What is the treatment for esophageal variceal bleeding?

From the Guidelines

Variceal bleeding treatment requires immediate intervention with a combination of pharmacological and endoscopic approaches, prioritizing resuscitation, vasoactive medications, and endoscopic therapy within 12 hours, as supported by the most recent guidelines 1. The initial step in managing variceal bleeding involves resuscitation and hemodynamic stabilization, administering IV fluids and blood products as needed to maintain hemoglobin above 7-8 g/dL.

• Initiate vasoactive medications promptly, such as octreotide at 50 mcg IV bolus followed by 50 mcg/hour infusion for 3-5 days, or terlipressin 2 mg IV every 4 hours for the first 48 hours, then 1 mg every 4 hours, as recommended by recent studies 1.
• Administer prophylactic antibiotics like ceftriaxone 1g IV daily for 5-7 days to prevent infections which are common and increase mortality, as emphasized by guidelines 1.
• Endoscopic therapy should be performed within 12 hours, with band ligation being the preferred method for esophageal varices, while cyanoacrylate glue injection is used for gastric varices, as supported by the latest evidence 1. If bleeding persists despite these measures, consider balloon tamponade as a temporary bridge or transjugular intrahepatic portosystemic shunt (TIPS) placement, with TIPS being a well-established treatment for esophageal variceal hemorrhage resulting from portal hypertension 1. After acute bleeding is controlled, start secondary prophylaxis with non-selective beta-blockers (propranolol 20-40 mg twice daily or nadolol 20-40 mg daily) and schedule follow-up endoscopic band ligation sessions until varices are eradicated, addressing the underlying pathophysiology of portal hypertension 1.

From the Research

Treatment Options for Variceal Bleed

• The standard treatment for acute variceal bleeding consists of immediate drug treatment with terlipressin or octreotide, together with early endoscopic band ligation or sclerotherapy 2.
• In cases where standard treatment fails, emergency transjugular intrahepatic portosystemic shunting (TIPS) is considered the rescue treatment of choice 2.
• Octreotide has been shown to be useful in the management of acute variceal bleeding, with no significant side effects, and can be used as an adjuvant treatment associated with endoscopic treatment 3.
• Variceal band ligation is considered the most effective therapy for oesophageal varices, while the best treatment for gastric varices is still uncertain, with both endoscopic therapy with cyanoacrylate or thrombin and TIPS reported to be of benefit 4.

Role of Octreotide in Variceal Bleed Treatment

• Octreotide infusion has been shown to reduce recurrent bleeding and the need for balloon tamponade in patients with variceal hemorrhage treated by endoscopic variceal ligation 5.
• The use of octreotide as an adjunct to endoscopic variceal ligation has been found to lower the relative risk of rebleeding and reduce in-hospital and 30-day mortality rates 5.

Endoscopic Therapy for Variceal Bleed

• Endoscopic therapy is the mainstay of management of bleeding varices, requiring attention to technique and the appropriate choice of therapy for a given patient at a given point in time 6.
• Continuous monitoring after initiation of therapy is necessary to control bleeding, and second-line definitive therapies must be introduced quickly if endoscopic and pharmacologic treatment fails 6.