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New Developments in Managing Variceal Bleeding

The most life-threatening complication of liver cirrhosis is acute variceal bleeding (AVB) which is associated with increased mortality that, despite recent progress in management, is still around 20% at 6 weeks. Combined treatment with vasoactive drugs, prophylactic antibiotics, and endoscopic techniques is the recommended standard of care for patients with acute variceal bleeding. There are many promising new modalities including the combination of coil and glue injection for management of bleeding or non-bleeding gastric varices and hemostatic powder application, that requires minimal expertise, when performed early after admission of a cirrhotic patient with AVB and overt hematemesis acting…

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 Variceal Hemorrhage

Vasoactive drugs also have been shown to benefit these patients. Terlipressin, a vasopressin analog, has been shown to improve prognosis in variceal bleeding, preserving renal function and controlling hemorrhage. Unfortunately, it is not available in the United States. Octreotide has a demonstrated benefit for controlling hemorrhage, but it has not been shown to improve mortality on its own. It does, however, significantly decrease early rebleeding when used in combination with sclerotherapy, and it has found wide acceptance in the United States. Octreotide is given in a 50 mcg bolus followed by an infusion of 25-50 mcg/hour for 2-5 days.

Articles of Interest

Air Care Series: Balloon Tamponade of Variceal Hemorrhage

Balloon tamponade is an effective way to achieve temporary hemostasis from bleeding esophagogastric varices. Due to potential for morbid complications it is reserved for unstable patients and is only a bridge to definitive treatment (EGD).

Diagnosis and Management of Esophagogastric Varices

Patients with high-risk varices should receive primary prophylaxis with either nonselective beta-blockers or endoscopic band ligation. In cases of AVB, patients should receive upper endoscopy within 12 h after resuscitation and hemodynamic stability, whereas endoscopy should be performed as soon as possible if patients are unstable.

Differences in bleeding behavior after endoscopic band ligation: a retrospective analysis

Endoscopic band ligation (EBL) is generally accepted as the treatment of choice for bleeding from esophageal varices. It is also used for secondary prophylaxis of esophageal variceal hemorrhage. However, there is no data or guidelines concerning endoscopic control of ligation ulcers.

Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding

In conclusion, in patients with Child–Pugh class C disease or class B disease with active bleeding who were admitted for acute variceal bleeding, the early use of TIPS with an e-PTFE–covered stent was associated with significant reductions in the failure to control bleeding, in rebleeding, and in mortality, with no increase in the risk of hepatic encephalopathy.

EarlyTIPS

Among patients with hepatic cirrhosis, early TIPS improves one-year overall survival and reduces the risk of rebleeding or failure to control bleeding when compared to pharmacotherapy group.

EM@3AM: Gastroesophageal Varices

Patients with evidence of cirrhosis on examination or by history are at risk of developing portal hypertension and subsequent esophageal varices. Bleeding from esophageal varices is a life threatening emergency as patients vomit and lose large quantities of blood. Patients often require aggressive fluid and blood resuscitation in addition to intubation for airway protection. Octreotide is a synthetic octapeptide which acts on somatostatin receptors causing inhibition of the release of chemicals that cause vasodilation of the portal venous system, thereby decreasing blood flow to the varices.

Endoscopic management of esophageal varices

Variceal bleeding is the most severe complication of cirrhosis and is the second most common cause of mortality among the patients. Endoscopic therapies for varices aim to reduce variceal wall tension by obliteration of the varix. The two principal methods available for esophageal varices are endoscopic sclerotherapy (EST) and band ligation (EBL).

Management of Acute Variceal Bleeding

The treatment goals for acute variceal bleeding are to correct hypovolemia; achieve rapid hemostasis; and prevent early rebleeding, complications related to bleeding, and deterioration of liver function. If variceal bleeding is suspected, treatment with vasopressors and antibiotics should be initiated immediately on arrival to the hospital.

Management of Gastric Varices

TIPS is very effective in controlling active GV bleeding and for secondary prophylaxis. However, it carries a risk of hepatic encephalopathy. TIPS is the best treatment strategy for patients who fail endoscopic therapy.

MKSAP: 50-year-old man with cirrhosis

The most appropriate treatment is endoscopic ligation. The lifetime risk for a first-time variceal bleed in the setting of cirrhosis is 30% and carries a mortality risk of 15% to 20%. Therefore, primary prophylaxis is crucial. Current practice guidelines recommend that all patients with cirrhosis undergo screening endoscopy to detect large esophageal varices.

Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis

Endoscopic variceal ligation has been established as an alternative to non­selective β-blockers for the prevention of initial variceal hemorrhage.

Quick Tips: Esophageal Varices

We created an infographic to help you understand varices

Recent Advances in the Management of Acute Variceal Hemorrhage

Gastrointestinal bleeding is one of the most relevant causes of death in patients with cirrhosis and clinically significant portal hypertension, with gastroesophageal varices being the most frequent source of hemorrhage. Despite survival has improved thanks to the standardization on medical treatment aiming to decrease portal hypertension and prevent infections, mortality remains significant.