What is the management for acute variceal bleeding?

Management of Acute Variceal Bleeding

The management of acute variceal bleeding requires immediate initiation of vasoactive drugs before endoscopy, followed by endoscopic variceal ligation within 12 hours, along with prophylactic antibiotics and restrictive blood transfusion strategy to optimize outcomes and reduce mortality. 1

Initial Resuscitation and General Measures

• Hemodynamic stabilization:

  • Prompt volume replacement with colloids or crystalloids (avoid starch) 1
  • Restrictive transfusion strategy: maintain hemoglobin 7-9 g/dL (threshold for transfusion: 7 g/dL) 1
  • Avoid excessive fluid resuscitation which can increase portal pressure and worsen bleeding 1

• Airway protection:

  • Consider tracheal intubation in patients with altered mental status or massive bleeding to prevent aspiration 1

Pharmacological Treatment

1. Vasoactive drugs:

   • Start immediately upon suspicion of variceal bleeding, even before endoscopy 1
   • Continue for 3-5 days after diagnosis confirmation 1
   • Options (all are effective):
     • Terlipressin: 2 mg IV every 4 hours initially, then 1 mg IV every 4 hours after bleeding control 1
     • Somatostatin: 250 μg IV bolus followed by 250 μg/hour infusion 1
     • Octreotide: 50 μg IV bolus followed by 50 μg/hour infusion 1

2. Prophylactic antibiotics:

   • Start immediately on admission and continue for up to 7 days 1
   • Options:
     • Ceftriaxone 1 g/24h IV (preferred in decompensated cirrhosis, patients on quinolone prophylaxis, or settings with high quinolone resistance) 1
     • Norfloxacin 400 mg BID orally (for other patients) 1

Endoscopic Management

• Timing: Perform endoscopy within 12 hours of admission once hemodynamic stability is achieved 1
• Procedure of choice: Endoscopic variceal ligation (EVL) when acute variceal bleeding is confirmed 1
• Pre-endoscopy erythromycin: Consider 250 mg IV 30-120 minutes before endoscopy to improve visualization (if no QT prolongation) 1

Management of Treatment Failure

For persistent bleeding or early rebleeding (10-15% of cases) despite standard therapy:

1. TIPS (Transjugular Intrahepatic Portosystemic Shunt):

   • First-line rescue therapy for uncontrolled bleeding 1
   • Consider early pre-emptive covered TIPS (within 24-72 hours) in high-risk patients:
     • Child C cirrhosis with score <14 1
     • Patients with HVPG ≥20 mmHg 1

2. Temporary measures (if TIPS not immediately available):

   • Balloon tamponade: Use only as a temporary bridge (maximum 24 hours) until definitive treatment 1
   • Self-expanding esophageal stents: Alternative to balloon tamponade with potentially fewer complications 1

Special Considerations

• Gastric varices:

  • GOV1 (extension of esophageal varices along lesser curvature): Treat same as esophageal varices 1
  • Fundal varices: Consider endoscopic variceal obturation with tissue adhesives (e.g., cyanoacrylate) 1

• Medications to avoid:

  • Beta-blockers and vasodilators during acute bleeding episode 1
  • Limit use of proton pump inhibitors (PPIs) to short courses as long-term use may increase risk of spontaneous bacterial peritonitis and hepatic encephalopathy 1

Prevention of Complications

• Consider prophylactic lactulose to prevent hepatic encephalopathy, though more studies are needed 1
• Monitor for renal dysfunction, which is common in patients with variceal bleeding

Algorithm for Management

1. Immediate measures (0-12 hours):

   • Start vasoactive drugs (terlipressin, somatostatin, or octreotide)
   • Begin prophylactic antibiotics
   • Restrictive blood transfusion (target Hb 7-9 g/dL)
   • Perform endoscopy within 12 hours with EVL

2. Continued management (12 hours-5 days):

   • Continue vasoactive drugs for 3-5 days
   • Continue antibiotics for up to 7 days
   • Monitor for rebleeding

3. If bleeding persists or recurs:

   • Consider early TIPS in high-risk patients
   • Use balloon tamponade or esophageal stents as temporary bridge if needed

This comprehensive approach has reduced mortality from variceal bleeding from 40% to 15-20% in recent decades 2.