Correct Answer : B
Rationale
This patient has large varices, which should be treated. In patients with cirrhosis and medium/large varices that have never bled, nonselective beta-blockers reduce the risk of first variceal hemorrhage by 50%. In high-quality randomized-controlled trials, endoscopic variceal ligation (EVL) is as effective as nonselective beta-blockers in preventing first variceal hemorrhage. Therefore, either of these therapies should be used for the prevention of first variceal bleeding. In this case, propranolol is not the best choice in the setting of diabetes, asthma as well as a blood pressure and pulse that are low already. Endoscopic variceal band ligation would be preferred in this patient. It is also more effective than sclerotherapy and is associated with fewer side effects. TIPS would be effective, but more invasive and not first-line for treatment of nonbleeding varices and comes with increased risk of hepatic encephalopathy and potentially mortality. The combination of nadolol and endoscopic variceal band ligation may have more side effects without a further reduction in the risk of first variceal hemorrhage beyond either therapy alone.
References
1. Gluud L.L., Klingenberg S., Nikolova D., Gluud C. Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials. Am J Gastroenterol. 2007;102(12):2842-8.
2. Gluud L.L., Krag A. Banding ligation versus betablockers for primary prevention in oesophageal varices in adults. Cochrane Database Syst Rev. 2012;8:CD004544. doi: 10.1002/14651858. CD004544.
3. Villanueva C., Piqueras M., Aracil C., et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol. 2006;45(4):560-7.
