What is not true in the management of variceal bleeding?

Management of Variceal Bleeding: False Statement Identification

Recurrent bleeding is prevented by surgery is the false statement in the management of variceal bleeding. 1, 2

Analysis of Each Statement

A. Terlipressin may be used before confirmed diagnosis

This statement is true. Vasoactive drugs, including terlipressin, should be started immediately upon suspicion of variceal bleeding, even before endoscopic confirmation. According to the British Society of Gastroenterology guidelines, vasoactive drugs are recommended as soon as variceal bleeding is suspected to help control bleeding 1. The American Association for the Study of Liver Diseases also recommends starting vasoactive drugs such as terlipressin immediately upon suspicion of variceal bleeding, even before endoscopy 2.

B. Recurrent bleeding is prevented by surgery

This statement is false. While surgery (particularly shunt surgery) may be used in select cases, it is not the primary or definitive method to prevent recurrent bleeding. According to guidelines:

• Non-selective beta-blockers are the first-line therapy for prevention of variceal rebleeding 1
• Endoscopic therapy (particularly band ligation) is recommended in combination with pharmacological therapy 2
• TIPS (transjugular intrahepatic portosystemic shunt) is indicated when bleeding cannot be controlled or recurs despite combined pharmacological and endoscopic therapy 2
• Surgery is considered only as a rescue therapy in specific situations, not as the standard approach for preventing recurrent bleeding 1

C. Child C patient should undergo transplant evaluation

This statement is true. Patients with advanced cirrhosis (Child-Pugh class C) who experience variceal bleeding have poor prognosis and should be evaluated for liver transplantation. This is considered the definitive treatment for patients with decompensated cirrhosis 1, 2. Liver transplantation addresses the underlying cause of portal hypertension and provides the best long-term survival benefit for these patients.

D. Sedatives should be given to reduce anxiety

This statement is true. Sedation is an important component of management in patients with variceal bleeding. Anxiety can increase portal pressure through sympathetic stimulation and potentially worsen bleeding. Appropriate sedation helps in controlling agitation, facilitating endoscopic procedures, and maintaining hemodynamic stability 1.

Correct Management of Variceal Bleeding

1. Initial management:

   • Hemodynamic stabilization with restrictive blood transfusion strategy (target Hb 7-9 g/dL)
   • Start vasoactive drugs immediately (terlipressin, somatostatin, or octreotide)
   • Antibiotic prophylaxis (IV ceftriaxone or oral norfloxacin)
   • Appropriate sedation to reduce anxiety

2. Endoscopic management:

   • Perform endoscopy within 12 hours once patient is stable
   • Endoscopic variceal ligation for esophageal varices
   • Tissue adhesives (cyanoacrylate) for gastric varices

3. Prevention of rebleeding:

   • Combination of non-selective beta-blockers and endoscopic band ligation
   • TIPS for patients who fail combined pharmacological and endoscopic therapy
   • Liver transplantation evaluation for Child C patients

4. Rescue therapies for uncontrolled bleeding:

   • Balloon tamponade as a temporary measure (maximum 24 hours)
   • Early TIPS placement in high-risk patients
   • Surgical options only in very select cases when other options have failed

The evidence clearly shows that a multimodal approach combining pharmacological therapy and endoscopic treatment is superior to surgery alone for preventing recurrent variceal bleeding.