Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 50-year-old man is evaluated in follow-up for a recent diagnosis of cirrhosis secondary to nonalcoholic steatohepatitis. He has a history of asthma, type 2 diabetes mellitus, hyperlipidemia, and obesity. His current medications are inhaled fluticasone, montelukast, insulin glargine, insulin lispro, simvastatin, and lisinopril.
On physical examination, temperature is 37.5 °C (99.5 °F), blood pressure is 120/70 mm Hg, pulse rate is 80/min, and respiration rate is 16/min; BMI is 31. Abdominal examination reveals a palpable spleen tip.
Laboratory studies disclose a platelet count of 100,000/µL (100 × 109/L), an INR of 0.9 (normal range, 0.8-1.2), and a total bilirubin level of 1.2 mg/dL (20.5 µmol/L). Abdominal ultrasound discloses a nodular-appearing liver, splenomegaly, and intra-abdominal venous collaterals consistent with portal hypertension. Upper endoscopy is notable for large (>5 mm) distal esophageal varices that persist despite air insufflation. There are no red wale signs.
Which of the following is the most appropriate treatment?
A: Endoscopic ligation
B: Endoscopic sclerotherapy
D: Transjugular intrahepatic portosystemic shunt
MKSAP Answer and Critique
The correct answer is A: Endoscopic ligation.
The most appropriate treatment is endoscopic ligation. The lifetime risk for a first-time variceal bleed in the setting of cirrhosis is 30% and carries a mortality risk of 15% to 20%. Therefore, primary prophylaxis is crucial. Current practice guidelines recommend that all patients with cirrhosis undergo screening endoscopy to detect large esophageal varices. Small varices are usually less than 5 mm in diameter and easily flatten with air insufflation during endoscopy. Large varices are larger than 5 mm or persist despite air insufflation. The presence of red wale markings (longitudinal red streaks on varices) indicates an increased risk of rupture. When large varices are present, as in this patient, the next step in management is to offer nonselective β-blockers or endoscopic variceal ligation as primary prophylaxis to prevent variceal hemorrhage. Although no head-to-head trials have been performed between these treatments, each modality has a similar effect on preventing an index variceal bleed compared with placebo. However, patients with contraindications to β-blocker therapy such as asthma or resting bradycardia can be offered endoscopic ligation. Thus, propranolol would not be the preferred choice in this patient.
Because of adverse effects such as esophageal stricturing, endoscopic sclerotherapy has been replaced by variceal band ligation and is not recommended by major guidelines for primary prophylaxis of large varices.
In patients with active variceal hemorrhage in whom band ligation does not control primary bleeding, or if bleeding recurs or is due to gastric varices, balloon tamponade followed by portal decompression by placement of a transjugular intrahepatic portosystemic shunt (TIPS) can be performed. In the absence of recurrent or refractory variceal hemorrhage, there is no indication for TIPS.
- Patients with large esophageal varices and contraindications to nonselective β-blockers should receive endoscopic variceal ligation as prophylactic treatment for variceal hemorrhage.
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