What is the first‑aid and immediate management for a patient presenting with acute esophageal variceal hemorrhage?

First Aid and Immediate Management of Acute Esophageal Variceal Hemorrhage

Patients with suspected acute esophageal variceal bleeding require immediate ICU admission, simultaneous initiation of vasoactive drugs (before endoscopy), restrictive blood transfusion (hemoglobin target 7-9 g/dL), prophylactic antibiotics (ceftriaxone 1g IV daily), airway protection if needed, and urgent endoscopy within 12 hours for diagnosis and endoscopic band ligation. 1, 2, 3

Immediate Resuscitation and Stabilization

Airway and Access

• Assess and secure the airway immediately – elective or emergent tracheal intubation is required for airway protection prior to endoscopy, particularly in patients with hepatic encephalopathy or massive hematemesis, as aspiration of blood is a significant risk 1
• Obtain peripheral venous access for resuscitation 1

Restrictive Transfusion Strategy

• Transfuse packed red blood cells only when hemoglobin drops below 7 g/dL, with a target of 7-9 g/dL 1, 2, 3
• This restrictive approach is critical because aggressive resuscitation increases portal pressure above baseline, leading to more rebleeding and higher mortality 1
• Avoid vigorous saline resuscitation as it precipitates recurrent variceal hemorrhage and worsens ascites 1
• Maintain hemodynamic stability and mean arterial pressure >65 mmHg while avoiding fluid overload 1

Coagulation Management

• Consider transfusion of fresh frozen plasma and platelets in patients with significant coagulopathy and/or thrombocytopenia 1
• Recombinant factor VIIa is not recommended as standard therapy, as multicenter trials failed to show benefit over standard treatment 1

Pharmacologic Therapy (Start Immediately)

Vasoactive Drugs – First Priority

Initiate vasoactive agents as soon as variceal hemorrhage is suspected, even before endoscopic confirmation – this is a Class I, Level A recommendation 1, 2, 3

Drug options:

• Terlipressin (preferred): 2 mg IV every 4 hours for first 48 hours, then 1 mg every 4 hours 2, 3
• Octreotide: 50 µg IV bolus, then 50 µg/hour continuous infusion 1, 2, 3
• Somatostatin: 250 µg bolus, then 250-500 µg/hour continuous infusion 2, 3

Continue vasoactive therapy for 3-5 days to prevent early rebleeding 1, 2, 3

Antibiotic Prophylaxis – Equally Critical

Start antibiotics immediately in all cirrhotic patients with GI bleeding – this reduces bacterial infections (especially spontaneous bacterial peritonitis), decreases rebleeding, and improves survival 1, 2, 3

Antibiotic regimen:

• Ceftriaxone 1g IV daily for up to 7 days (preferred) 1, 2, 3
• Alternative: Norfloxacin 400 mg PO twice daily for 7 days 2
• Adjust based on local antibiotic resistance patterns and patient allergies 3

The high risk of bacterial infections in cirrhotic patients with upper GI bleeding is well-established, with infections associated with early rebleeding recurrence and greater mortality, particularly in Child B/C patients 1

Endoscopic Management

Timing and Preparation

• Perform endoscopy within 12 hours of presentation once the patient is hemodynamically resuscitated 1, 2, 3
• Administer erythromycin 250 mg IV 30-120 minutes before endoscopy (if no contraindications) to optimize visualization by promoting gastric emptying – check QT interval prior to administration 1, 3

Endoscopic Treatment

• Endoscopic band ligation (EBL) is the treatment of choice for acute esophageal variceal hemorrhage 1, 3, 4
• EBL is superior to sclerotherapy with fewer complications and lower rebleeding rates 3, 5, 4
• Endoscopy serves dual purposes: confirming the variceal source and providing immediate hemostasis 1, 2

Risk Stratification and Advanced Interventions

Identify High-Risk Patients

High-risk criteria for early rebleeding and mortality:

• Child-Pugh C score ≤13 2, 3
• Child-Pugh B >7 with active bleeding at endoscopy despite vasoactive agents 2, 3
• Hepatic venous pressure gradient (HVPG) >20 mmHg 3

Early TIPS for High-Risk Patients

Consider preemptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (ideally <24 hours) in high-risk patients following successful endoscopic hemostasis 1, 2, 3

Rescue Therapy for Refractory Bleeding

If bleeding persists despite combined pharmacological and endoscopic therapy:

• Urgent rescue TIPS is the definitive treatment where available 1, 3
• Balloon tamponade (Sengstaken-Blakemore tube) can be used as a bridge therapy for up to 24 hours maximum 1, 4
  • Provides hemostasis in 80-90% of patients but has 50% rebleeding rate after deflation 1
  • High risk of serious complications including esophageal ulceration, rupture, and aspiration pneumonia 1
• Self-expandable esophageal covered metal stent is an alternative to balloon tamponade with higher bleeding control (85% vs 47%) and fewer serious adverse events 1

Critical Pitfalls to Avoid

• Never delay vasoactive drugs waiting for endoscopy – start immediately upon suspicion 1, 2, 3
• Never over-transfuse – aggressive blood product administration increases portal pressure and mortality 1, 2
• Never skip antibiotic prophylaxis – bacterial infections dramatically worsen outcomes 1, 2, 3
• Never assume hemodynamic stability means safety – cirrhotic patients can decompensate rapidly, and 60% will rebleed within the first year with 10-20% rebleeding within 5 days despite treatment 2
• Never use balloon tamponade for >24 hours due to high complication rates 1
• Never use sclerotherapy for primary prevention – it increases mortality compared to sham therapy 1