Prevention of Variceal Rebleeding: Stratifying Risk and Individualizing Care

Abstract

The standard of care for the prevention of variceal rebleeding, i.e. combination of variceal ligation and beta-blockers, is uniformly applied to all cirrhotic patients with a previous variceal bleed. Risk stratification would allow tailor therapy. Preliminary results of individual patient data meta-analysis of randomized controlled trials comparing the efficacy of variceal ligation and beta-blockers with either therapy alone to prevent rebleeding indicate that the efficacy of these therapies is different between Child A and Child B/C patients. In Child A, combination therapy is associated with lower rebleeding rate, but without differences in survival. In Child B/C, and compared to variceal ligation alone, combination therapy is associated with lower rebleeding and mortality. Although combination therapy should continue to be the standard of care for variceal rebleeding prevention, it should take into account that beta-blockers are the mainstay of such therapy. Covered TIPS is recommended as the second line therapy for patients who have failed standard combination therapy, and also for those likely to fail combination therapy or with complications of portal hypertension other than bleeding