The natural history of cirrhosis following an episode of variceal hemorrhage has been defined from clinical trials in which "control" subjects did not receive any specific treatment to prevent rebleeding. The cumulative data indicate that over 70 percent of patients experience recurrent variceal hemorrhage within one year of their index bleed [1,2]. The risk of rebleeding is greatest immediately after cessation of active bleeding and then declines, reaching close to baseline values by six weeks. Approximately 70 percent of all untreated patients die within the first year after their initial variceal bleed. The causes of death include recurrent variceal hemorrhage, liver failure, hepatic encephalopathy, and progressive ascites and infections.
These data underscore the importance of preventing recurrent hemorrhage, sustaining liver function, maintaining an ascites-free state, and avoiding infections to achieve prolonged survival. At this time, orthotopic liver transplant (OLT) is the only treatment that achieves all of these objectives and prolongs long-term survival with any degree of certainty. However, some patients are not suitable subjects for liver transplants and, even when OLT is being considered, patients often have to wait several months before an organ becomes available. During this time, they are at risk for recurrent variceal hemorrhage and therefore require treatment to prevent this complication. (See "Patient selection for liver transplantation".)
The ideal treatment would be one that is universally effective, safe, freely available, easy to administer and inexpensive. Because such a treatment does not exist, the choice of a given modality of treatment over another involves consideration of its relative efficacy and safety, availability, and cost considerations. The major options are endoscopic sclerotherapy, endoscopic band ligation, pharmacologic therapy with beta blockers and oral nitrates, insertion of a transjugular intrahepatic portosystemic shunt, and surgery.
This topic with will review the options for preventing recurrent variceal hemorrhage in patients with cirrhosis. The treatment of acute variceal hemorrhage is discussed elsewhere. (See "General principles of the management of variceal hemorrhage" and "Treatment of active variceal hemorrhage" and "Endoscopic variceal ligation".)
The American Association for the Study of Liver Diseases (AASLD) issued guidelines in 2007 for the prevention of variceal recurrent bleeding . The approaches recommended by the guidelines (nonselective beta blockers, endoscopic variceal ligation, transjugular intrahepatic portosystemic shunts, and liver transplantation), as well as other options for the prevention of recurrent variceal bleeding, are discussed in detail below.