A 52-year-old man comes to the office due to abnormal liver chemistry results found during a life insurance medical examination. He occasionally feels fatigued and has pedal edema after prolonged standing but otherwise feels well. The patient has no medical history and takes no medications. He drinks 1 or 2 cans of beer on weekends and does not smoke. He used intravenous drugs in his 20s but has not since then. Vital signs are within normal range. Physical examination shows palmar erythema and multiple spider angiomas. Laboratory results are as follows: Abdominal ultrasonography reveals a coarse, nodular-appearing liver with no masses, mild ascites, and splenomegaly. Upper gastrointestinal endoscopy demonstrates medium-sized but nonbleeding esophageal varices. He is referred for a hepatitis C evaluation with a gastroenterologist. Which of the following is the best management for this patient at this time?

Question

A 52-year-old man comes to the office due to abnormal liver chemistry results found during a life insurance medical examination.  He occasionally feels fatigued and has pedal edema after prolonged standing but otherwise feels well.  The patient has no medical history and takes no medications.  He drinks 1 or 2 cans of beer on weekends and does not smoke.  He used intravenous drugs in his 20s but has not since then.  Vital signs are within normal range.  Physical examination shows palmar erythema and multiple spider angiomas.  Laboratory results are as follows: Abdominal ultrasonography reveals a coarse, nodular-appearing liver with no masses, mild ascites, and splenomegaly.  Upper gastrointestinal endoscopy demonstrates medium-sized but nonbleeding esophageal varices.  He is referred for a hepatitis C evaluation with a gastroenterologist.  Which of the following is the best management for this patient at this time?

Quizplus · Accepted Answer

This patient has evidence of cirrhosis (eg, spider angioma, nodular coarse liver, varices), likely from chronic hepatitis C. He is found to have medium-sized, nonbleeding esophageal varices. Variceal hemorrhage develops in approximately one third of all patients with varices and is a major cause of morbidity and mortality. Most cirrhotic patients should undergo diagnostic upper endoscopy to assess for varices and to determine their risk of hemorrhage. Those with (medium- or large-sized) varices, such as this patient, generally should be started on a nonselective beta blocker. varices Nonselective beta blockers (eg, propranolol, nadolol) are recommended to decrease progression to large varices and the risk of variceal hemorrhage. They are thought to act by decreasing adrenergic tone in mesenteric arterioles, which results in unopposed alpha-mediated vasoconstriction and decreased portal venous flow. Endoscopic variceal ligation is an alternate primary preventive therapy in patients with contraindications to beta blocker therapy. (Choice A) ACE inhibitors have not been shown to reduce variceal bleeding or improve outcomes in cirrhosis, and they have no role in the management of patients with esophageal varices. (Choice C) Endoscopic sclerotherapy is an effective treatment for actively bleeding esophageal varices. It is not recommended for primary prophylaxis of variceal hemorrhage. (Choice D) H2 histamine receptor blockers have not been shown to reduce progression or bleeding complications in patients with cirrhosis and varices. (Choice E) Octreotide is a long-acting somatostatin analogue that causes splanchnic vasoconstriction and reduced portal blood flow by inhibiting the release of glucagon. It is used in the treatment of active variceal bleeding and has no role in primary prophylaxis. Educational objective: In most patients with nonbleeding varices, prophylactic treatment with nonselective beta blockers (eg, propranolol, nadolol) is recommended to reduce the likelihood of progression to large varices as well as the risk of variceal hemorrhage. Endoscopic variceal ligation can be used as an alternate primary preventive therapy in patients with contraindications to beta blocker therapy. References: Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. (http://www.ncbi.nlm.nih.gov/pubmed/26047908)

A 52-Year-Old Man Comes to the Office Due to Abnormal