What is the management approach for a patient with an upper gastrointestinal (GI) bleed due to varices?

Management of Upper GI Bleed with Varices

Immediately initiate vasoactive drugs (terlipressin, octreotide, or somatostatin), IV ceftriaxone 1g daily, restrictive blood transfusion (target hemoglobin 7-9 g/dL), and perform urgent endoscopy within 12 hours for band ligation of esophageal varices or cyanoacrylate injection for gastric varices. 1, 2

Immediate Resuscitation and Stabilization

• Establish large-bore IV access and restore hemodynamic stability with crystalloid fluids, assessing airway, breathing, and circulation immediately 1, 2
• Transfuse packed red blood cells only when hemoglobin drops below 7 g/dL, maintaining target of 7-9 g/dL to avoid increasing portal pressure and rebleeding risk 3, 1, 2
• Intubate for airway protection if massive bleeding or hepatic encephalopathy is present 2
• Avoid nephrotoxic drugs, large volume paracentesis, beta-blockers, and vasodilators during acute bleeding 3, 2

Pharmacological Management (Start Immediately)

• Initiate vasoactive drug therapy as soon as variceal bleeding is suspected, even before endoscopic confirmation, and continue for 3-5 days 3, 1, 2
  • Terlipressin is preferred where available due to proven survival benefit 4
  • Octreotide or somatostatin are acceptable alternatives 3, 4
• Start antibiotic prophylaxis immediately with IV ceftriaxone 1g daily for up to 7 days in patients with decompensated cirrhosis, those on quinolone prophylaxis, or in settings with high quinolone resistance 3, 1, 2
  • Oral norfloxacin 400mg twice daily is an alternative in less advanced cirrhosis 3
• Consider IV erythromycin 250mg 30-120 minutes before endoscopy to improve visualization (check QT interval first) 3, 2

Urgent Endoscopic Management

• Perform upper endoscopy within 12 hours of presentation once hemodynamic stability is achieved 3, 1, 2

For Esophageal Varices (Most Common)

• Endoscopic band ligation (EBL) is the preferred treatment for esophageal varices, superior to sclerotherapy with fewer complications 3, 1, 2
• Sclerotherapy can be used only when band ligation is technically not feasible 3
• Repeat EBL sessions every 7-14 days until variceal obliteration (typically 2-4 sessions required) 3, 2

For Gastric Varices (Type-Specific Approach)

• GOV1 (lesser curve varices): Treat similarly to esophageal varices with band ligation or cyanoacrylate injection 3
• GOV2 and IGV1 (fundal varices): Cyanoacrylate injection is preferred over band ligation, with superior hemostasis (94% vs 80%) and lower rebleeding rates (18% vs 86%) 3, 5
• EUS-guided therapy with coils plus cyanoacrylate shows excellent results (99% technical success, 5% recurrence rate) for fundal varices 5

Rescue Therapy for Treatment Failure

Treatment failure occurs in 10-20% of patients despite standard therapy. 4, 6

• TIPS with covered stents is the rescue therapy of choice for persistent bleeding or early rebleeding 3, 1, 2
• Consider early pre-emptive TIPS within 24-72 hours in high-risk patients: Child-Pugh C <14 points or Child-Pugh B with active bleeding at endoscopy 3, 2
  • Early TIPS in high-risk patients markedly decreases rebleeding and improves survival 3, 4
• Balloon tamponade is a temporary bridge only (maximum 24 hours) while awaiting definitive therapy like TIPS 3, 2
• BRTO or PARTO are alternatives for fundal varices with gastrorenal shunt, achieving >90% hemostasis rates 3

Prevention of Complications

• Monitor and treat hepatic encephalopathy with lactulose or lactitol if it develops 3, 1, 2
• Maintain adequate fluid and electrolyte balance to preserve renal function 3, 2
• Consider short-course PPI therapy after band ligation to reduce post-banding ulcer size 3, 5
• Bacterial infections occur in >50% of patients and independently predict treatment failure and death 3

Secondary Prophylaxis After Bleeding Control

• Initiate non-selective beta-blockers and/or continue endoscopic band ligation once acute bleeding is controlled 1, 2
• Use beta-blockers cautiously in severe/refractory ascites, discontinue if systolic BP <90 mmHg 1, 2
• Surveillance endoscopy every 3-6 months after variceal eradication to detect recurrence 3, 2

Critical Pitfalls to Avoid

• Over-transfusion increases portal pressure and rebleeding risk—strict adherence to hemoglobin 7-9 g/dL target is essential 3, 2
• Delaying vasoactive drugs until endoscopy confirmation loses critical time—start immediately on suspicion 3, 1, 4
• Routine correction of INR/platelets is not recommended as cirrhotic coagulopathy is complex and blood products carry thrombotic risks 3
• Attempting band ligation on large fundal varices is ineffective—use cyanoacrylate instead 3
• Continuing beta-blockers during acute bleeding worsens hypotension—hold until stabilized 3, 2