How to manage a teenager with hematemesis and known esophageal varices?

Management of Acute Esophageal Variceal Bleeding in a 15-Year-Old

This teenager requires immediate resuscitation, urgent endoscopy within 12 hours, vasoactive drug therapy, prophylactic antibiotics, and endoscopic variceal ligation as the definitive treatment for active bleeding from known esophageal varices. 1, 2

Immediate Initial Management (Start Before Endoscopy)

Resuscitation and Hemodynamic Stabilization

• Establish large-bore IV access (two 16-gauge peripheral lines) and begin restrictive transfusion strategy targeting hemoglobin 7-9 g/dL. 1 Overtransfusion increases portal pressure and worsens bleeding outcomes. 1
• Avoid aggressive fluid resuscitation that could precipitate rebleeding through increased portal pressure. 1
• Transfer to intensive care unit or monitored setting given high mortality risk. 1

Pharmacologic Therapy (Start Immediately)

• Initiate vasoactive drugs as soon as variceal bleeding is suspected, even before endoscopy is performed. 1, 2 Options include:
  • Octreotide (somatostatin analog) - most commonly available in the US 2, 3
  • Terlipressin (if available) 3
  • Continue for 3-5 days after bleeding control 3
• Do NOT give beta-blockers during acute bleeding - they decrease blood pressure and blunt compensatory tachycardia. 2

Antibiotic Prophylaxis (Critical)

• Start prophylactic antibiotics immediately - this reduces infections, rebleeding, and mortality. 1
• Intravenous ceftriaxone 1 g every 24 hours (maximum 7 days) is preferred in centers with quinolone resistance or in patients with advanced cirrhosis. 1, 3
• Alternative: oral norfloxacin 400 mg every 12 hours if IV access limited and patient stable. 3

Urgent Endoscopic Management

Timing and Preparation

• Perform endoscopy within 12 hours of presentation, once hemodynamically stabilized. 1, 2
• Consider erythromycin 250 mg IV 30-120 minutes before endoscopy to clear gastric contents and optimize visualization (check QT interval first). 1
• In massive ongoing bleeding, consider endotracheal intubation before endoscopy to prevent aspiration. 1

Endoscopic Treatment

• Endoscopic variceal ligation (EVL/band ligation) is the first-line endoscopic treatment for acute esophageal variceal bleeding. 1, 2, 3, 4
• EVL achieves hemostasis in approximately 90% of cases. 4
• Sclerotherapy is an alternative if banding is technically difficult, though less preferred. 4

Rescue Therapies for Refractory Bleeding

If bleeding persists or recurs despite pharmacologic and endoscopic therapy (occurs in 10-20% of cases):

• Balloon tamponade (Sengstaken-Blakemore tube) as temporary bridge therapy for up to 24 hours while arranging definitive treatment. 1, 3, 4
• Early TIPS (transjugular intrahepatic portosystemic shunt) placement for high-risk patients or those failing combined therapy. 1, 3
• Self-expanding covered metallic esophageal stent as alternative temporizing measure. 4

Secondary Prevention (Before Hospital Discharge)

Combination Therapy is Essential

• Start non-selective beta-blocker (propranolol or nadolol) once recovered from acute bleeding and before discharge. 2
• Combine beta-blocker with repeat EVL sessions every 2-8 weeks until variceal eradication achieved. 1, 2
• This combination reduces rebleeding to 14-23% versus 38-47% with EVL alone. 2

Follow-up Endoscopy

• Schedule repeat endoscopy within 2-4 weeks to continue variceal eradication program. 1
• Continue surveillance even after eradication as varices can recur. 1

Critical Pitfalls to Avoid

• Never delay vasoactive drugs waiting for endoscopy - start immediately on clinical suspicion. 1, 2
• Never omit antibiotics - they reduce mortality independent of bleeding control. 1
• Never transfuse to "normal" hemoglobin - restrictive strategy (7-9 g/dL) improves outcomes. 1
• Never give beta-blockers during active bleeding - reserve for secondary prevention after stabilization. 2
• Never correct coagulopathy aggressively - portal hypertension, not coagulopathy, drives variceal bleeding, and excessive blood products risk portal vein thrombosis. 1