Bleeding prophylaxis

Question: A 49 year old female with PBC and compensated cirrhosis undergoes screening EGD.  There is mild portal hypertensive gastropathy and no esophageal varices.  You are interested in preventing future bleeding from varices.  What is your next step?

A. prescribe a beta-blocker to help prevent the formation of varices

B. prescribe a calcium-channel blocker to decrease cardiac inotropy

C. repeat the EGD in one year

D. prescribe no pharmaceutical- it’s already been shown to be useless

Answer: Primary prophylaxis for variceal bleeding is an important topic to understand, and you will face these decisions time and again.  If a patient has no esophageal varices, medication is not indicated.  It was shown in this New England J of Medicine paper in 2005 that prophylaxis with beta-blockade does not prevent the formation of varices, but does increase side effects.

Calcium channel blockers are not used for bleeding prophylaxis in cirrhotics.  With respect to time between endoscopies, I recommend the following: every 1 year for decompensated cirrhotics; every 2-3 years for compensated cirrhotics.  A 1 year interval in this patient may be too soon; it is very unlikely to progress from no varices to large varices in 12 months.

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