What is the step-by-step guideline for treating active esophageal varices (enlarged veins in the esophagus) in the Emergency Department (ED)?

From the Guidelines

Management of active esophageal varices in the emergency department requires prompt intervention to control bleeding and prevent complications, with the most effective approach being a combination of vasoactive therapy and endoscopic treatment, as evidenced by the most recent and highest quality study 1. The step-by-step guideline for treating active esophageal varices involves:

• Establishing two large-bore IV lines (16-18 gauge) and initiating fluid resuscitation with crystalloids to maintain hemodynamic stability
• Beginning vasoactive therapy immediately with octreotide at 50 mcg IV bolus followed by 50 mcg/hour continuous infusion for 3-5 days to reduce portal pressure, as supported by the study 1
• Administering antibiotics prophylactically with ceftriaxone 1g IV daily for 5-7 days to prevent bacterial infections, which is recommended by the guidelines 1
• Correcting coagulopathy with fresh frozen plasma if INR >1.5 and maintaining platelets above 50,000/mm³
• Performing urgent endoscopy within 12 hours of presentation for definitive diagnosis and treatment, with band ligation as the preferred endoscopic intervention, as endorsed by the Baveno VI Consensus Workshop 1 Some key points to consider:
• The combination of endoscopic therapy and vasoactive drugs is more effective than the isolated use of either of these options alone, as shown in the study 1
• Endoscopic variceal ligation (EVL) is more effective than endoscopic sclerotherapy (ES) in decreasing the risk of rebleeding from esophageal varices, with fewer complications, as demonstrated in the meta-analysis 1
• Balloon tamponade with a Sengstaken-Blakemore or Minnesota tube can be considered as a temporary bridge (maximum 24 hours) to prevent tissue necrosis if endoscopy is delayed or unsuccessful, as recommended by the guidelines 1
• Early TIPS placement can be considered in patients at high risk of rebleeding, as suggested by the study 1 The goal of these interventions is to reduce portal pressure, control active bleeding, and prevent rebleeding while addressing potential complications like infection and coagulopathy that can worsen outcomes in these critically ill patients, ultimately improving morbidity, mortality, and quality of life.

From the Research

Step-by-Step Guideline for Treating Active Esophageal Varices

• Initial assessment and stabilization: Patients with suspected acute variceal bleeding should be risk stratified according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy 2.
• Fluid resuscitation and transfusion: A restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion, and a post-transfusion target hemoglobin of 70-90 g/L is desired 2, 3.
• Pharmacotherapy: Vasoactive agents such as terlipressin, octreotide, or somatostatin should be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days 2, 3.
• Antibiotic prophylaxis: Antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies 2.
• Endoscopic evaluation: Endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated 2.
• Endoscopic therapy: Endoscopic band ligation (EBL) is the recommended endoscopic treatment for acute esophageal variceal hemorrhage (EVH) 2, 3.
• Secondary prophylaxis: Patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices, and nonselective beta blockers (NSBBs) should be used in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD 2.

Rescue Therapies

• Transjugular intrahepatic portosystemic shunt (TIPS): TIPS should be considered in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis, or in patients with persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy 2, 3.
• Balloon tamponade: Balloon tamponade may be used as a temporary bridge to TIPS in refractory variceal bleeding episodes 3.
• Esophageal stents: Esophageal stents may be used as a rescue therapy in patients who fail initial endoscopic therapy 4.