What is the management of variceal bleeding in adults?

Management of Variceal Bleeding in Adults

The management of variceal bleeding requires immediate resuscitation, pharmacological therapy with somatostatin analogs, early endoscopy with variceal band ligation, and consideration of rescue therapies like TIPS for treatment failures. 1

Initial Resuscitation and Stabilization

• Patients should be treated in a unit where personnel are familiar with managing variceal bleeding and where hemodynamic monitoring is possible 1
• Establish at least two 16-gauge peripheral IV cannulas for fluid resuscitation 1
• Cross-match 6 units of blood and maintain hemoglobin around 7-8 g/dL to avoid overtransfusion 1, 2
• Correct coagulopathy by addressing prothrombin time and platelet count abnormalities 1
• Establish central venous access for monitoring and medication administration 1
• Consider airway protection with elective intubation in cases of:
  • Severe uncontrolled bleeding
  • Severe encephalopathy
  • Inability to maintain oxygen saturation above 90%
  • Aspiration pneumonia 1
• Administer short-term antibiotic prophylaxis (maximum 7 days) to all cirrhotic patients with GI hemorrhage 1
  • Oral norfloxacin (400 mg twice daily) or IV ciprofloxacin if oral administration isn't possible 1
  • IV ceftriaxone (1 g/day) may be preferable in advanced cirrhosis or centers with high quinolone resistance 1

Pharmacological Management

• Initiate vasoactive drugs as soon as variceal bleeding is suspected and continue for 3-5 days 1, 2
• Recommended pharmacological options:
  • Octreotide or somatostatin analogs are strongly recommended for portal hypertensive bleeding (strong recommendation, moderate quality evidence) 1
  • Terlipressin (where available) is preferred as it's the only agent with proven survival benefit 2
  • If endoscopy is unavailable, vasoconstrictors like octreotide or glypressin can be used temporarily while arranging definitive therapy 1
• Proton pump inhibitors are recommended in portal hypertensive bleeding (strong recommendation, low quality evidence) 1

Endoscopic Management

• Perform esophagogastroduodenoscopy (EGD) as soon as the patient is hemodynamically stable, ideally within 12 hours of presentation 1
• Variceal band ligation is the first-choice endoscopic treatment for esophageal varices 1
• If banding is difficult due to continued bleeding or unavailability, endoscopic variceal sclerotherapy should be performed 1
• For gastric varices, especially fundal varices:
  • Endoscopic variceal obturation with tissue adhesives (e.g., N-butyl-cyanoacrylate) is more effective than band ligation 1
  • This approach provides better control of initial hemorrhage and lower rebleeding rates 1

Management of Treatment Failure

• Treatment failure is defined as continued bleeding or significant rebleeding within 48 hours 3
• In cases of difficult-to-control bleeding:
  • Insert a Sengstaken-Blakemore tube as a temporary bridge until further treatment 1, 3
  • Seek specialist help and consider transfer to a specialized center 1
• Transjugular intrahepatic portosystemic shunt (TIPS) is the recommended rescue therapy when standard treatment fails 1, 3
  • For recurrent variceal bleeding after medical and endoscopic intervention, TIPS is suggested over continued endoscopic therapy (conditional recommendation, low quality evidence) 1
  • Early TIPS placement (within 72 hours) in high-risk patients (HVPG ≥20 mmHg or Child B with active bleeding/Child C <14 points) has been shown to decrease rebleeding and improve survival 1, 2

Secondary Prophylaxis

• After the acute bleeding episode is controlled, implement measures to prevent rebleeding 1
• Beta-blockers (propranolol or nadolol) are the mainstay of therapy for secondary prophylaxis 1, 4
• Endoscopic therapy with sclerotherapy or band ligation significantly reduces rebleeding risk 1
• Combined approaches:
  • Beta-blockers can be combined with organic nitrates in secondary prophylaxis 4
  • Some studies show combined therapy (sclerotherapy and beta-blockers) significantly reduces rebleeding and mortality compared to beta-blockers alone 1

Special Considerations

• For gastric varices, especially fundal varices (IGV1), endoscopic variceal obturation with tissue adhesives is more effective than band ligation or sclerotherapy 1
• Isolated splenic vein thrombosis causing IGV1 should be treated with splenectomy 1
• Extended pre-endoscopy octreotide may be beneficial in preventing rebleeding when endoscopy is delayed 5
• Smaller TIPS shunts (8mm diameter) may be preferable in patients at increased risk of liver failure 3