What is the management of a patient with ruptured esophageal varices?

Management of Ruptured Esophageal Varices

Ruptured esophageal varices require immediate resuscitation with restrictive transfusion (target hemoglobin 7-9 g/dL), simultaneous initiation of vasoactive drugs (terlipressin preferred, or octreotide if unavailable) and antibiotics (ceftriaxone 1g IV daily), followed by urgent endoscopic variceal ligation within 12 hours. 1, 2

Immediate Resuscitation (First 30 Minutes)

• Secure the airway in patients with active hematemesis or altered mental status to prevent aspiration 1
• Establish large-bore IV access and transfer to ICU or monitored setting given high mortality risk 2
• Use restrictive transfusion strategy targeting hemoglobin 7-9 g/dL - overtransfusion increases portal pressure and worsens rebleeding 1, 2
• Avoid aggressive crystalloid resuscitation as this precipitates rebleeding through increased portal pressure 2
• Consider fresh frozen plasma and platelets only in patients with significant coagulopathy/thrombocytopenia 3

Critical Pitfall: Do NOT overtransfuse beyond hemoglobin 8 g/dL, as this increases portal pressure and rebleeding risk 1

Pharmacological Therapy (Start Immediately, Before Endoscopy)

Vasoactive Drugs (Initiate on Clinical Suspicion)

Terlipressin is the preferred agent due to proven 34% mortality reduction (RR 0.66,95% CI 0.49-0.88) 1:

• Continuous infusion: 4 mg/24 hours (superior hepatic venous pressure gradient reduction and lower rebleeding) 1
• Alternative bolus dosing: 2 mg IV every 4 hours initially, then titrate to 1 mg IV every 4 hours once controlled 1
• Continue for 2-5 days after diagnosis confirmation 1, 3
• Contraindications: Active coronary/peripheral/mesenteric ischemia, hypoxia, worsening respiratory symptoms, pregnancy 1

If terlipressin unavailable, use octreotide 1, 3:

• 50 µg IV bolus followed by continuous infusion of 50 µg/hour 1
• Continue for 3-5 days 3

Alternative: Somatostatin 250 µg IV bolus followed by 250 µg/hour infusion 1

Critical Pitfall: Do NOT delay vasoactive drugs waiting for endoscopy - start immediately upon clinical suspicion 1

Critical Pitfall: Do NOT use non-selective beta-blockers during acute bleeding, as they decrease blood pressure and blunt compensatory tachycardia 2

Antibiotic Prophylaxis (Mandatory)

• Ceftriaxone 1g IV daily for maximum 7 days (preferred in advanced cirrhosis and centers with quinolone resistance) 3, 1, 2
• Alternative: Norfloxacin 400 mg PO BID or IV ciprofloxacin if oral not possible 3
• Antibiotics reduce mortality, bacterial infections, and rebleeding 1, 2

Endoscopic Management (Within 12 Hours)

• Perform urgent endoscopy within 12 hours once hemodynamically stabilized 3, 1, 2
• Endoscopic variceal ligation (EVL) is first-line therapy, achieving hemostasis in approximately 90% of cases 4, 2
• EVL is superior to sclerotherapy with better safety profile 1
• Combination of EVL plus vasoactive drugs is superior to either alone, reducing very early rebleeding and treatment failure 4
• Consider proton pump inhibitor (pantoprazole 40 mg IV then 40 mg PO daily for 9 days) after EVL to reduce post-ligation ulcer size 3

Rescue Therapy for Treatment Failure (10-20% of Patients)

Balloon Tamponade (Temporary Bridge Only)

• Use as temporizing measure for maximum 24 hours in uncontrollable bleeding while arranging definitive therapy 3, 1, 2
• Alternative: Removable covered self-expanding esophageal stents 1

Early TIPS (Definitive Rescue)

Early TIPS (within 24-72 hours, ideally <24 hours) is indicated for 1, 4:

• Failure to control bleeding with combined pharmacological and endoscopic therapy 3
• High-risk patients:
  • Child-Pugh class B with active bleeding at endoscopy 1, 4
  • Child-Pugh class C with MELD score <14 1, 4
  • Hepatic venous pressure gradient (HVPG) ≥20 mmHg measured within 24 hours 1, 4
• TIPS achieves 90-100% hemostasis in rescue settings but carries 15-25% risk of hepatic encephalopathy 4

Special Considerations for Gastric Varices

• Type 1 gastric varices (GOV1) along lesser curvature: Manage identically to esophageal varices with EVL 1, 4
• Fundal varices (GOV2, IGV1): Use endoscopic variceal obturation with cyanoacrylate injection rather than EVL 1, 4
  • Cyanoacrylate achieves better control (94% vs 80%) and lower rebleeding (23% vs 47%) compared to EVL 4
• Isolated splenic vein thrombosis: Treat with splenectomy 1, 4

Post-Acute Management (Before Discharge)

• Start non-selective beta-blocker once recovered from acute bleeding and before discharge 2
• Combine with repeat EVL sessions every 2-8 weeks until variceal eradication (usually 2-4 sessions) 3, 2
• This combination reduces rebleeding to 14-23% versus 38-47% with EVL alone 2
• Refer to transplant center if Child-Pugh score ≥7 or MELD score ≥15 3

Key Algorithmic Approach

1. Immediate (0-30 min): Airway protection + IV access + restrictive transfusion (Hgb 7-9) + ICU transfer
2. Simultaneous (0-30 min): Start terlipressin (or octreotide) + ceftriaxone 1g IV
3. Within 12 hours: Urgent EGD with EVL
4. Continue: Vasoactive drugs 2-5 days, antibiotics maximum 7 days
5. If failure: Early TIPS within 24-72 hours for high-risk patients or uncontrolled bleeding
6. Before discharge: Start beta-blocker + schedule repeat EVL sessions