What oral medications are helpful in managing variceal bleeding?

Oral Medications for Variceal Bleeding

Acute Bleeding Setting

Beta-blockers should NOT be used during acute variceal bleeding as they decrease blood pressure and blunt the compensatory tachycardia needed during hemorrhage 1, 2. While beta-blockers are the cornerstone of prophylaxis, they must be temporarily suspended in the acute bleeding setting, particularly when patients are hypotensive (systolic BP <90 mmHg or MAP <65 mmHg) 1.

Oral Antibiotic Prophylaxis

Oral norfloxacin 400 mg twice daily for 7 days is the recommended oral medication for acute variceal bleeding in patients who can tolerate oral administration 1, 2. This antibiotic prophylaxis:

• Reduces bacterial infection rates and improves survival in all cirrhotic patients with GI bleeding 1
• Decreases early rebleeding incidence 1
• Should be initiated immediately upon presentation 1, 2

Important caveat: In patients with advanced cirrhosis (Child-Pugh B/C) or in centers with high quinolone-resistant organism prevalence, IV ceftriaxone 1 g daily is superior to oral norfloxacin 1. Oral quinolones should be reserved for less advanced cirrhosis (Child A) or settings without quinolone resistance 1.

Vasoactive Drugs Are NOT Oral

The most effective medications for acute variceal bleeding—terlipressin, octreotide, and somatostatin—are all administered intravenously, not orally 1, 2, 3. These should be started immediately when variceal bleeding is suspected, even before endoscopy 2, 3.

Prophylaxis Setting (Prevention of First or Recurrent Bleeding)

Non-selective beta-blockers are the oral medications of choice for both primary and secondary prophylaxis of variceal bleeding 1, 4, 5:

• Propranolol or carvedilol achieve the desired 20% reduction in portal pressure gradient in 50-75% of patients 1
• These work by causing splanchnic vasoconstriction (β2-receptor inhibition) and decreasing cardiac output (β1-receptor blockade), thereby lowering portal venous inflow and portal pressure 1
• In secondary prophylaxis (but not primary prophylaxis), beta-blockers can be combined with organic nitrates 4

Clinical Algorithm

For acute bleeding:

1. Start oral norfloxacin 400 mg BID immediately (if patient can take oral medications and has less advanced cirrhosis) 1
2. Suspend any existing beta-blocker therapy 1
3. Initiate IV vasoactive drugs (terlipressin, octreotide, or somatostatin) 2, 3

For prophylaxis (after acute episode resolves):

1. Restart or initiate non-selective beta-blockers once hemodynamically stable 1, 4
2. Continue indefinitely for secondary prophylaxis 4, 5

Common Pitfall

The most critical error is continuing beta-blockers during acute bleeding episodes. While these medications are essential for long-term management, they are contraindicated during active hemorrhage due to their hypotensive effects 1. Always verify blood pressure before administering beta-blockers and hold them if systolic BP is below 90 mmHg 1.