What is the management for bleeding related to portal vein (PV) issues?

Management of Bleeding Related to Portal Vein Issues

For bleeding gastric varices related to portal hypertension, immediate resuscitation with restrictive transfusion (target Hb >7 g/dL), vasoactive drugs (octreotide), and prophylactic antibiotics should be initiated, followed by urgent endoscopy within 24 hours for diagnosis and cyanoacrylate injection, with definitive therapy determined by cross-sectional imaging and multidisciplinary discussion regarding TIPS, BRTO, or portal vein recanalization based on vascular anatomy. 1

Initial Resuscitation and Medical Management

Hemodynamic Stabilization

• Maintain restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target 7-9 g/dL to avoid increasing portal pressure and worsening bleeding 1, 2, 3
• Ensure adequate vascular access with two large-bore peripheral IVs or central venous access 1
• Target mean arterial pressure >65 mmHg while avoiding fluid overload that can exacerbate portal pressure 1
• Consider tracheal intubation for active hematemesis or inability to protect airway 1

Pharmacological Therapy

• Initiate octreotide immediately: 50 mcg IV bolus (can repeat in first hour), then 50 mcg/h continuous infusion for 2-5 days 1
• Start prophylactic antibiotics: ceftriaxone 1 g IV every 24 hours for maximum 7 days to reduce infections, rebleeding, and mortality 1
• Avoid over-correction of coagulopathy; transfusion thresholds should target hematocrit >25%, platelets >50,000, and fibrinogen >120 mg/dL only if needed 1

Diagnostic Evaluation

Urgent Endoscopy

• Perform urgent colonoscopy or upper endoscopy within 24 hours to identify bleeding source and classify variceal bleeding site 1
• Up to 8% of presumed lower GI bleeds have an upper source, so consider upper endoscopy if diagnosis unclear 1
• Goals include acute hemostasis for hemodynamic stabilization and planning for transfer to tertiary center if needed 1

Cross-Sectional Imaging

• Obtain CT or MR imaging with portal venous contrast phase after initial endoscopic hemostasis to determine vascular anatomy, including presence of portosystemic shunts and gastrorenal shunts 1
• This imaging is critical for determining definitive therapy options 1

Definitive Treatment Based on Anatomy

For Cardiofundal Gastric Varices with Gastrorenal Shunt

• BRTO (balloon-occluded retrograde transvenous obliteration) is optimal when gastrorenal shunt present, local expertise available, and severe comorbid portal hypertension complications absent 1
• BRTO has less rebleeding and encephalopathy compared to TIPS for cardiofundal varices 1
• Perform endoscopic assessment within 48 hours post-BRTO to confirm obliteration; if residual flow detected, perform cyanoacrylate injection 1
• Follow-up CT/MR at 4-6 weeks to confirm obliteration and evaluate for complications 1
• Important caveat: BRTO increases portal pressure, so surveillance endoscopy required to assess and treat exacerbated esophageal varices 1

For Endoscopic Management

• Cyanoacrylate (CA) injection is treatment of choice when definitive endoscopic therapy favored 1
• CA injection should be performed without plant-based oils like lipiodol 1
• Repeat endoscopy every 2-4 weeks for additional CA injection as needed 1
• Once completely treated, endoscopic reevaluation at 3-6 months, then yearly 1

For TIPS Placement

• TIPS indicated when significant inflow from coronary vein and/or significant comorbid portal hypertension complications (ascites, esophageal varices) 1
• When TIPS used for gastric varices, endovascular sclerosis and/or direct embolization of varices should also be performed when feasible 1
• TIPS alone for cardiofundal varices has up to 50% rebleeding rate due to lower portal pressures in these varices 1
• Perform endoscopy 1 month after TIPS to ensure gastric varix resolution 1

For Portal Vein Thrombosis/Occlusion

• Portal vein recanalization plus TIPS is required when portal vein occlusion present 1
• TIPS alone should not be performed without recanalization as it will inevitably thrombose 1
• Technical success rate for TIPS with portal vein recanalization is 98% with 92% patency 1
• In noncirrhotic patients with splenic vein occlusion, splenectomy or splenic embolization achieves 100% success without recurrent bleeding 1

Multidisciplinary Decision-Making

Determination of definitive therapy must be made via multidisciplinary discussion between gastroenterologist/hepatologist and interventional radiologist based on: 1

• Endoscopic appearance of gastric varix
• Underlying vascular anatomy
• Presence of comorbid portal hypertensive complications
• Available local resources

Special Considerations for Anorectal Varices

For bleeding anorectal varices specifically:

• Involve hepatology specialist team early with focus on optimal control of comorbidities 1
• In mild bleeding: IV fluids, blood transfusion if necessary, correction of coagulopathy, optimal medication for portal hypertension 1
• In severe bleeding: maintain Hb >7 g/dL and MAP >65 mmHg, avoid fluid overload 1
• Consider endorectal compression tube as bridging maneuver for stabilization or transfer 1

Critical Pitfalls to Avoid

• Never over-transfuse: Large volume transfusions paradoxically increase portal pressure and worsen bleeding 2, 3
• Do not perform TIPS alone in portal vein occlusion without recanalization 1
• Do not use endoscopic classification systems to guide primary prophylaxis of gastric varices 1
• Avoid splenectomy for splenomegaly/thrombocytopenia alone in portal hypertension—serious consequences documented 1