Esophageal varices that are refractory to endoscopic treatment are addressed through multiple approaches, according to a recent review that compared international clinical guidelines and outlined updated strategies when first-line therapies are unsuccessful.
Esophageal varices—swollen veins in the esophagus caused by increased portal vein pressure from liver disease—can rupture and cause life-threatening bleeding. Endoscopic variceal ligation (EVL) is the primary treatment worldwide and is effective in approximately 90% of cases. However, it may fail in patients with large varices or those who have undergone previous interventions.
The review categorized treatment strategies into four areas: endoscopic therapy, interventional radiology (IVR), surgery, and internal medicine. When EVL fails, researchers noted that clinicians may use endoscopic injection sclerotherapy (EIS) or endoscopic tissue adhesives (ETA). While ETA is widely used internationally, it is not approved for esophageal use in Japan.
For endoscopy-refractory cases, IVR offers several options. A transjugular intrahepatic portosystemic shunt (TIPS) is commonly used in Western countries to reduce portal pressure by creating a stent-based connection between the portal and hepatic veins. Early TIPS, performed within 72 hours of bleeding, may reduce rebleeding and mortality in high-risk patients.
TIPS, however, is rarely performed in Japan due to limited access and lack of insurance coverage. Japanese clinicians more often use partial splenic embolization (PSE), which reduces blood flow to the spleen, lowering portal pressure and improving platelet counts.
Additional IVR options include percutaneous transhepatic obliteration (PTO) and transileocolic vein obliteration (TIO), which target collateral circulation contributing to variceal pressure. These procedures are sometimes combined with endoscopic therapy for improved outcomes.
Surgical interventions, such as esophageal transection and shunt surgeries, are considered when less invasive methods are unsuccessful. These procedures are associated with increased risk, but newer laparoscopic techniques are under investigation to reduce complications.
Medical management serves as supportive or bridge therapy. Self-expandable metal stents (SEMS) and balloon tamponade are used temporarily when endoscopic hemostasis fails. Non-selective beta-blockers (NSBBs), particularly carvedilol, are recommended in Western guidelines for both primary and secondary prevention.
The review also underscored regional differences in clinical guidelines. Western approaches emphasize pharmacologic and pressure-based strategies, while Japanese protocols favor endoscopy and IVR, reflecting healthcare system variations and treatment availability.
As technology and interdisciplinary coordination continue to improve, more tailored, region-specific approaches are being implemented for patients with refractory esophageal varices. These evolving strategies aim to reduce mortality and improve outcomes in this high-risk population.
The authors reported no conflicts of interest.
Source: DEN Open