Editing Variceal bleeding (section)

== '''Bleeding varices''' ==

=== '''Principles     of managing UGIB secondary to varices''' ===

** Resuscitate and institute      medical management as below - may need to secure airway in an      encephalopathic patient
** Bleeding stops spontaneously      in about half of patients - less likely to stop in CP-C cirrhosis or if      HVPG > 20mmHg
** Endoscopy immediately      post-resus if unstable, within 24 hours otherwise (UK consensus      guidelines 2013)
** Consider TIPS in the acute      setting if necessary - especially for gastric varices, as they are harder      to treat endoscopically
** Surgical shunt is also an      option if all else fails

=== '''Medical     management''' ===

** IV ceftriaxone (decreases      infection rate, re-bleeding, and improves survival)
** Octreotide infusion (reduces      variceal flow) - initial bolus 50mcg then 50mcg/hr, which is continued      for 2-5 days
** Aim Hb 70-90 - any higher      actually increases portal pressure and risks more bleeding, with higher      6-week mortality
** Attempt INR < 2 and      platelets >50,000
** May need to be discharged on      propanolol? Probably no need for PPI
** If ascites, they may need      spironolactone
** In severe bleeding,      vasopressin infusions can decrease splanchnic flow (need to also give      nitroglycerin to ameliorate systemic effects)
** Luminal tamponade -      Sengstaken-Blakemore tube works 90% of the time, but recurs 50% of the      time when tamponade is released
*** Really should only be done       to an intubated patient
*** Test the integrity of the       balloons prior to insertion
*** Insert orally, stop at 50cm
*** Inflate the gastric balloon       with saline to 200-250mL, stopping and readjusting if there is       resistance (ideally stop after 50mL and confirm gastric position with       XR)
*** Apply about 1kg traction       using an IVF bag on a pole
*** After 10 minutes, use the       gastric suction and accessory NGT to evaluate for bleeding below and       above the balloon respectively
*** Stop and see if the patient       stabilises - in most cases (Schein) the oesophageal balloon isn't       needed. If needed due to ongoing bleeding, inflate to 30-45mm Hg.
*** If the patient still       doesn't stabilise, take it out and repeat the endoscopy or do a CT
*** Must be removed within       24-36 hours of placement
***

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