Primary prophylaxis of variceal hemorrhage.

Figure 3 shows an algorithm for the primary prevention of variceal hemorrhage. Pharmacologic therapy is the current standard of treatment for the primary prophylaxis of esophageal variceal bleeding. Patients with medium or large varices should be treated with a nonselective beta-blocker with the dose titrated to achieve a 25% decrement in resting heart rate or a heart rate of 55 to 60 bpm. The development of symptoms will, of course, limit the dose used. As discussed previously, these therapeutic endpoints are not well correlated with decreases in portal pressure. Measurement of the HVPG before therapy and after 3 months of therapy provides a rational approach to drug dosing. If the HVPG decreases by 20% or to less than 12 mm Hg, the medication dose will be effective in preventing hemorrhage. If, however, the HVPG is not appropriately lowered, a long-acting nitrate may be added. Patients with small varices should be observed, with endoscopic examinations every 2 years to assess progression of variceal size. Endoscopic therapy is not indicated for the primary prevention of variceal bleeding.