What is the medical management of variceal bleeding?

Medical Management of Variceal Bleeding

Variceal band ligation combined with vasoactive drugs (terlipressin, somatostatin, or octreotide) and prophylactic antibiotics represents the standard of care for acute variceal bleeding, with this triple therapy approach reducing mortality, controlling bleeding, and preventing early rebleeding. 1, 2

Immediate Resuscitation and Stabilization

Resuscitation Protocol:

• Establish at least two 16-gauge peripheral IV lines for rapid volume resuscitation 1, 2
• Maintain restrictive transfusion strategy with hemoglobin target of 7-8 g/dL (not higher), as this approach decreases mortality and rebleeding rates 1, 3, 4
• Manage in intensive care unit or high-dependency unit with continuous hemodynamic monitoring 1, 2
• Cross-match 6 units of blood immediately 1

Airway Protection: Perform elective intubation for: 1, 2

• Severe uncontrolled variceal bleeding
• Severe hepatic encephalopathy
• Inability to maintain oxygen saturation >90%
• Aspiration pneumonia or risk thereof

Critical Pitfall: Avoid over-transfusion above hemoglobin 7-9 g/dL, as higher targets increase portal pressure, worsen rebleeding, and increase mortality. 1

Pharmacological Therapy (Start Immediately)

Initiate vasoactive drugs as soon as variceal bleeding is suspected, even before endoscopy. 1, 2, 3

Vasoactive Drug Selection (Choose One):

First-line: Terlipressin (where available)

• Dosing: 2 mg IV every 4 hours initially, then reduce to 1 mg IV every 4 hours once bleeding controlled 1
• Duration: Continue for 24-72 hours after endoscopic control; evidence supports that 24 hours may be sufficient when combined with successful endoscopic therapy 5
• Advantage: Only vasoactive drug proven to reduce mortality 1, 4
• Contraindication: Pregnancy (may cause uterine contraction and fetal loss) 1

Alternative: Octreotide or Somatostatin

• Octreotide dosing: 50 mcg IV bolus, then 50 mcg/hour continuous infusion 1, 2
• Somatostatin dosing: Similar efficacy to terlipressin for bleeding control 1
• Duration: 3-5 days 1, 2, 3
• Note: These agents control bleeding as effectively as terlipressin but lack proven mortality benefit 4, 6

Avoid: Beta-blockers in acute setting (will worsen hypotension and prevent compensatory tachycardia) 1

Antibiotic Prophylaxis (Mandatory for All Patients)

Standard regimen:

• Norfloxacin 400 mg PO twice daily for 7 days (maximum duration) 1, 2, 3
• Alternative if oral not possible: IV ciprofloxacin 1, 3

Upgraded regimen for high-risk patients:

• IV ceftriaxone 1 g daily for up to 7 days for: 1, 3
  • Advanced cirrhosis (Child-Pugh B/C)
  • Centers with high quinolone-resistant organism prevalence
  • Patients with ascites

Rationale: Antibiotics reduce bacterial infections, decrease early rebleeding, and improve survival—effects independent of infection prevention alone. 1, 4

Proton Pump Inhibitors

• Administer PPI (strong recommendation, though low-quality evidence) 2, 3
• May reduce post-band ligation ulcer size and bleeding risk 3

Endoscopic Management

Timing: Perform esophagogastroduodenoscopy within 12 hours of presentation once hemodynamically stable 1, 2, 3

Pre-endoscopy optimization:

• Consider erythromycin 250 mg IV 30-120 minutes before endoscopy to improve visualization (check QT interval first) 1

Endoscopic Treatment by Varix Type:

Esophageal Varices:

• Variceal band ligation is first-line therapy (Grade AI recommendation) 1, 2, 3
• If band ligation technically difficult due to ongoing bleeding or unavailable, perform sclerotherapy 1

Gastric Varices:

• Cyanoacrylate injection (tissue adhesive) is superior to band ligation, especially for fundal varices (GOV2, IGV1) 2, 3
• GOV1 varices (lesser curve extension of esophageal varices) can be managed like esophageal varices 1, 3

Rescue Therapy for Treatment Failure

Definition of failure: 10-20% of patients fail initial therapy through inability to control bleeding or early rebleeding within 5 days. 4, 7

Rescue Algorithm:

First-line rescue: Transjugular Intrahepatic Portosystemic Shunt (TIPS)

• Use covered stents for TIPS placement 4, 7
• Early TIPS strategy (within 72 hours) for high-risk patients: 4, 7
  • Child-Pugh B with active bleeding at endoscopy, OR
  • Child-Pugh C <14 points
  • This approach markedly reduces rebleeding and improves survival

Temporary bridge: Balloon tamponade

• Use only as temporary measure (maximum 24 hours) while arranging definitive therapy (TIPS or repeat endoscopy) 1, 3, 4
• Requires airway protection due to aspiration risk 1

Alternative for mild early rebleeding:

• Second attempt at endoscopic therapy may be reasonable 4
• If severe rebleeding, proceed directly to TIPS 4

Coagulation Management

Important caveat: Variceal bleeding results from portal hypertension, not coagulopathy. 1

• No specific INR or platelet threshold reliably predicts procedural bleeding risk 1
• Avoid routine correction of INR or platelets, as blood product overuse risks portal vein thrombosis 1
• Low fibrinogen associated with bleeding in critically ill cirrhotic patients, but no validated transfusion threshold exists 1

Duration of Therapy Summary

• Vasoactive drugs: 3-5 days (or 24 hours if using terlipressin with successful endoscopic control) 1, 2, 3, 5
• Antibiotics: Maximum 7 days 1, 3
• Balloon tamponade: Maximum 24 hours 3, 4

Secondary Prevention (After Acute Episode)

Combination therapy is superior to monotherapy:

• Beta-blockers (propranolol or nadolol) PLUS endoscopic band ligation significantly reduces rebleeding risk 2, 7
• Carvedilol may be preferred beta-blocker (greater portal pressure reduction) 1, 7
• Consider adding statins for additional survival benefit 7
• If rebleeding occurs despite secondary prophylaxis, TIPS is indicated 7

Special consideration for pregnancy: Beta-blockers can be continued during pregnancy; carvedilol preferred over propranolol (less fetal growth restriction). 1