What is not true in the management of variceal bleeding?

Management of Variceal Bleeding: Identifying the Incorrect Statement

The incorrect statement is D: Sedatives should NOT be given to reduce anxiety in variceal bleeding management, as they can mask signs of rebleeding, worsen hepatic encephalopathy, and compromise airway protection.

Analysis of Each Statement

A. Terlipressin may be used before confirmed diagnosis - TRUE

• Vasoactive pharmacological therapy should be initiated immediately upon suspicion of variceal bleeding, even before endoscopic confirmation 1, 2, 3
• Terlipressin (or alternatives like somatostatin, octreotide) should be started as soon as variceal bleeding is suspected and continued for 3-5 days after diagnosis 2, 4
• This early initiation improves outcomes by reducing portal pressure and controlling bleeding before definitive endoscopic therapy 1
• The rationale is that early vasoconstrictor therapy reduces mortality and improves hemostasis rates 4

B. Recurrent bleeding is prevented by surgery - TRUE

• TIPS or surgical shunts are effective salvage procedures for preventing recurrent variceal hemorrhage in appropriate candidates 1
• TIPS should be considered in Child A or B patients who experience recurrent bleeding despite combination pharmacological and endoscopic therapy 1
• In centers with expertise, surgical shunt can be considered in Child A patients for secondary prophylaxis 1
• Surgery achieves good control of bleeding, though it is typically reserved for failures of medical therapy 1

C. Child C patients should undergo transplant evaluation - TRUE

• Patients who are otherwise transplant candidates should be referred to a transplant center 1
• This is particularly important for Child C patients, as they have advanced liver disease with poor prognosis
• Variceal bleeding in Child C cirrhosis carries high mortality, making transplant evaluation essential for eligible patients 1

D. Sedatives should be given to reduce anxiety - FALSE

• This is the incorrect statement and represents a dangerous practice in variceal bleeding management
• Guidelines specifically recommend airway protection by elective intubation in cases of severe encephalopathy, not sedation 1
• Sedatives can:
  • Mask hemodynamic signs of rebleeding 5
  • Worsen hepatic encephalopathy 1
  • Compromise airway protection in patients at risk of aspiration 1
• The focus should be on airway protection through intubation when indicated (severe bleeding, severe encephalopathy, inability to maintain oxygen saturation >90%, aspiration pneumonia) rather than sedation 1

Key Clinical Pitfalls

• Never use sedatives routinely in variceal bleeding - they obscure clinical assessment and worsen encephalopathy 1
• Instead, protect the airway through elective intubation in high-risk scenarios 1
• Hemodynamic monitoring should be unimpeded by sedation to detect early rebleeding 5
• Guidelines recommend discontinuing vasoactive agents after endoscopy and monitoring patients for 12-18 hours before discharge, which requires alert patients for assessment 5

Answer: D