What is the initial management for variceal bleeding?

Initial Management for Variceal Bleeding

The initial management for variceal bleeding should include immediate administration of vasoactive drugs (terlipressin, somatostatin, or octreotide), followed by endoscopic therapy within 12 hours after adequate resuscitation, along with antibiotic prophylaxis. 1, 2

Immediate Resuscitation and Medical Management

• Initial resuscitation should focus on hemodynamic stabilization, airway protection to prevent aspiration, and blood transfusion with a restrictive strategy (hemoglobin threshold ≤70 g/L) 1, 2

• Vasoactive drugs should be initiated as soon as variceal bleeding is suspected, even before diagnostic endoscopy, as they reduce splanchnic blood flow and portal pressure 1

• Options for vasoactive therapy include:

  • Terlipressin: Initial dose of 2 mg IV every 4 hours, which can be reduced to 1 mg IV every 4 hours once bleeding is controlled; has shown survival benefit 1
  • Somatostatin: 250 μg IV bolus followed by infusion of 250 μg/hour 1
  • Octreotide: 50 μg IV bolus followed by continuous infusion of 50 μg/hour 1, 3
  • Vasopressin with nitroglycerin: Less preferred due to higher side effect profile 1

• Antibiotic prophylaxis should be administered to all patients with cirrhosis and acute variceal bleeding:

  • Ceftriaxone 1 g/day for up to 7 days is recommended 1, 2
  • Norfloxacin 400 mg twice daily is an alternative 4

Endoscopic Management

• Endoscopic evaluation should be performed within 12 hours of presentation after the patient has been hemodynamically stabilized 1, 2

• Endoscopic variceal band ligation (EVL) is the preferred endoscopic treatment for esophageal variceal hemorrhage 1, 2

• For gastroesophageal varices type 1 (GOV1), either band ligation or cyanoacrylate injection can be used 1, 2

• For gastric fundal varices (GOV2, IGV1), endoscopic cyanoacrylate injection is the recommended treatment 1, 2

• Combination therapy with vasoactive drugs and endoscopic treatment is more effective than either therapy alone, with success rates of 85-90% for initial control of bleeding 1

Rescue Therapies for Treatment Failures

• Despite standard therapy, 10-20% of patients may have persistent bleeding or early rebleeding within 5 days 4

• For patients with persistent bleeding despite pharmacological and endoscopic therapy, urgent transjugular intrahepatic portosystemic shunt (TIPS) should be considered 1, 2

• Pre-emptive TIPS within 72 hours (preferably within 24 hours) should be considered in high-risk patients:

  • Child-Pugh C ≤13 or Child-Pugh B >7 with active bleeding despite vasoactive agents
  • HVPG >20 mmHg 1, 2, 4

• Self-expanding metal stents may be considered as a bridge to definitive treatment in patients with contraindications to TIPS 1

Common Pitfalls and Caveats

• Beta-blockers should not be used during acute bleeding as they decrease blood pressure and blunt physiologic heart rate increases associated with bleeding 1

• Overtransfusion should be avoided; a restrictive transfusion strategy (target hemoglobin 70-90 g/L) is associated with better outcomes 2, 4

• Vasopressin alone has significant cardiovascular side effects and should only be used with nitroglycerin if other vasoactive agents are unavailable 1

• Endoscopic therapy should only be performed after initial resuscitation when the patient is stable and bleeding has slowed or ceased 1

• Risk stratification using Child-Pugh and MELD scores is essential for determining prognosis and guiding therapy decisions, particularly for TIPS consideration 1, 2