Variceal Primary Prophylaxis — RACP Adult Medicine MCQ

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ModerateGastroenterology & HepatologyVariceal Primary ProphylaxisRACP Adult Medicine

A 55-year-old man with cirrhosis and portal hypertension has never had a variceal bleed. Endoscopy shows large oesophageal varices with red wale signs. What is the recommended primary prophylaxis?

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Correct answer: B — Isosorbide mononitrate alone

For primary prophylaxis of variceal bleeding in patients with large varices (especially with red wale signs or Child-Pugh C cirrhosis), either non-selective beta-blockers (carvedilol is increasingly preferred – PREDESCI trial; or propranolol/nadolol) OR endoscopic band ligation (EVL) is recommended. The choice between NSBB and EVL depends on patient preference, compliance, and contraindications. Combining NSBB and EVL for primary prophylaxis is NOT routinely recommended (no additional benefit, Baveno VII). Carvedilol 6.25–12.5 mg daily is emerging as the preferred NSBB.

Reference: eTG – 2025 – Gastrointestinal; Baveno VII – 2022 – Portal Hypertension Consensus