A 52-year-old man with alcohol-related cirrhosis (Child-Pugh B) undergoes screening esophagogastroduodenoscopy. Grade 3 esophageal varices are identified, and the endoscopist notes the presence of **B** — longitudinal red streaks overlying the varix surface. Which of the following is the most appropriate next step in management?

Explanation

## Why "Initiate carvedilol 6.25–12.5 mg daily or perform endoscopic variceal band ligation" is right The structure marked **B** — red wale marks (longitudinal red streaks on the varix surface) — represents dilated subepithelial venules and is a high-risk stigma for imminent variceal rupture. According to Baveno VII Consensus and Harrison 21e, the presence of red signs (including red wale marks) on esophageal varices is an absolute indication for primary prophylaxis, regardless of varix size. The patient has large varices (Grade 3) with red signs, placing him at 15–25% annual bleeding risk. Primary prophylaxis options are non-selective beta-blockers (carvedilol preferred per Baveno VII for its additional α1-blockade benefit) or endoscopic variceal band ligation — either one is appropriate, but NOT both. This is a preventive intervention, not acute bleed management. ## Why each distractor is wrong - **Perform immediate balloon tamponade followed by transjugular intrahepatic portosystemic shunt**: Balloon tamponade is reserved for acute variceal hemorrhage refractory to endoscopy, not for primary prophylaxis. TIPS is indicated for refractory rebleeding or early/pre-emptive TIPS in Child-Pugh C with active bleeding — not for asymptomatic varices with red signs. - **Repeat endoscopy in 1–2 years without pharmacological intervention**: Small varices without red signs may be observed with surveillance EGD in 1–2 years. However, this patient has large varices WITH red wale marks (high-risk stigmata), which mandates primary prophylaxis. Observation alone carries unacceptable bleeding risk. - **Administer terlipressin 2 mg intravenously every 4 hours and schedule urgent repeat EGD within 12 hours**: Terlipressin is a vasoactive agent used during acute variceal hemorrhage, not for primary prophylaxis. This patient is not actively bleeding; therefore, acute bleed protocols are inappropriate. **High-Yield:** Red wale marks = high-risk varix stigma → primary prophylaxis with NSBB (carvedilol preferred) or EVL; annual bleed risk 15–25%/year without treatment. [cite: Harrison 21e Ch 343; Baveno VII Consensus 2022]