What is the recommended acute management of bleeding esophageal varices in a cirrhotic patient with portal hypertension?

Management of Bleeding Esophageal Varices

Start vasoactive drugs immediately upon clinical suspicion of variceal bleeding—before endoscopy—and combine with urgent endoscopic band ligation within 12 hours, restrictive transfusion (hemoglobin 7-9 g/dL), and antibiotic prophylaxis with ceftriaxone to achieve optimal outcomes. 1, 2

Immediate Resuscitation and Pharmacotherapy

Airway and Volume Management

• Secure the airway in patients with active hematemesis, particularly those with altered mental status, to prevent aspiration 2
• Initiate volume resuscitation with crystalloids while awaiting blood products 1, 2
• Use a restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL to avoid increasing portal pressure from excessive volume expansion 1, 2
• Over-transfusion (maintaining hemoglobin >8 g/dL) increases portal pressure and rebleeding risk—this is a critical pitfall to avoid 2

Vasoactive Drug Therapy

Terlipressin is the preferred first-line vasoactive agent because it is the only drug with proven mortality reduction of 34% (RR 0.66,95% CI 0.49-0.88) 2

Dosing options for terlipressin: 1, 2

• Continuous infusion: 4 mg/24 hours (provides superior hepatic venous pressure gradient reduction and lower rebleeding rates)
• Bolus dosing: 2 mg IV every 4 hours initially, then titrate down to 1 mg IV every 4 hours once bleeding is controlled

Continue terlipressin for 2-5 days as adjuvant therapy to endoscopic intervention 1, 2

Critical contraindications to terlipressin include: 2

• Active coronary, peripheral, or mesenteric ischemia
• Hypoxia or worsening respiratory symptoms
• Pregnancy

If terlipressin is unavailable, use alternative vasoactive agents: 1, 2

• Octreotide: 50 µg IV bolus followed by continuous infusion of 50 µg/hour
• Somatostatin: 250 µg IV bolus followed by infusion of 250 µg/hour (can be increased to 500 µg/hour)

Antibiotic Prophylaxis

Administer ceftriaxone 1g IV daily (maximum 7 days) as mandatory adjunctive therapy—this reduces mortality, bacterial infections, and rebleeding 1, 2

Alternative: norfloxacin if ceftriaxone is unavailable 1

Endoscopic Intervention

Perform urgent upper endoscopy within 12 hours after initial resuscitation and hemodynamic stabilization 1, 2

Consider erythromycin 250 mg IV 30-120 minutes before endoscopy to improve visibility, unless contraindicated by QT prolongation 1

Endoscopic variceal ligation (EVL) is the preferred technique over sclerotherapy due to better safety profile and fewer adverse effects 1, 2

• EVL achieves 85-90% rates of initial bleeding control 1
• Sclerotherapy should only be used when ligation is not technically feasible 1

The combination of vasoactive drugs plus endoscopic therapy is superior to either alone, achieving better 5-day hemostasis rates (77% vs 58%) 1, 2

Special Variceal Considerations

• Type 1 gastric varices (GOV1) along the lesser curvature: Manage identically to esophageal varices with EVL 2
• Fundal varices: Require endoscopic variceal obturation with cyanoacrylate injection rather than EVL to reduce rebleeding rates 2

Rescue Therapy for Treatment Failure

Despite optimal therapy, 10-20% of patients will have uncontrolled bleeding or early rebleeding 2

Early TIPS (Transjugular Intrahepatic Portosystemic Shunt)

High-risk patients should receive early TIPS within 24-72 hours (ideally <24 hours): 1, 2

• Child-Pugh class B with active bleeding at endoscopy
• Child-Pugh class C with MELD score <14
• Hepatic venous pressure gradient (HVPG) ≥20 mmHg measured within 24 hours of presentation

For patients failing combined pharmacological and endoscopic therapy, early TIPS is the recommended rescue intervention 2

Temporary Bridge Therapy

Balloon tamponade can be used as a bridge for maximum 24 hours in uncontrolled bleeding, or removable covered self-expanding esophageal stents as an alternative 2

Critical Pitfalls to Avoid

1. DO NOT delay vasoactive drugs waiting for endoscopy—start immediately upon clinical suspicion 1, 2
2. DO NOT use non-selective beta-blockers during acute bleeding—these are reserved for secondary prophylaxis after bleeding is controlled 2
3. DO NOT overtransfuse—maintaining hemoglobin >8 g/dL increases portal pressure and rebleeding risk 2
4. DO NOT use vasopressin alone due to severe side effects 2

Monitoring During Treatment

Monitor for terlipressin-related complications: 2

• Hyponatremia
• Chest pain and cardiovascular complications
• Abdominal pain
• Respiratory failure
• Nausea and diarrhea

Rebleeding risk is highest in the first 5 days, emphasizing the importance of close monitoring and continued vasoactive drugs during this period 3