From the Guidelines
Preventing recurrent bleeding with surgery is not a primary intervention in the management of variceal bleeding. The primary interventions for variceal bleeding include pharmacological therapy with vasoactive drugs like terlipressin, octreotide, or somatostatin; endoscopic therapy such as band ligation or sclerotherapy; and supportive care including airway protection and hemodynamic stabilization.
- Using terlipressin before confirmed diagnosis is appropriate as early administration of vasoactive drugs improves outcomes, as suggested by 1.
- Evaluating Child-Pugh C patients for transplant is essential for long-term management, as indicated by 1.
- Judicious sedation may be necessary during procedures, but it is not a primary intervention for variceal bleeding.
- Transjugular intrahepatic portosystemic shunt (TIPS) is preferred over surgery for refractory bleeding or prevention of rebleeding, as recommended by 1 and 1. Surgical options like shunt procedures or esophageal transection carry high morbidity and mortality in patients with advanced liver disease and are rarely used as primary interventions in the current era of endoscopic and radiological techniques, as noted by 1.
From the Research
Management of Variceal Bleeding
The management of variceal bleeding involves several strategies to control bleeding, prevent recurrence, and manage underlying liver disease.
- Terlipressin Use: Terlipressin may be used before confirmed diagnosis, as it is recommended to start vasoactive drugs as soon as variceal bleeding is suspected 2, 3.
- Prevention of Recurrent Bleeding: Recurrent bleeding is prevented by a combination of beta-blockers and endoscopic band ligation, or transjugular intrahepatic portosystemic shunt (TIPS) in cases where these treatments fail 4, 5. Surgery, such as shunt surgery, may also be considered but is not the primary intervention for preventing recurrent bleeding.
- Child C Patient Management: Child C patients should undergo transplant evaluation, as liver transplantation is a treatment option for patients with advanced liver disease 2, 6.
- Sedatives in Management: There is no direct evidence to support the use of sedatives as a primary intervention in the management of variceal bleeding among the provided options. The primary focus is on controlling the bleeding, managing the underlying liver disease, and preventing recurrence.
Primary Intervention
The primary interventions in the management of variceal bleeding include:
- Controlling the acute bleed with vasoactive drugs like terlipressin
- Endoscopic treatments such as band ligation
- Prevention of recurrent bleeding with beta-blockers and/or endoscopic therapy
- Evaluation for liver transplantation in advanced cases
Given the options provided, D. Sedatives should be given to reduce anxiety stands out as not being a primary intervention in the management of variceal bleeding, based on the evidence provided 2, 6, 3, 4, 5.