Role of endoscopy for primary prophylaxis of variceal bleeding

Varices are seen in one-third of unselected patients with cirrhosis and of these approximately one-third will bleed within 2 years from the time of diagnosis. The mortality with each bleeding episode ranges from 20% to 40% depending on the severity of liver disease. Although cost-effective, universal prophylaxis without endoscopic confirmation of large varices or varices with red signs is not recommended because of the treatment associated side effects. All cirrhotic patients should be screened and staged in a consistent and reproducible manner. Those with small varices or no varices should be re-screened every 1 to 2 years, respectively, thereafter. All high-risk (large esophageal or gastric varices, and those with red signs) patients should be treated with adequate doses (target heart rate of 60 per minute or less) of nonselective β-blockers. Endoscopic sclerotherapy has no role for primary prophylaxis. Endoscopic band ligation is as effective as β-blockers, but it should be reserved for those who are noncompliant or intolerant of β-blockers.