What is the protocol for managing esophageal variceal bleeding?

From the Guidelines

The protocol for managing esophageal variceal bleeding involves immediate resuscitation followed by specific interventions to control bleeding, with the most recent and highest quality study recommending the initiation of vasoactive pharmacologic agents and performing endoscopic therapy after initial resuscitation when the patient is stable and bleeding has slowed or ceased 1. The management of esophageal variceal bleeding is a complex process that requires a multifaceted approach.

Initial Resuscitation

Start with two large-bore IV lines for fluid resuscitation, using crystalloids and blood products to maintain hemodynamic stability with a hemoglobin target of 7-8 g/dL, as recommended by recent guidelines 1.

Vasoactive Medications

Administer vasoactive medications promptly, with terlipressin 2mg IV every 4 hours or octreotide as a 50μg bolus followed by 50μg/hour infusion for 3-5 days, as these medications have been shown to reduce splanchnic blood flow and portal pressure, thereby controlling bleeding 1.

Antibiotic Prophylaxis

Antibiotic prophylaxis with ceftriaxone 1g daily for 5-7 days is essential to prevent infections, which are a common complication of esophageal variceal bleeding 1.

Endoscopic Therapy

Perform endoscopic therapy within 12 hours, preferably with band ligation or sclerotherapy if banding isn't available, as endoscopic variceal ligation (EVL) is the endoscopic treatment of choice for patients with acute bleeding from esophageal varices 1.

Secondary Prophylaxis

After acute bleeding is controlled, start secondary prophylaxis with non-selective beta-blockers like propranolol 20-40mg twice daily or nadolol 20-40mg daily, titrated to reduce heart rate by 25%, to prevent rebleeding 1. Some key points to consider in the management of esophageal variceal bleeding include:

• The combination of endoscopic variceal ligation (EVL) plus non-selective beta-blockers (NSBBs) is recommended as the primary treatment for esophageal variceal bleeding 1.
• If primary treatment for esophageal variceal rebleeding fails, TIPS placement should be considered as a rescue therapy 1.
• Balloon tamponade can be considered as a bridge therapy for patients who fail to achieve hemostasis after endoscopic treatment 1.

From the Research

Protocol for Esophageal Variceal Bleeding

The protocol for esophageal variceal bleeding involves a combination of pharmacologic and endoscopic treatments.

• Initial treatment should include:
  • Adequate fluid resuscitation and transfusion to maintain hemoglobin around 7 to 8 g/dL 2
  • Prophylactic antibiotics (norfloxacin or ceftriaxone) 2
• Vasoactive therapy should be started as soon as variceal bleeding is suspected and maintained for up to 5 days to prevent early rebleeding 2
• Terlipressin, a vasopressin derivative, is the preferred agent due to its safety profile and proven efficacy in improving survival 2
• Somatostatin and octreotide are used and are as effective as terlipressin in control of bleeding but have not been shown to reduce mortality 2, 3, 4

Endoscopic Therapy

• Endoscopic therapy must be performed within the first 12 hours after admission when the patient is stable 2
• Variceal band ligation is the recommended endoscopic treatment, but injection sclerotherapy is an alternative if band ligation is technically difficult 2, 5
• Sclerotherapy may have a role in the treatment of acute variceal bleeding, especially when combined with somatostatin or octreotide 6, 4

Rescue Therapies

• In failures to control bleeding, the use of rescue transjugular intrahepatic portosystemic shunt (TIPS) using covered stents is the best alternative 2
• In mild early rebleeding, a second course of endoscopic therapy may be attempted 2
• If rebleeding is severe, placement of TIPS using covered stents is the first-choice rescue treatment 2
• Balloon tamponade may be used as a temporary bridge to TIPS in refractory variceal bleeding episodes 2