What is the management approach for oesophageal varices bleeding?

Management of Oesophageal Varices Bleeding

Initiate vasoactive drugs immediately upon suspicion of variceal bleeding—even before endoscopy—combined with prophylactic antibiotics, followed by urgent endoscopic variceal ligation once the patient is stabilized. 1, 2, 3

Immediate Resuscitation and Initial Pharmacotherapy

Airway and Volume Management

• Secure the airway in patients with active hematemesis to prevent aspiration, particularly in those with altered mental status. 3
• Use restrictive transfusion strategy targeting hemoglobin of 7-9 g/dL (threshold 7 g/dL) to avoid increasing portal pressure from excessive volume expansion. 4, 2
• Administer crystalloids for initial volume resuscitation while awaiting blood products. 2

Vasoactive Drug Therapy (Start Immediately)

Terlipressin is the preferred vasoactive agent due to proven mortality reduction of 34% (RR 0.66,95% CI 0.49-0.88). 2

Dosing options for terlipressin:

• Preferred method: Continuous infusion at 4 mg/24 hours, which provides superior hepatic venous pressure gradient reduction (85% vs 58% at 24 hours) and lower rebleeding rates (2% vs 15% between days 2-5) compared to bolus dosing. 1
• Alternative method: Bolus dosing of 2 mg IV every 4 hours initially, then titrate down to 1 mg IV every 4 hours once bleeding is controlled. 4, 1, 2
• Continue treatment for 2-5 days as adjuvant therapy to endoscopic intervention. 1, 2

If terlipressin is unavailable:

• Octreotide: 50 µg IV bolus followed by continuous infusion of 50 µg/hour. 4
• Somatostatin: 250 µg IV bolus followed by infusion of 250 µg/hour. 4
• These agents are safe for continuous use up to 5 days or longer but lack the proven mortality benefit of terlipressin. 4, 2

Critical contraindications to terlipressin:

• Active coronary, peripheral, or mesenteric ischemia. 1, 2
• Hypoxia or worsening respiratory symptoms. 1, 2
• Pregnancy. 2

Antibiotic Prophylaxis (Mandatory)

• Administer prophylactic antibiotics to all cirrhotic patients with GI hemorrhage for maximum 7 days. 4, 2, 3
• Preferred regimen: Ceftriaxone 1 g IV daily, particularly in centers with high quinolone resistance or in patients with advanced cirrhosis. 4, 2
• Alternative: Norfloxacin 400 mg PO twice daily or IV ciprofloxacin if oral administration is not possible. 4

Endoscopic Intervention

Timing and Technique

• Perform urgent endoscopy after initial resuscitation and hemodynamic stabilization, ideally within 12 hours. 3
• Endoscopic variceal ligation (EVL) is the preferred endoscopic technique over sclerotherapy due to better safety profile. 1, 3
• The combination of vasoactive drugs plus endoscopic therapy achieves superior 5-day hemostasis rates (77% vs 58%) compared to endoscopic treatment alone. 3

Temporary Balloon Tamponade

• Use Sengstaken-Blakemore or Minnesota tube only as a temporary bridge (maximum 24 hours) when bleeding cannot be controlled endoscopically and definitive therapy (TIPS) is being arranged. 5
• This is a rescue measure for profusely bleeding varices that obscure endoscopic visualization. 5

Rescue Therapy for Treatment Failure

Despite optimal therapy, 10-20% of patients will have uncontrolled bleeding or early rebleeding. 4

Indications for Early TIPS

• Failure to control bleeding with combined pharmacological and endoscopic therapy. 4, 3
• High-risk patients should receive early TIPS (within 24-72 hours, ideally <24 hours): 3
  • Child-Pugh class B with active bleeding at endoscopy. 3
  • Child-Pugh class C with MELD score <14. 3
  • Hepatic venous pressure gradient (HVPG) ≥20 mmHg measured within 24 hours of presentation. 4

Surgical Shunt

• Consider portocaval shunt in Child-Pugh class A patients who fail endoscopic/pharmacological therapy, though this approach is not widely practiced. 4

Special Considerations

Gastric Varices

• Type 1 gastric varices (GOV1) along the lesser curvature should be managed identically to esophageal varices. 4
• Fundal varices require endoscopic variceal obturation with tissue adhesives (N-butyl-cyanoacrylate or 2-octyl cyanoacrylate) rather than EVL, as this reduces rebleeding rates (23% vs 47%). 4
• Isolated splenic vein thrombosis causing gastric varices is treated with splenectomy. 4

Monitoring and Complications

• Monitor for hyponatremia, chest pain, abdominal pain, and cardiovascular complications during terlipressin therapy. 1
• Common adverse reactions include abdominal pain, nausea, respiratory failure, diarrhea, and dyspnea. 1

Critical Pitfalls to Avoid

• Do NOT use non-selective beta-blockers during acute bleeding—they are reserved for secondary prophylaxis after bleeding is controlled. 3
• Do NOT overtransfuse—maintaining hemoglobin >8 g/dL increases portal pressure and rebleeding risk. 4
• Do NOT delay vasoactive drugs waiting for endoscopy—start immediately upon clinical suspicion. 1, 2, 3
• Do NOT use vasopressin alone due to severe side effects (arrhythmias, hypertension, bowel ischemia); if used, must combine with IV nitroglycerin and limit to 24 hours maximum. 4