What is the difference in management between non-variceal (ulcer or erosion) and variceal (esophageal or gastric varices) gastrointestinal bleeding?

Management Differences Between Non-Variceal and Variceal Upper GI Bleeding

Non-variceal and variceal upper gastrointestinal bleeding require fundamentally different therapeutic approaches, with variceal bleeding demanding immediate vasoactive drug therapy before endoscopy and specific endoscopic techniques, while non-variceal bleeding relies primarily on endoscopic hemostasis with thermal or mechanical methods plus high-dose proton pump inhibitors. 1, 2, 3

Key Distinguishing Features

Etiology and Epidemiology

• Non-variceal bleeding accounts for 80-90% of all upper GI bleeds, with peptic ulcers (35-50%), gastroduodenal erosions (8-15%), and esophagitis (5-15%) being the most common causes 4, 3
• Variceal bleeding represents only 5-10% of cases but occurs exclusively in patients with portal hypertension (portal pressure >10 mmHg) and carries a 20% mortality at 6 weeks 4, 1
• Non-variceal bleeding has a mortality of 5-10%, while variceal bleeding has significantly higher mortality rates 3

Prognosis Determinants

• In non-variceal bleeding, prognosis is determined by age, comorbidities, hemodynamic status, and endoscopic findings (active bleeding, visible vessel, adherent clot) 4
• In variceal bleeding, prognosis relates primarily to the severity of underlying liver disease (Child-Pugh score) rather than the magnitude of hemorrhage itself 4, 1
• Patients with liver disease and variceal bleeding who develop hepatorenal syndrome have a 16.5-fold increased mortality risk 5

Initial Resuscitation (Similar for Both)

Hemodynamic Management

• Establish IV access and initiate fluid resuscitation to correct hypotension in both types 4, 2
• Transfuse packed red blood cells when hemoglobin falls below 70 g/L (target 70-90 g/L), or 90 g/L if massive bleeding or cardiovascular comorbidities present 4, 1, 2
• Critical caveat for variceal bleeding: Avoid excessive fluid resuscitation as this increases portal pressure and can aggravate variceal bleeding 1

Risk Stratification

• Use prognostic scales (Rockall score, Blatchford score) for early stratification into low- and high-risk categories 4, 2
• The Rockall score (incorporating age, shock, comorbidity, diagnosis, and endoscopic stigmata) best identifies low-risk patients and predicts mortality 4
• Patients with Rockall score <3 have excellent prognosis; score >8 indicates high mortality risk 4

Divergent Pre-Endoscopy Medical Management

Non-Variceal Bleeding

• Initiate high-dose proton pump inhibitor infusion before endoscopy to reduce stigmata of recent hemorrhage and improve endoscopic outcomes 3
• No specific vasoactive drugs are indicated pre-endoscopy 3

Variceal Bleeding (Critical Difference)

• Immediately start vasoactive drugs (octreotide or terlipressin) upon suspicion, before endoscopy - this is a fundamental distinction from non-variceal management 1, 2
• Administer prophylactic antibiotics to prevent bacterial infections and reduce mortality 2
• Start high-dose PPI therapy only after endoscopic intervention is completed 1

Endoscopic Management (Fundamentally Different)

Timing

• Both require urgent endoscopy within 24 hours of presentation 1, 2
• Hemodynamically unstable patients need endoscopy sooner, ideally within 12 hours 2

Non-Variceal Bleeding Techniques

• Combination therapy is superior: Four-quadrant epinephrine injection combined with either thermal therapy (heater probe, coaptive coagulation) or hemostatic clips reduces mortality 3
• Thermal methods include argon plasma coagulation and heater probe 3, 6
• Through-the-scope clips can be used for visible vessels 6
• Epinephrine injection alone is insufficient and must be combined with a second modality 3

Variceal Bleeding Techniques (Completely Different)

• Endoscopic variceal ligation (EVL) is the treatment of choice for esophageal varices, with success rates exceeding 90% 1
• Gastric varices require cyanoacrylate injection, not band ligation 7
• Thermal coagulation and clips are NOT appropriate for variceal bleeding 7

Post-Endoscopy Management

Non-Variceal Bleeding

• Continue high-dose PPI therapy after successful endoscopic hemostasis 3
• Address underlying causes: Helicobacter pylori eradication, discontinue NSAIDs, manage acid-related disease 4
• Risk of rebleeding decreases significantly after 72 hours 3

Variceal Bleeding

• Continue vasoactive drugs for 2-5 days post-endoscopy 1
• Initiate nonselective beta-blockers (propranolol or nadolol) for secondary prophylaxis once acute bleeding is controlled, reducing rebleeding risk by up to 50% 1
• Continue antibiotic prophylaxis 2
• Monitor for and aggressively treat hepatic encephalopathy and hepatorenal syndrome, as these independently predict mortality 5

Management of Rebleeding

Non-Variceal

• Repeat endoscopy with combination therapy is the first-line approach 3
• If endoscopic therapy fails persistently, consider interventional radiology (embolization) or surgery 3

Variceal

• Repeat endoscopic therapy can be attempted 7
• Early consideration for transjugular intrahepatic portosystemic shunt (TIPS) if rebleeding occurs despite optimal medical and endoscopic therapy 7
• Surgical therapy or hepatic transplant evaluation may be necessary 7

Common Pitfalls to Avoid

• Never delay vasoactive drugs in suspected variceal bleeding - they must be started before endoscopy, not after diagnosis is confirmed 1, 2
• Never use thermal coagulation or clips for variceal bleeding - these are ineffective and potentially dangerous 7
• Never forget antibiotic prophylaxis in variceal bleeding - only 55.5% of patients receive this life-saving intervention despite clear guidelines 5
• Never over-resuscitate variceal bleeders with fluids - this worsens portal hypertension 1
• Never use epinephrine injection alone for non-variceal bleeding - always combine with thermal or mechanical therapy 3