Treatment of Esophageal Varices: Primary Prophylaxis, Acute Bleeding, and Secondary Prophylaxis

Year 2025, Volume: 20 Issue: 3, 249 - 260

Mesut Kuş , Serhat Akpınar , Bülent Kantarçeken , Kadir Gişi

https://doi.org/10.17517/ksutfd.1744248

Abstract

Cirrhosis is an advanced stage of chronic liver disease, and one of its most critical prognostic determinants is portal hypertension. Esophageal varices that develop as a consequence of portal hypertension, along with the gastrointestinal bleeding arising from them, represent among the most severe and life-threatening complications of cirrhosis. Approximately 50% of cirrhotic patients have esophageal varices, and one-third of these patients experience variceal bleeding, which is a major cause of morbidity and mortality. Pre-primary prophylaxis aimed at preventing the development of varices is not recommended. However, in patients with established varices, primary prophylaxis against bleeding is guided by the size of the varices, the stage of liver failure, and the patient's tolerance to treatment, and involves the use of non-selective β-blockers and/or endoscopic band ligation (EVL). In cases of acute variceal bleeding, emergency combination therapy (EVL combined with vasoactive agents), along with close monitoring in an intensive care setting, is recommended. In secondary prophylaxis, complete variceal obliteration should be achieved, and the hepatic venous pressure gradient (HVPG) should be reduced to below 12 mmHg; this approach is currently considered the standard of care. In the future, advances in the treatment of the underlying liver disease may allow for more effective reduction of portal pressure, and possibly, a single pharmacologic agent could emerge that significantly improves outcomes and offers a more optimistic perspective for managing this fatal complication.

Keywords

Cirrhosis , esophageal varices , prophylaxis , endoscopic band ligation , endoscopic sclerotherapy , non-selective beta blocker

Özofagus Varislerinin Tedavisi: Primer Profilaksi, Akut Kanama ve Sekonder Profilaksi

Abstract

Siroz, karaciğerin ileri evre kronik hastalığı olup prognozu belirleyen en önemli komplikasyonlardan biri portal hipertansiyondur. Portal hipertansiyon sonucu gelişen özofagus varisleri ve bunlardan kaynaklanan gastrointestinal kanamalar, sirozun en ciddi ve yaşamı tehdit eden komplikasyonları arasında yer almaktadır. Sirotik hastaların yaklaşık %50’sinde özofagus varisleri bulunmakta olup, bu hastaların üçte birinde majör morbidite ve mortalite nedeni olan varis kanaması gelişmektedir. Özofagus varislerinin gelişimini önlemeye yönelik pre-primer profilaksi önerilmemektedir. Ancak varis saptanan hastalarda primer kanama profilaksisi, varisin boyutuna, karaciğer yetmezliğinin evresine ve hastanın tedaviye toleransına göre non-selektif β-blokerler ve/veya endoskopik band ligasyonu (EVL) ile yapılmaktadır. Akut varis kanamasında ise, acil kombine tedavi (EVL + vazoaktif ajanlar), yoğun bakım koşullarında dikkatli izlemle birlikte önerilmektedir. Sekonder profilakside, varislerin tamamen obliterasyonu sağlanmalı ve hepatik venöz basınç gradyenti (HVPG) 12 mmHg’nın altına düşürülmelidir; bu yaklaşım günümüzde standart kabul edilmektedir. Gelecekte, altta yatan karaciğer hastalığının tedavisinde sağlanacak ilerlemelerle portal basıncın daha etkin şekilde düşürülmesi mümkün olabilecek, hatta tek bir ilaç ile bu mortal komplikasyonun önlenmesi konusunda daha iyimser bir tablo ortaya çıkabilecektir.

Keywords

Siroz , özefagus varisi , profilaksi , endoskopik band ligasyonu , endoskopik skleroterapi , non selektif beta bloker

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