilised, what is the most appropriate medication to start to prevent a variceal re-bleed?
a