What is the management of variceal bleeding?

Management of Variceal Bleeding

The management of variceal bleeding requires immediate resuscitation, pharmacological therapy with vasoactive drugs, endoscopic band ligation as first-line treatment, and antibiotic prophylaxis to reduce mortality and prevent rebleeding. 1

Initial Resuscitation and Stabilization

• Hemodynamic Stabilization:

  • Place at least two 16-gauge peripheral cannulae
  • Cross-match 6 units of blood
  • Maintain hemoglobin around 8 g/dL (restrictive transfusion strategy) 2, 1
  • Correct coagulopathy and establish central venous access 2

• Airway Protection: Consider elective intubation in cases of:

  • Severe uncontrolled bleeding
  • Severe encephalopathy
  • Inability to maintain oxygen saturation >90%
  • Aspiration pneumonia 2, 1

Pharmacological Management

• Vasoactive Drugs: Start immediately when variceal bleeding is suspected, even before endoscopy

  • First choice: Terlipressin 2 mg IV every 4 hours for 48 hours, then 1 mg IV every 4 hours 1
  • Alternatives:
    • Somatostatin (250 μg IV bolus followed by infusion of 250 μg/hour)
    • Octreotide (50 μg IV bolus followed by 50 μg/hour) 2
    • Vapreotide (50 μg IV bolus followed by 50 μg/hour) 2
  • Continue for 3-5 days after bleeding control 2, 1

• Antibiotic Prophylaxis: Short-term (maximum 7 days)

  • Oral norfloxacin (400 mg BID) or IV ciprofloxacin if oral route not possible
  • IV ceftriaxone (1 g/day) preferred in advanced cirrhosis or centers with high quinolone resistance 2, 1

Endoscopic Management

• Timing: Perform endoscopy within 12 hours once patient is hemodynamically stable 2, 1

• For Esophageal Varices:

  • First choice: Endoscopic variceal band ligation (EVL) 2, 1
  • Alternative: Sclerotherapy if banding is difficult due to continued bleeding or technique unavailable 2

• For Gastric Varices:

  • For GOV1 (extension along lesser curvature): Same approach as esophageal varices 2
  • For Fundal Varices (GOV2, IGV1): Endoscopic variceal obturation with tissue adhesives like N-butyl-cyanoacrylate 2, 1
  • For IGV1 secondary to isolated splenic vein thrombosis: Splenectomy 2

Management of Treatment Failure

Treatment failure defined as inability to control bleeding within 6 hours or recurrence within 5 days 1

• Rescue Therapies:
  • First choice: TIPS (Transjugular Intrahepatic Portosystemic Shunt) 2, 1
  • Temporary measure: Balloon tamponade (Sengstaken tube) for maximum 24 hours while arranging definitive therapy 2, 1
  • Consider early TIPS (within 24-72 hours) in high-risk patients (HVPG ≥20 mmHg or Child B with active bleeding/Child C <14 points) 2, 3

Prevention of Rebleeding (Secondary Prophylaxis)

• Combination therapy: Non-selective beta-blockers plus endoscopic band ligation 1
• Follow-up endoscopy: At 3 months and every 6 months thereafter 1
• Consider liver transplantation evaluation for patients with advanced cirrhosis (Child-Pugh class C) 1

Special Considerations and Pitfalls

• Avoid over-transfusion: Target hemoglobin 7-9 g/dL as higher levels may increase portal pressure and rebleeding risk 1
• Do not delay vasoactive drugs: Start immediately when variceal bleeding is suspected, even before confirming diagnosis 4
• Avoid correcting coagulation parameters with blood products or factor concentrates unless there is active bleeding 1
• Avoid tranexamic acid in patients with cirrhosis and active variceal bleeding 1
• Monitor for complications: Renal dysfunction, hepatic encephalopathy, and infection 1

This comprehensive approach to variceal bleeding management has reduced mortality from 40% to 15-20% over the past two decades 3.