A 52-year-old man with biopsy-proven cirrhosis (Child-Pugh Class B) presents with haematemesis and melaena. On endoscopy, active bleeding from oesophageal varices is confirmed. After initial resuscitation and blood product transfusion, bleeding is controlled with endoscopic variceal ligation (EVL). What is the most appropriate next step in management?

Explanation

## Management of Acute Variceal Bleeding in Cirrhosis ### Immediate Post-EVL Strategy **Key Point:** After successful EVL for acute variceal bleeding, the next step is to initiate beta-blocker therapy AND schedule repeat EVL sessions to achieve variceal eradication. **High-Yield:** EVL is a mechanical intervention that controls acute bleeding but does not prevent recurrence. Repeat sessions (typically 2–4 weeks apart) are required until variceal eradication is achieved (defined as absence of varices on endoscopy). ### Rationale for Beta-Blocker Therapy 1. **Portal pressure reduction:** Propranolol (and other non-selective beta-blockers) reduce portal venous pressure by decreasing cardiac output and splanchnic vasodilation. 2. **Prevention of rebleeding:** Beta-blockers reduce the risk of rebleeding by ~40% and improve survival. 3. **Target:** Heart rate reduction of 20–25% or absolute reduction to 55–60 bpm indicates adequate beta-blockade. ### EVL Eradication Protocol | Aspect | Details | | --- | --- | | **Timing of repeat EVL** | 2–4 weeks after initial session | | **Goal** | Complete variceal eradication (no visible varices) | | **Sessions required** | Usually 2–4 sessions | | **Follow-up after eradication** | Surveillance endoscopy at 3 months, then 6-monthly | **Clinical Pearl:** The combination of EVL + beta-blocker therapy is superior to either modality alone in preventing rebleeding and improving survival in cirrhotic patients with oesophageal varices. ### Why Other Options Are Incorrect - **Repeat endoscopy in 2 weeks alone:** Surveillance without beta-blocker therapy leaves the patient at high risk of rebleeding. - **Discharge without beta-blocker:** Premature discharge without pharmacological support increases mortality. - **Immediate TIPS:** TIPS is reserved for EVL failure (rebleeding despite 2 EVL sessions) or for patients with gastric varices or portal vein thrombosis. It is not first-line after successful EVL. [cite:Harrison 21e Ch 297]