What is the management of a variceal bleed?

Management of Variceal Bleeding

The management of variceal bleeding requires immediate vasoactive drug therapy (terlipressin, somatostatin, or octreotide), followed by endoscopic band ligation within 12 hours of admission, with transjugular intrahepatic portosystemic shunt (TIPS) reserved for treatment failures. 1

Initial Resuscitation and Stabilization

• Resuscitation priorities:

  • Place at least two 16-gauge peripheral cannulae
  • Cross-match 6 units of blood
  • Correct coagulopathy (prothrombin time, platelet count)
  • Establish central venous access
  • Consider airway protection via elective intubation in cases of:
    • Severe uncontrolled bleeding
    • Severe encephalopathy
    • Inability to maintain oxygen saturation >90%
    • Aspiration pneumonia 2

• Transfusion strategy:

  • Follow restrictive transfusion approach with hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL 1
  • Avoid over-transfusion which can increase portal pressure

Pharmacological Management

• Vasoactive drugs:

  • Start immediately when variceal bleeding is suspected, even before endoscopy 1
  • Options (in order of preference):
    1. Terlipressin: 2 mg IV every 4 hours for first 48 hours, then 1 mg IV every 4 hours; continue for 3-5 days after bleeding control 1
    2. Somatostatin or Octreotide: If terlipressin unavailable 1
  • Continue for 3-5 days to prevent early rebleeding 1

• Antibiotic prophylaxis:

  • Short course (up to 7 days) of ceftriaxone or norfloxacin 1
  • Reduces risk of infection, rebleeding, and mortality

Endoscopic Management

• Timing: Perform endoscopy within 12 hours of admission once patient is hemodynamically stable 1

• Technique based on varix location:

  • Esophageal varices: Endoscopic band ligation is first choice 2, 1
  • Gastric varices: Endoscopic injection with tissue adhesives (cyanoacrylate) for fundal varices 1
  • If band ligation unavailable: Use sclerotherapy 2

• Post-procedure:

  • Consider short-course proton pump inhibitor therapy to reduce post-banding ulcer size 1
  • Schedule follow-up endoscopy for variceal eradication

Management of Treatment Failure

• Definition of treatment failure:

  • Transfusion requirement ≥4 units with inability to increase systolic BP by 20 mmHg or to ≥70 mmHg
  • Inability to reduce pulse rate to <100 beats/min within 6 hours
  • Recurrent hematemesis, reduction in BP >20 mmHg, increase in pulse rate >20 beats/min
  • Transfusion of ≥2 additional units of blood after 6 hours 1

• Rescue therapy options:

  1. TIPS: First-line rescue therapy for uncontrolled bleeding or early rebleeding 3, 4

     • Consider early (within 72 hours) in high-risk patients (Child-Pugh B with active bleeding or Child-Pugh C <14 points) 4
     • Use covered stents for better outcomes 4

  2. Balloon tamponade: Temporary measure (maximum 24 hours) while arranging definitive therapy 1, 5

     • Effective for immediate control but high risk of rebleeding if used alone
     • Requires airway protection

  3. Self-expanding metal stents (SEMS): Alternative to balloon tamponade with fewer complications 5

Secondary Prophylaxis

• Start after acute bleeding is controlled:

  • Combination of non-selective beta-blockers and endoscopic band ligation 1
  • Schedule band ligation at weekly intervals until variceal eradication 2
  • Follow-up endoscopy at 3 months and every 6 months thereafter 2

• For patients with advanced cirrhosis:

  • Evaluate for liver transplantation, especially in Child-Pugh C patients 1

Special Considerations

• Gastric varices:

  • Cyanoacrylate ("super glue") injection is more effective than sclerotherapy 2
  • Consider TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for refractory gastric variceal bleeding 5

• Monitoring for complications:

  • Hepatic encephalopathy: Treat with lactulose or lactitol when it develops 1
  • Renal dysfunction: Maintain adequate fluid and electrolyte balance, avoid nephrotoxic drugs 1
  • Cardiac complications: Monitor for bradycardia, especially with octreotide 6

Common Pitfalls to Avoid

• Delaying vasoactive drug administration until endoscopic confirmation
• Excessive fluid resuscitation or over-transfusion
• Delaying endoscopy beyond 12 hours in stable patients
• Failing to recognize treatment failure promptly
• Neglecting antibiotic prophylaxis
• Not considering early TIPS in high-risk patients