What is the management for a patient with gastric varices and coffee ground emesis?

Management of Gastric Varices with Coffee Ground Emesis

Initiate immediate resuscitation with vasoactive drugs and antibiotics, perform urgent endoscopy within 12 hours, and treat gastric fundal varices with cyanoacrylate injection rather than band ligation. 1, 2

Initial Resuscitation and Medical Management

Begin vasoactive pharmacological therapy immediately upon suspicion of variceal bleeding, even before endoscopic confirmation:

• Start terlipressin, somatostatin, or octreotide as soon as gastric variceal bleeding is suspected and continue for 3-5 days after diagnosis confirmation 1, 2
• Implement restrictive transfusion strategy targeting hemoglobin 7-9 g/dL to avoid increasing portal pressure 3
• Establish large-bore IV access and avoid aggressive fluid resuscitation that could worsen portal pressure and precipitate rebleeding 3

Initiate antibiotic prophylaxis immediately:

• Ceftriaxone 1 g IV every 24 hours is first-line, particularly in patients with advanced cirrhosis or in settings with quinolone-resistant organisms 1, 2
• Alternative: norfloxacin 400 mg orally twice daily for up to 7 days in less advanced disease 1, 2
• Antibiotic prophylaxis reduces infections, improves bleeding control, and decreases mortality 1

Avoid medications that worsen outcomes during acute bleeding:

• Do not use beta-blockers, vasodilators, NSAIDs, or nephrotoxic drugs during the acute bleeding episode 1

Urgent Diagnostic and Therapeutic Endoscopy

Perform upper endoscopy within 12 hours of presentation once hemodynamic stability is achieved:

• Endoscopy confirms the diagnosis (up to 30% of cirrhotic patients bleed from non-variceal causes) and provides therapeutic intervention 1, 2
• Consider erythromycin 250 mg IV 30-120 minutes before endoscopy to improve visualization, unless contraindicated by QT prolongation 1

Endoscopic treatment depends on gastric varix type:

• For gastroesophageal varices type 1 (GOV1) extending along the lesser curvature: treat as esophageal varices with endoscopic band ligation 1, 2
• For cardiofundal varices (GOV2 and IGV1): cyanoacrylate injection is the preferred endoscopic therapy 1, 4
  • Cyanoacrylate achieves superior hemostasis (94% vs 80%) and significantly lower rebleeding rates (23% vs 47%) compared to band ligation 2, 4
  • Band ligation should only be performed on small gastric varices where the complete vessel can be suctioned into the device 1
• Newer EUS-guided therapies with coils and cyanoacrylate show excellent results (99% technical success, 5% recurrence with combination therapy) 4

Important caveat: Cyanoacrylate injection carries a rare but potentially fatal risk of pulmonary embolism from glue migration 5

Adjunctive Measures

Consider proton pump inhibitors after endoscopic therapy:

• PPIs have not shown efficacy for acute variceal hemorrhage management 1
• However, short-course PPI therapy after endoscopic band ligation may reduce post-banding ulcer size 1
• After cyanoacrylate injection, PPIs decrease rebleeding risk (OR 0.554) 4

Obtain contrast-enhanced CT or MRI for treatment planning:

• Imaging identifies inflow/outflow patterns crucial for determining feasibility of balloon-occluded retrograde transvenous obliteration (BRTO) 1
• Identifies portal or splenic vein thrombosis, which affects treatment selection 1

Rescue Therapies for Refractory Bleeding

If bleeding persists or recurs early (10-20% of cases) despite combined medical and endoscopic therapy:

• TIPS (transjugular intrahepatic portosystemic shunt) achieves 90-100% hemostasis in rescue settings 1, 4
• BRTO or PARTO (balloon/plug-assisted retrograde transvenous obliteration) shows >90% hemostasis rates with lower rebleeding risk than TIPS 4
• Balloon tamponade with Linton-Nachlas tube serves as temporary bridge (up to 24 hours) to definitive therapy in massive hemorrhage 1, 3

Special Consideration for Coffee Ground Emesis

Coffee ground vomiting alone has lower endoscopic yield and intervention requirements compared to frank hematemesis:

• CGV is associated with significantly lower rates of high-risk lesions (gastric ulcer, duodenal ulcer, varices, malignancy) and higher rates of esophagitis or no identifiable source 6
• However, in a patient with known gastric varices, coffee ground emesis represents upper GI bleeding requiring the full acute management protocol described above 1, 2
• The 30-day mortality remains similar regardless of presentation type, emphasizing the need for aggressive management when varices are the suspected source 6