From the Guidelines
Intravenous (IV) treatment plays a crucial role in variceal bleeding, primarily through the use of vasoactive agents to reduce portal pressure and control bleeding.
Key Vasoactive Agents
- Octreotide: Initial IV bolus of 50 micrograms, followed by a continuous IV infusion of 50 mg/hr for 2-5 days 1
- Terlipressin: Initial 2 mg IV every 4 hours for 48 hours, then 1 mg IV every 4 hours for maintenance 1
- Somatostatin: Initial IV bolus of 250 mg, followed by a continuous IV infusion of 250-500 mg/h for 2-5 days 1
- Vasopressin: Although effective, its use is not recommended due to significant side effects, such as increased peripheral vascular resistance and reduced cardiac output and coronary blood flow 1
Importance of Early Treatment
The initiation of vasoactive pharmacologic agents as soon as possible, along with prophylactic antibiotics, is crucial in managing acute variceal bleeding 1. This approach facilitates endoscopy, improves early hemostasis, and lowers the rate of rebleeding at 5 days 1.
Combination Therapy
Combining vasoactive agents with endoscopic variceal ligation (EVL) is the preferred approach for managing acute variceal hemorrhage 1. This combination has been shown to be more effective than endoscopic treatment alone in achieving 5-day hemostasis and reducing 5-day mortality rates 1.
Duration of Treatment
Vasoactive agents should be continued for 3-5 days, depending on the control of bleeding and the severity of liver disease 1.
High-Risk Patients
In high-risk patients, defined by factors such as HVPG >20 mm Hg or CTP class C cirrhosis with a score of 10-13, early TIPS (transjugular intrahepatic portosystemic shunt) placement within 72 hours of admission may be associated with significantly lower treatment failure and mortality rates 1. However, the decision to proceed with TIPS should be made on a case-by-case basis, considering the patient's overall condition and the availability of liver transplantation.
From the Research
Role of Intravenous (IV) Treatment in Variceal Bleeding
The role of IV treatment in variceal bleeding is to reduce variceal wall tension or prevent any abrupt increase in this parameter, thereby stopping the acute bleeding episode 2. IV vasoactive agents such as terlipressin, somatostatin, octreotide, or vapreotide are administered in patients with suspected variceal bleeding to achieve this goal 3.
Types of IV Treatments
There are two main groups of vasoactive agents used in the management of acute variceal bleeding:
Efficacy and Safety of IV Treatments
The efficacy and safety of T-V versus O-S for the management of acute variceal bleeding have been assessed in a systematic review and meta-analysis 4. The results showed that:
- The risk of mortality was similar between T-V and O-S groups
- The risk of adverse events was significantly higher in the T-V compared to the O-S group
- The certainty of evidence was moderate for the main outcomes, and low or very low for others
Key Points
- IV treatment with vasoactive drugs should be started as soon as possible to reduce portal pressure and control bleeding 5
- Terlipressin has demonstrated effects on control of bleeding and on mortality in meta-analysis 5
- Somatostatin and its analogues improve control of bleeding, but show no effects on mortality in meta-analysis 5
- Antibiotic prophylaxis improves survival in patients with variceal bleeding 5