What is the diagnostic workup and treatment for variceal bleeding?

Management of Variceal Bleeding

Immediate initiation of vasoactive drugs (terlipressin, somatostatin, or octreotide) combined with prophylactic antibiotics before endoscopy, followed by endoscopic variceal ligation within 12 hours, represents the standard of care for acute variceal bleeding. 1, 2

Initial Resuscitation and Stabilization

Begin vasoactive therapy immediately upon suspicion of variceal bleeding—even before diagnostic endoscopy is performed. 1, 2

• Fluid resuscitation: Target hemoglobin of 7-8 g/dL using a restrictive transfusion strategy 2, 3
• Vasoactive drugs: Start one of the following agents as soon as variceal bleeding is suspected and continue for 3-5 days 1, 2:
  • Terlipressin: 2 mg IV every 4-6 hours (initial dose), then 1-2 mg IV every 4-6 hours (preferred agent where available due to proven mortality benefit) 1, 3
  • Somatostatin: 250 μg IV bolus, then 250 μg/hr continuous infusion 1
  • Octreotide: 50 μg IV bolus, then 50 μg/hr continuous infusion 1

The rationale for early vasoactive therapy: Meta-analyses demonstrate that early administration facilitates endoscopy, improves early hemostasis, and reduces 5-day rebleeding rates (77% hemostasis with combination therapy vs. 58% with endoscopy alone) 1

Critical Caveat on Drug Selection

Terlipressin is the only vasoactive agent proven to reduce mortality (RR 0.66; 95% CI 0.49-0.88), though it carries risks of hyponatremia and myocardial ischemia that require monitoring 1, 3. However, all three agents (terlipressin, somatostatin, octreotide) show equivalent efficacy for hemostasis control 1.

Antibiotic Prophylaxis

Administer prophylactic antibiotics immediately—this is mandatory and improves survival, not just infection rates. 1, 2

• Standard regimen: Norfloxacin 400 mg PO twice daily for 7 days 1, 2
• If oral administration not possible: IV ciprofloxacin 1
• Advanced cirrhosis (Child-Pugh B/C): IV ceftriaxone 1 g daily is superior to norfloxacin, particularly in centers with quinolone-resistant organisms 1, 2

Why antibiotics matter: They reduce bacterial infections, decrease early rebleeding, and improve survival—the benefit extends beyond infection prevention to hemostasis itself 1

Diagnostic Endoscopy and Treatment

Perform upper endoscopy within 12 hours once hemodynamically stable. 1, 2

Endoscopic Management

• Esophageal varices: Endoscopic variceal ligation (EVL) is the treatment of choice, achieving 85-90% initial hemostasis rates 1, 2
• Gastric varices (GOV1): Manage similarly to esophageal varices with EVL 1, 2
• Fundal varices (GOV2, IGV1): Cyanoacrylate injection is superior to band ligation (23% vs. 47% rebleeding rate) 2

Combination therapy is superior: EVL plus vasoactive drugs for 2 days reduces very early rebleeding and treatment failure compared to vasoactive drugs alone for 5 days 1

Important Pitfall

Do NOT use endoscopic injection sclerotherapy as first-line treatment—it has higher treatment failure rates, bleeding-related mortality, and adverse events compared to EVL 1. Use sclerotherapy only if EVL is technically impossible.

Management of Treatment Failure

10-20% of patients will experience persistent bleeding or early rebleeding despite standard therapy. 2, 3

Rescue Therapies (in order of preference):

1. Transjugular intrahepatic portosystemic shunt (TIPS) with covered stents: First-line rescue therapy for refractory bleeding 2, 3

   • Early TIPS strategy: In high-risk patients (Child-Pugh B with active bleeding or Child-Pugh C <14 points), placement within 72 hours markedly decreases rebleeding and improves survival 3
   • MELD score considerations: MELD ≥19 predicts high mortality risk; MELD >25 associated with 36-83% 90-day post-TIPS mortality 1

2. Balloon tamponade: Use only as temporary bridge (maximum 24 hours) to definitive therapy while arranging TIPS 2, 3

What NOT to Do

Avoid these interventions in acute variceal bleeding:

• Beta-blockers: Do not use acutely—they decrease blood pressure and blunt compensatory tachycardia 1
• Tranexamic acid: No benefit demonstrated; should not be used 1
• Routine correction of coagulopathy: If hemostasis is achieved with standard therapy, correction of INR/platelets is not indicated 1
• Recombinant factor VIIa: No net clinical benefit; potential increased thromboembolic risk 1

Post-Treatment Considerations

• Proton pump inhibitors: May be considered after EVL to reduce post-ligation ulcer size and bleeding risk 2
• Secondary prophylaxis: Combination of beta-blockers plus repeat EVL until variceal obliteration is preferred for preventing rebleeding 4

Key Prognostic Indicators

Monitor for high-risk features predicting treatment failure:

• Active bleeding at endoscopy 1
• Child-Pugh class C or B with active bleeding 3
• MELD score ≥19 (associated with ≥20% 6-week mortality) 1
• Hepatocellular carcinoma with portal vein thrombosis 1