Treating esophageal varices

Question: In the endoscopy suite, you’re looking at the distal esophagus of a 54 year old alcoholic male with compensated cirrhosis.  Three cords of varices are noted to flatten upon insufflation.  The remainder of the exam is normal.  What should you recommend in the way of treatment for these varices?

A. no treatment is necessary

B. propranolol to decrease the rate of growth of the varices

C. band ligation

D. propranolol and band ligation

Answer: Here is a case of grade 1 esophageal varices, defined by the way they flatten during insufflation.  They would be considered grade 2 if they protruded into less than half of the lumen and did not flatten with insufflation.  Grade 1 esophageal varices generally do not bleed.  There are really only two situations when you would consider treating grade 1 esophageal varices: if the patient is a Child C (this guy isn’t) or if there are stigmata of impending bleed, like red wale or cherry red spots.

Therefore, no treatment is necessary at this time, and because this is a compensated cirrhotic, you can wait two years before repeating the EGD.  In a decompensated cirrhotic with grade 1 varices, you’d probably wait just one year before the next surveillance EGD.

Beta-blockade is not known to prevent the growth of small varices, or prevent the formation of varices.  For a detailed look into this notion, click on this link to a 2005 article written by Groszmann et al. in the NEJM:

Beta-blockers and prevention of varices: NEJM 2005

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