Variceal bleeding

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

Initial endoscopic management (works in 85%)

• • Should be intubated
  • Look for active bleeding vs stigmata of bleeding (red wale markings, nipple sign, cherry red spots, overlying clot)
  • Options for treatment
    • Endoscopic band ligation is gold standard
    • Sclerotherapy is next best
      • Sclerotherapy more useful for gastric varices - inject cyanoacrylate polymer or morrhuate sodium or ethanolamine - complicated by non-specific chest pain in 10% of patients
      • Cyanoacrylate process: inject 1-2ml directly into varix then 1ml flush of sterile water
      • Embolisation is most dreaded complication - <1% of patients
    • Glue
    • Thrombin injection
    • Placement of self-expanding metal stent can be used for refractory bleeds as a bridge to TIPS
  • Gastric varices
    • GOV1 (both oesophagus and lesser curvature of stomach) should be treated same as oesophageal varices
    • Isolated gastric varices from splenic vein thrombosis should not be treated solely endoscopically - needs splenectomy - see separate topic

Failed endoscopy/pharmacotherapy

• • Sengstaken-Blakemore tube, continue resuscitation in ICU, and return to re-trial endoscopy in 24 hours
  • TIPS

Recurrent bleeding after initial control

• • Highest risk for recurrence within the first few days
  • CP-A/B: surgical shunt - see separate varices topic
  • CP-C: TIPS - see separate varices topic

Post-op management

• • If banding has been done, they may need repeat banding in a fortnight until varices obliterated
  • Keep NBM until the next day, followed by soft diet for 24 hours, then normal diet
  • See separate 'varices' topic under UGIS for long-term medical management

Prognosis

• • Mortality currently is around 10-20% at 6 weeks
  • Mortality closely related to hepatic functional reserve - mortality >50% in CP-C in some sources.