How to manage a hemodynamically unstable patient with variceal bleeding?

Management of Hemodynamically Unstable Variceal Bleeding

Immediate vasoactive drug therapy should be initiated as soon as acute variceal bleeding is suspected, followed by prompt resuscitation and endoscopic therapy once hemodynamic stability is achieved. 1

Initial Resuscitation and Stabilization

• Establish hemodynamic monitoring in a setting where close monitoring is possible 1
• Insert at least two 16-gauge peripheral cannulae for rapid volume replacement 1
• Initiate prompt volume replacement with crystalloids and/or colloids (avoid starch) to restore and maintain hemodynamic stability 1
• Follow a restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL 1
• Cross-match 6 units of blood and correct coagulopathy (prothrombin time, platelet count) 1
• Establish central venous access for monitoring and medication administration 1
• Consider airway protection by elective intubation in cases of:
  • Severe uncontrolled bleeding
  • Severe encephalopathy
  • Inability to maintain oxygen saturation above 90%
  • Aspiration pneumonia 1

Pharmacological Management

• Start vasoactive drugs immediately when variceal bleeding is suspected, even before endoscopy 1
• Use terlipressin, somatostatin, or octreotide as accepted options 1
• Continue vasoactive drug therapy for 3-5 days 1
• Initiate antibiotic prophylaxis immediately on presentation and continue for up to 7 days 1
  • Ceftriaxone (1g/24h) is first choice in patients with decompensated cirrhosis, those already on quinolone prophylaxis, or in settings with high quinolone resistance 1
  • Oral quinolones (norfloxacin 400mg twice daily) can be used in other patients 1
• Avoid beta-blockers and vasodilators during the acute bleeding episode 1
• Consider prophylactic lactulose to prevent hepatic encephalopathy 1

Endoscopic Management

• Perform gastroscopy within 12 hours after admission once hemodynamic stability is achieved 1
• In the absence of contraindications, consider pre-endoscopy erythromycin (250mg IV, 30-120 min before) to facilitate the procedure 1
• For esophageal varices, perform endoscopic variceal band ligation (first choice) 1
• If banding is difficult due to continued bleeding or unavailable, perform endoscopic variceal sclerotherapy 1

Management of Refractory Bleeding

• For persistent bleeding or early rebleeding (10-15% of cases) despite standard therapy, TIPS (transjugular intrahepatic portosystemic shunt) should be used as the rescue therapy of choice 1
• If bleeding is difficult to control and TIPS is not immediately available, insert a Sengstaken-Blakemore tube (balloon tamponade) as a temporary "bridge" until definitive treatment 1
  • Use balloon tamponade for a maximum of 24 hours 1
  • Ensure adequate airway protection when using balloon tamponade 1
• Consider removable, covered, self-expanding esophageal stents as an alternative to balloon tamponade 1
• Seek specialist help and consider transfer to a specialized center 1

Common Pitfalls and Caveats

• Avoid delaying vasoactive drug therapy while waiting for endoscopy 1
• Do not use starch for volume replacement 1
• Avoid nephrotoxic drugs (aminoglycosides, NSAIDs) during acute variceal bleeding 1
• Proton pump inhibitors have not shown efficacy for management of acute variceal bleeding, though a short course after band ligation may reduce post-banding ulcers 1
• Avoid large volume paracentesis during active bleeding 1
• Recognize that despite control of bleeding, patients may still die of liver and multiorgan failure 2
• Early pre-emptive covered TIPS (within 24-72 hours) should be considered in selected high-risk patients, such as those with Child class C cirrhosis with score <14 1