Secondary prevention of bleeding gastro-oesophageal varices

After an initial episode of bleeding from gastro-oesophageal varices, the risk of rebleeding within 12 months in patients with cirrhosis is approximately 60%. Combined endoscopic and long-term beta blocker therapy is the most effective strategy to reduce this risk. Endoscopic band ligation of oesophageal varices should be repeated until varices have been obliterated. Regular endoscopy (every 6 to 12 months) is indicated to check for recurrence.

Pre-emptive placement of a transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours of variceal haemorrhage can reduce mortality and may be considered in selected patients who are at high risk of rebleeding after endoscopic therapy.

For patients who rebleed despite appropriate prevention strategies, TIPS should be considered.

In patients with recurrent episodes of bleeding gastro-oesophageal varices, establish whether an advance care plan is in place, and in those not eligible for liver transplantation or TIPS, consider referral for palliative care.