What is the management of bleeding esophageal varices?

From the Guidelines

Management of bleeding esophageal varices requires immediate intervention with a combination of pharmacological, endoscopic, and supportive measures, with the primary goal of reducing morbidity, mortality, and improving quality of life. Initial management includes hemodynamic stabilization with fluid resuscitation, blood transfusion to maintain hemoglobin above 7-8 g/dL, and correction of coagulopathy.

• Vasoactive medications should be started immediately, with terlipressin (2 mg IV every 4-6 hours), octreotide (50 mcg IV bolus followed by 50 mcg/hour infusion), or somatostatin (250 mcg IV bolus followed by 250-500 mcg/hour infusion) being the preferred agents, as supported by the study by Lo et al 1.
• Antibiotic prophylaxis with ceftriaxone 1g IV daily for 5-7 days is essential to prevent bacterial infections, as recommended by the KASL clinical practice guidelines 1.
• Urgent endoscopy should be performed within 12 hours, with band ligation being the preferred endoscopic therapy, as it has been shown to be more effective than sclerotherapy in reducing the risk of rebleeding and mortality, according to a meta-analysis of seven randomized trials 1.
• If band ligation is not feasible, sclerotherapy can be used, although it may require more sessions than band ligation, as shown by Ferrari et al 1.
• For patients with severe or refractory bleeding, balloon tamponade with a Sengstaken-Blakemore tube may provide temporary control for up to 24 hours, as recommended by the KASL clinical practice guidelines 1.
• Transjugular intrahepatic portosystemic shunt (TIPS) should be considered for patients who fail endoscopic and pharmacological therapy, as it can reduce portal pressure and prevent rebleeding, as supported by the study by Banares et al 1. After acute bleeding is controlled, non-selective beta-blockers (propranolol 20-40 mg twice daily or nadolol 20-40 mg daily) should be initiated for secondary prophylaxis, along with scheduled endoscopic band ligation sessions until varices are eradicated, as recommended by the KASL clinical practice guidelines 1. These interventions work by reducing portal pressure, promoting hemostasis, and preventing rebleeding, which is crucial as mortality from variceal bleeding remains high despite advances in management.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Bleeding Esophageal Varices

• The initial approach to managing bleeding esophageal varices requires adequate volume replacement with blood and other fluids, followed by upper gastrointestinal endoscopy to establish the source of bleeding 2.
• Endoscopic variceal sclerotherapy and balloon tamponade are effective in achieving temporary control of acute ongoing hemorrhage from esophageal varices 2, 3.
• Vasoactive drugs such as somatostatin, terlipressin, and octreotide can be used to decrease pressure and blood flow in the gastroesophageal collaterals, with somatostatin showing improved safety profile and efficacy compared to vasopressin 4, 5.
• Endoscopic variceal ligation is useful for controlling bleeding from esophageal varices, while endoscopic injection sclerotherapy with a tissue adhesive is effective for acute bleeding from gastric varices 3.
• The role of pharmacologic agents such as propranolol in preventing variceal hemorrhage by reducing portal pressure remains to be established 2.
• Shunt surgery can be used to prevent rebleeding, but it carries considerable early morbidity and mortality, as well as substantial longer-term morbidity and mortality from hepatic encephalopathy and liver failure 2.

Treatment Modalities

• Treatment modalities for bleeding esophageal varices include:
  • Endoscopic treatment (variceal ligation, sclerotherapy)
  • Pharmacologic therapy (vasoactive drugs)
  • Balloon tamponade
  • Surgery (shunt surgery)
  • Interventional radiology (transportal obliteration, balloon-occluded retrograde transvenous obliteration) 2, 3, 4, 6

Prevention of Rebleeding

• Complete eradication of esophageal varices and maintenance of low portal venous pressure are essential for preventing recurrence of variceal hemorrhage 3.
• Repeated endoscopic variceal sclerotherapy can be used to prevent rebleeding in better-risk patients (Child class A or B), while shunt surgery may be considered for patients who continue to rebleed 2.