This patient has esophageal varices secondary to alcoholic cirrhosis. Medical management with propanolol or nadolol is indicated for a patient with non-bleeding esophageal varices.
Portal hypertension results from irreversible liver damage impeding the flow of blood through the liver, which is the key linkage between the portal and systemic systems. Patients with portal hypertension are at risk of esophageal varices, which may bleed, resulting in hematemesis and melena. Other vascular signs of portal hypertension include caput medusae and hemorrhoids, each of which represents a portosystemic shunt. Other clinical signs of portal hypertension including splenomegaly, ascites, and portal hypertensive gastropathy. Notably, esophageal varices account for 90% of all varices in patients with portal hypertension while the remaining 10% are gastric. There are multiple treatments for bleeding esophageal varices including ligation or banding and sclerotherapy, both which are done during endoscopy, in addition to IV vasopression, IV octreotide, balloon tamponade, and transjugular intrahepatic portosystemic shunting.
Heidelbaugh and Sherbondy discuss cirrhosis and chronic liver failure complications and treatment. Major complications of cirrhosis include ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, portal hypertension, variceal bleeding, and hepatorenal syndrome. Endoscopic banding is the preferred treatment, but sclerotherapy with vasoconstrictors such as octreotide may also be used. Prophylaxis with propranolol or nadalol is recommended in patients with cirrhosis once varices have been identified.
Karadsheh and Allison discuss prevention of variceal bleeding and compare and contrast pharmacological therapy and endoscopic banding. Recently, carvedilol (an alternative beta blocker with alpha blocking properties) has been utilized. Mortality has been similar between pharmacological therapy and endoscopic banding in most trials. Beta blockers remain the first line treatment, as they are cheaper and relatively effective in preventing both esophageal and gastric bleeding.
Illustration A depicts nonbleeding esophageal varicies.
Answer 1: Phentolamine is a reversible nonselective alpha blocker. It is not an effective prophylactic treatment for non-bleeding esophageal varacies.
Answers 2 and 5: Prazosin and doxazosin are a selective alpha 1 blocker that can be used for hypertension and urinary retention.
Answer 3: Nifedipine is a calcium channel blocker. It can be used for diffuse esophageal spasm but is not recommended for esophageal varices.
Heidelbaugh JJ, Sherbondy M. Cirrhosis and chronic liver failure: part II. Complications and treatment. Am Fam Physician. 2006 Sep 1;74(5):767-76.
PMID: 16970020 (Link to Abstract)
Karadsheh Z, Allison H. Primary Prevention of Variceal Bleeding: Pharmacological Therapy Versus Endoscopic Banding. N Am J Med Sci. 2013 Oct;5(10):573-579.
PMID: 24350068 (Link to Abstract)