A 50-year-old man with cirrhosis develops an acute esophageal variceal bleed. After resuscitation, endoscopic band ligation (EBL) is performed and haemostasis achieved. For secondary prophylaxis to prevent re-bleeding, the recommended long-term therapy is:

• A Non-selective beta-blockers (propranolol or carvedilol) combined with repeat endoscopic band ligation sessions until variceal eradication ✓
• B Long-term proton pump inhibitor therapy only
• C TIPS (transjugular intrahepatic portosystemic shunt) as the first choice for all patients after first rebleed
• D Vasopressin infusion maintained indefinitely

Explanation

Secondary prophylaxis after index variceal haemorrhage consists of combining non-selective beta-blockers (NSBBs — propranolol or carvedilol, which reduce portal pressure) with repeated endoscopic band ligation sessions at 2–4 week intervals until variceal eradication. The combination is superior to either modality alone (Baveno VII guidelines 2022). TIPS is reserved for Child-Pugh A/B patients with recurrent variceal bleeding despite combined therapy, or as early pre-emptive TIPS (within 72h) in high-risk patients (Child-Pugh C <14 or B with active bleeding on endoscopy). Vasopressin infusion is acute treatment only.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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