What is the management of Gastroesophageal variceal (GOV) bleeding?

From the Guidelines

Gastroesophageal variceal (GOV) bleeding should be managed with a combination of endoscopic and pharmacological therapies.

Management Approach

• Endoscopic variceal ligation (EVL) is the preferred endoscopic treatment for acute esophageal variceal bleeding, as it has been shown to reduce the risk of rebleeding and improve variceal eradication compared to endoscopic injection sclerotherapy (EIS) 1.
• Vasoactive drugs such as terlipressin, somatostatin, and octreotide should be administered to reduce portal pressure and control bleeding, with the following dosing regimens:
  • Terlipressin: 2 mg intravenously initially, followed by 1-2 mg intravenously every 4-6 hours
  • Somatostatin: 250 μg intravenously initially, followed by 250 μg/hr intravenously
  • Octreotide: 50 μg intravenously initially, followed by 50 μg/hr intravenously
• Antibiotic prophylaxis should be administered to prevent bacterial infections, which are common in patients with cirrhosis and acute GI bleeding, with ceftriaxone (1 g/24 h) or oral quinolones (norfloxacin 400 mg b.i.d) being recommended options 1.
• Endoscopy should be performed within 12 hours of presentation to confirm the diagnosis and provide endoscopic therapy, with erythromycin (250 mg i.v., 30-120 min before) considered to facilitate the procedure by improving visibility 1.

Additional Considerations

• The combination of endoscopic therapy and vasoactive drugs is more effective than either treatment alone in controlling bleeding and improving survival 1.
• Cyanoacrylate injection and EVL are accepted options for endoscopic therapy in patients bleeding from gastric (cardiofundal) varices, with both therapies being equally effective 1.
• Restrictive blood transfusion strategy (with a target range for the post-transfusion hemoglobin level of 7 to 9 g/dL) and antibiotic prophylaxis can improve survival in patients with cirrhosis and acute upper gastrointestinal bleeding, including those with gastric variceal bleeding 1.

From the Research

Management of Gastroesophageal Variceal (GOV) Bleeding

The management of GOV bleeding involves several steps, including:

• Hemodynamic stabilization and pharmacological treatment, which includes administration of vasoactive drugs and short-term antibiotic prophylaxis 2
• Endoscopic therapy, with endoscopic variceal ligation (EVL) or endoscopic injection sclerotherapy (EIS) as the first choice of treatment for esophageal bleeding 2
• Rescue therapies, such as application of balloon tamponade, a self-expandable metal stent (SEMS), or a transjugular intrahepatic portosystemic shunt (TIPS), for cases of resistant variceal bleeding that cannot be controlled with endoscopic therapies 2

Treatment of Gastric Varices

The treatment of gastric varices is not yet standardized due to diverse underlying pathologies and the lack of large, randomized controlled trials 2. However, some treatment options include:

• Endoscopic variceal obturation (EVO) as a reliable endoscopic technique 2
• Balloon-occluded retrograde transvenous obliteration (B-RTO) of gastric varices and TIPS as common rescue therapies 2
• Endoscopic injection sclerotherapy with a tissue adhesive, such as N-butyl-cyanoacrylate or isobutyl-2-cyanoacrylate, for acute bleeding from gastric varices 3
• EUS-guided interventions, including coil injection, as promising modalities with high technical and clinical success rates and low rates of recurrence 4

Prevention of Recurrent Variceal Hemorrhage

Prevention of recurrent variceal hemorrhage is essential, given the high recurrence rate 3. This can be achieved through:

• Complete eradication of esophageal or gastric varices 3
• Maintenance of low portal venous pressure 3
• Treatment to prevent recurrence, such as endoscopic variceal ligation or beta-blockers 5, 6